肝硬化和TIPS

1 Liver Cirrhosis and TIPS Teran W. Colen, HMS IV Gillian Lieberman, MD Harvard Medical School Advanced Radiology Clerkship Beth-Israel Deaconess Medical Center Department of Radiology 9/12/02 BBETHETH I ISRAELSRAEL DDEACONESSEACONESS MMEDICALEDICAL C CENTERENTER A member of CA member of CAREAREGGROUPROUP HHARVARDARVARD MMEDICALEDICAL SSCHOOLCHOOL 2 Agenda • Patient Presentation • Liver Cirrhosis and Portal Hypertension • Role of Imaging • Transjugular Intrahepatic Portosystemic Shunt (TIPS) for the Treatment and Prevention of Variceal Bleeding Teran Colen, HMS IV Gillian Lieberman, MD 3 Patient History • 47 y/o male w h/o cirrhosis/HCV/ETOH, transferred from OSH w esophageal variceal bleeding • Child C disease, treated w Octreotide, continues to bleed despite endoscopic treatment • In the ICU, received resuscitation including 6 units of blood and FFP • Hct 33.8, AST/ALT 98/42, TBili 5.2, Albumin 2.0 Teran Colen, HMS IV Gillian Lieberman, MD 4 Recent Ultrasound Courtesy of BIDMC Teran Colen, HMS IV Gillian Lieberman, MD 5 DDX of Imaging Findings: Heterogeneous Echo Pattern • Cirrhosis • Metastatic disease • Hepatocellular carcinoma • Fatty infiltration (uncommon) • Hepatoblastoma (uncommon) Teran Colen, HMS IV Gillian Lieberman, MD 6 Liver Cirrhosis: Definition and Problem • Late stage of progressive hepatic fibrosis, characterized by distortion of normal architecture and formation of regenerative nodules • Responsible for 373,000 hospitalizations and 25,000 deaths in the US Vital and Health Statistics Series 13, No. 14. 1998. Teran Colen, HMS IV Gillian Lieberman, MD 7 1. Alcoholism 2. Viral hepatitis 3. Immunologic disorders 4. Biliary disorders 5. Metabolic disorders 6. Cardiovascular disease 7. Drugs and toxins 8. Misc. Liver Cirrhosis: Etiologies Teran Colen, HMS IV Gillian Lieberman, MD 8 Liver Cirrhosis: Complications • Portal hypertension • Ascites • Variceal hemorrhage • Spontaneous bacterial peritonitis • Hepatorenal syndrome • Encephalopathy • Hepatocellular Carcinoma • Hepatopulmonary syndrome Teran Colen, HMS IV Gillian Lieberman, MD 9 Portal Hypertension • Hepatic Venous Pressure Gradient (HVPG) – HVPG = WHVP - FHVP • Portal hypertension is defined as a HVPG > 5 mmHg • The complications of portal hypertension do not appear until the HVPG > 12 mmHg Teran Colen, HMS IV Gillian Lieberman, MD 10 Collateral Circulation • Gastroesophageal • Paraumbilical • Hemorrhoidal • Splenic venous bed • Pancreato-duodenal • Retroperitoneal Teran Colen, HMS IV Gillian Lieberman, MD 11 Imaging Options • Ultrasound • CT • MRI • MR Angiography • Nuclear Medicine The major utility of imaging is in the evaluation of the complications of cirrhosis. Teran Colen, HMS IV Gillian Lieberman, MD 12 Liver Cirrhosis Imaging: Ultrasound http://www.gemedicalsystems.com/rad/us/images/med/cmehd50029.jpg Teran Colen, HMS IV Gillian Lieberman, MD 13 Valls et al. Seminars in Ultrasound, CT, and MRI Vol 32, No 1, 2002:37-61 Liver Cirrhosis Imaging: CT Teran Colen, HMS IV Gillian Lieberman, MD 14 Liver Cirrhosis Imaging: MRI www.radinfonet.com/imaging_update/protocols/protocol13.html Teran Colen, HMS IV Gillian Lieberman, MD 15 Treatment Goals • Slowing the progression of liver disease • Prevention of superimposed disease • Preventing and treating complications Teran Colen, HMS IV Gillian Lieberman, MD 16 Variceal Bleeding: High Mortality Graham DV, Gastroenterology 1981, 80:800 Teran Colen, HMS IV Gillian Lieberman, MD Survival curve illustrating the poor prognosis after a 1st variceal bleed. 30% risk of death each episode, 30-40% are alive after 2 years. 