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