eMedicine Specialties > Radiology > Gastrointestinal

Cirrhosis: Follow-up

Author: Caroline R Taylor, MD, Associate Professor, Department of Diagnostic Imaging, Yale University School of Medicine; Chief, Diagnostic Imaging Service, Department of Radiology, VA Connecticut Healthcare System
Contributor Information and Disclosures

Updated: Jan 7, 2009

Intervention

Of those patients with cirrhosis and varices, 25-40% experience bleeding. The management of portal hypertension and upper tract GI bleeding has been revolutionized by endoscopic and angiographic treatment. The use of the intravascularly placed transjugular intrahepatic portosystemic shunt (TIPS) has provided a second-line therapy for the management of portal hypertension, with reduced mortality and morbidity compared with that associated with the open surgical procedure.

See also the following on Medscape:
Advances in the Treatment of Complications of Cirrhosis and Portal Hypertension-Variceal Bleeding

Management of GI bleeding with TIPS

In the management of GI bleeding, Grace, Kerlan, and colleagues recommended that the TIPS generally be reserved for patients in whom a combined approach of vasoactive pharmacologic agents and endoscopic sclerotherapy or ligation has failed.70,71 The procedure is more than 95% technically successful, with a high success rate in controlling acute or recurrent variceal hemorrhage.

A cost-effectiveness analysis by Russo and coauthors suggested that use of the TIPS may be associated with lower recurrence rates of GI bleeding in the short term.72 However, the lower rebleed rate in patients treated with a TIPS (with rebleeding occurring in 24% of TIPS patients and in 51% of persons undergoing sclerotherapy, in a randomized series of 81 patients with cirrhosis), as reported by Merli and colleagues from a multi-institutional study, was offset by a higher risk of hepatic encephalopathy (55% of TIPS patients vs 26% of sclerotherapy patients) and the fact that the use of a TIPS was associated with no significant difference in mortality (24% mortality in TIPS patients vs 19% in sclerotherapy patients; P = 0.5).73 Zoller and coauthors reported that without sclerotherapy or ligation, 40-80% of patients experience rebleeding within 1 year after an initial variceal bleed.74

Contraindications to TIPS

Absolute contraindications to TIPS include right-sided heart failure, polycystic liver disease, and severe hepatic failure. Relative contraindications include active hepatic or systemic infection, hypervascular tumors, portal vein thrombosis, and severe, poorly controlled hepatic encephalopathy. Ring and colleagues described the successful use of the TIPS as an emergency intervention in patients with acute GI bleed who are awaiting transplantation, and Mingoli and coauthors reported encouraging results in patients with HCCA and bleeding esophageal varices.75,76 The TIPS is also used in treating patients with cirrhosis who have refractory ascites (see Images 40-41, Images 80-82). The TIPS appears to be most effective in patients with a high HVPG (see Image 69).

Problems associated with TIPS

Procedure-related mortality is rare, as is serious morbidity, including hepatic failure attributed to reduced hepatic perfusion, and right-sided heart failure associated with the rise in central venous pressure. The most common longer-term problem associated with the TIPS is stenosis, which may result in decreased effectiveness of the shunt or in occlusion. This leads to an estimated recurrence of variceal bleeding of up to 30%, according to Kerlan and colleagues.71

Fischer, Kimura, and coauthors have used noninvasive modalities, such as Doppler US, to monitor shunt patency (with a reasonably high accuracy of greater than 90%; see Image 82).77,78 Occasionally, however, conventional Doppler techniques fail to image signals. Thus, enhancement by US contrast agents appears promising in improving visualization (see Image 83).

Modifying TIPS

A stenotic TIPS, and even an occluded one, can be revised to improve longevity. In one series, LaBerge and colleagues reported that the use of shunt revision can maintain patency higher than 90% at 2 years.79 Developments described by Haskal include the use of polytetrafluoroethylene stent grafts to prolong TIPS patency and to treat TIPS-related biliary fistulas.80 The TIPS may worsen hepatic encephalopathy, but this can be alleviated by modification of the TIPS to reduce shunt diameter.

 


More on Cirrhosis

Overview: Cirrhosis
Imaging: Cirrhosis
Follow-up: Cirrhosis
Multimedia: Cirrhosis
References
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Further Reading

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Keywords

hepatic fibrosis, chronic end-stage liver disease, transjugular intrahepatic portosystemic shunt, TIP, hepatocellular carcinoma, HCCA, HCC, hepatic arterial circulation, portal venous circulation, hepatic vein pressure gradient, HVPG

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Contributor Information and Disclosures

Author

Caroline R Taylor, MD, Associate Professor, Department of Diagnostic Imaging, Yale University School of Medicine; Chief, Diagnostic Imaging Service, Department of Radiology, VA Connecticut Healthcare System
Caroline R Taylor, MD is a member of the following medical societies: Radiological Society of North America
Disclosure: Nothing to disclose.

Medical Editor

Glenn Krinsky, MD, Chief of Abdominal Imaging Section, Associate Professor, Department of Radiology, New York University School of Medicine
Glenn Krinsky, MD is a member of the following medical societies: Alpha Omega Alpha and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Udo P Schmiedl, MD, PhD, Clinical Professor, Department of Radiology, University of Washington; Consulting Staff, Swedish Medical Center, University of Washington Medical Center, Seattle Radiologists
Udo P Schmiedl, MD, PhD is a member of the following medical societies: American College of Radiology and Radiological Society of North America
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

John Karani, MBBS, FRCR, Clinical Director of Radiology and Consultant Radiologist, Department of Radiology, King's College Hospital, London
John Karani, MBBS, FRCR is a member of the following medical societies: British Institute of Radiology, British Society of Interventional Radiology, Cardiovascular and Interventional Radiological Society of Europe, European Society of Gastrointestinal and Abdominal Radiology, European Society of Radiology, Radiological Society of North America, and Royal College of Radiologists
Disclosure: Nothing to disclose.

 
 
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