17 Primary Prevention of Variceal Bleeding • Patients with cirrhosis should be screened endoscopically to evaluate the presence of varicies • Patients with varicies or at risk for bleeding should be managed medically – ß blockers ShararaSharara and and RockeyRockey, NEJM 2001, NEJM 2001 Teran Colen, HMS IV Gillian Lieberman, MD 18 Active or Secondary Prevention of Variceal Bleeding ShararaSharara and and RockeyRockey, NEJM 2001, NEJM 2001 • Medical management – Octreotide • Endoscopic therapy – Band ligation – Sclerotherapy • TIPS • Shunt Surgery Teran Colen, HMS IV Gillian Lieberman, MD 19 Transjugular Intrahepatic Portosystemic Shunt (TIPS) • Interventional procedure • Shunt between PV and IVC • Established indications – Portal Hypertension with variceal bleeding that has failed endoscopic treatment – Refractory ascites Teran Colen, HMS IV Gillian Lieberman, MD 20 Transjugular Intrahepatic Portosystemic Shunt (TIPS) University of Michigan Health System http://www.med.umich.edu/ •Rt IJ access •Obtain WHVP and venogram •16 G needle through RHV to PV •Obtain portal pressures and veno- gram Teran Colen, HMS IV Gillian Lieberman, MD 21 Transjugular Intrahepatic Portosystemic Shunt (TIPS) University of Michigan Health System http://www.med.umich.edu/ • Dilate tract with PTA balloon Teran Colen, HMS IV Gillian Lieberman, MD • Deploy metallic stent • Dilate stent until pressure < 10 mmHg • Embolization of varicies (optional) 22 TIPS Images Courtesy of BIDMC Teran Colen, HMS IV Gillian Lieberman, MD 23 TIPS Images Courtesy of BIDMC Teran Colen, HMS IV Gillian Lieberman, MD 24 Courtesy of BIDMC TIPS Images Teran Colen, HMS IV Gillian Lieberman, MD 25 TIPS: Upside • TIPS has been proven to control acute variceal bleeding where conventional therapy has failed • TIPS is associated with less procedural mortality and morbidity than shunt surgery in advanced liver disease Williams et al. Journal of Gastroenterology and Williams et al. Journal of Gastroenterology and HepatologyHepatology Teran Colen, HMS IV Gillian Lieberman, MD 26 TIPS: Downside • TIPS does not improve survival • Complications – New onset encephalopathy (10-25%) – Shunt occlusion (30% at one year) – Right heart failure • Contraindications – Prehepatic portal hypertension – Pulmonary hypertension ShararaSharara and and RockeyRockey, NEJM 2001, NEJM 2001 Teran Colen, HMS IV Gillian Lieberman, MD 27 TIPS: Use • TIPS is best used as a bridge to transplantation in patients with advanced liver disease ShararaSharara and and RockeyRockey, NEJM 2001, NEJM 2001 Teran Colen, HMS IV Gillian Lieberman, MD 28 Patient Outcome • 47 y/o male w advanced cirrhosis (Child C) who has failed endoscopic management of variceal bleeding • Undergoes successful TIPS procedure – HVPG <10 mmHg – Follow up US: patent shunt • Transferred from ICU to medical floor • Bleeding from NGT has subsided • Now being considered for transplant • Awaiting discharge Teran Colen, HMS IV Gillian Lieberman, MD 29 Summary • Cirrhosis – Portal hypertension – Variceal hemorrhage • Role of imaging in Cirrhosis • Successful case of TIPS used as a bridge to transplantation for patients with advanced liver disease Teran Colen, HMS IV Gillian Lieberman, MD 30 References 1. Bravo A, Sheth S, Chopra S. Liver Biopsy. NEJM. 344:495-500. Feb. 15, 2001. 2. Sharara A, Rockey D. Gastroesophageal Variceal Hemorrhage. NEJM. 345:669-681. Aug. 30, 2001. 3. Williams D, et al. Mortality and Rebleeding following Transjugular Intrahepatic Portosystemic Stent Shunt for Variceal Haemorrhage. Journal of Gastroenterology and Hepatology. 13:163-169. 1998. 4. Vital and Health Statistics Series 13, No. 14. 1998. 5. Valls C et al. CT in Hepatic Cirrhosis and Chronic Hepatitis. Seminars in Ultrasound, CT, and MRI. Vol 23, No 1, 2002:37-61. 6. UptoDate® Teran Colen, HMS IV Gillian Lieberman, MD 31 Thank You • Melvin Clouse, MD • Wei Du, MD • Tamer El-Helw, MD • Bertrand Janne D’Othee, MD • Wayne Monsky, MD • Gillian Lieberman, MD • Webmasters BBETHETH I ISRAELSRAEL DDEACONESSEACONESS MMEDICALEDICAL C CENTERENTER A member of CA member of CAREAREGGROUPROUP HHARVARDARVARD MMEDICALEDICAL SSCHOOLCHOOL Liver Cirrhosis and TIPS Slide Number 2 Slide Number 3 Slide Number 4 Slide Number 5 Slide Number 6 Slide Number 7 Slide Number 8 Slide Number 9 Slide Number 10 Slide Number 11 Slide Number 12 Slide Number 13 Slide Number 14 Slide Number 15 Slide Number 16 Slide Number 17 Slide Number 18 Slide Number 19 Slide Number 20 Slide Number 21 Slide Number 22 Slide Number 23 Slide Number 24 Slide Number 25 Slide Number 26 Slide Number 27 Slide Number 28 Slide Number 29 Slide Number 30 Slide Number 31