TIPS on Portal Hypertension for Surgeons John R. Potts, III, M.D., F.A.C.S. Program Director in Surgery Assistant Dean Graduate Medical Education University of Texas Medical School - Houston

TIPS on Portal Hypertension

Resuscitation VARICEAL BLEEDING Resuscitation Treat hemorrhagic shock Crystalloid (Limited) Platelets (Rarely) Red Cells + FFP Goal: Tissue Perfusion Monitor: Urine Output Caveat: Do NOT overload

TIPS on Portal Hypertension VARICEAL BLEEDING Initial Treatment Continue Tx hemorrhagic shock IV therapy Sandostatin® INITIATE WHEN Dx SUSPECTED!!!

TIPS on Portal Hypertension VARICEAL BLEEDING Diagnosis 50% UGI bleeds not variceal (MW Tear, Gastritis, Gastric/Duodenal Ulcer) Early endoscopy mandatory Variceal bleeding Dx’d: Active bleeding Stigmata Varices and NO other source

TIPS on Portal Hypertension Initial Therapy VARICEAL BLEEDING Initial Therapy Continue I.V. Sandostatin ® Endoscopic Therapy Sengstaaken-Blakemore tube TIPS Emergency operation

TIPS on Portal Hypertension Supportive Therapy VARICEAL BLEEDING Supportive Therapy Correct coagulopathy FFP, vitamin K, +/- platelets Pulmonary Other infection Encephalopathy Nutrition

TIPS on Portal Hypertension VARICEAL BLEEDING Evaluation Child class History Hepatitis profile Angiography Transplant evaluation

TIPS on Portal Hypertension Child-Pugh Classification Points 123 Bilirubin (mg/dL) < 22 – 3> 3 Albumin (g/dL) > – 3.5< 2.8 Prothrombin time (seconds ↑) 1 – 34 – 6> 6 Ascites NoneSlightModerate Encephalopathy NoneMinimalAdvanced Grade A, 5-6 points; Grade B, 7-9 points; Grade C, points

TIPS on Portal Hypertension VARICEAL BLEEDING Definitive Therapy Rationale: 67% rebleed Most rebleed < 6 weeks Definitive Tx during initial stay

TIPS on Portal Hypertension VARICEAL BLEEDING Definitive Therapy Medical Endoscopic Surgical Radiological

TIPS on Portal Hypertension Medical Therapy VARICEAL BLEEDING Medical Therapy Beta blockade  bleeding by  cardiac output Goal: 25%  in heart rate Reduces # bleeding episodes Does not reduce mortality Use as adjunct

TIPS on Portal Hypertension Endoscopic Banding Occludes venous channels Multiple sessions + surveillance >60% rebleed 1/3 fail treatment  complications vs scleroTx = /  efficacy vs scleroTx ENDOSCOPIC Tx OF CHOICE

TIPS on Portal Hypertension Endoscopic Banding

TIPS on Portal Hypertension VARICEAL BLEEDING SURGICAL OPTIONS Total Shunt Selective Shunt Partial Shunt Non-Shunt

TIPS on Portal Hypertension Total Shunts End to Side PortocavalSide to Side Portocaval Interposition ShuntsCentral Splenorenal

TIPS on Portal Hypertension Total Shunt Results Prevent rebleed > 90% Thrombosis with graft Encephalopathy rate 40%

TIPS on Portal Hypertension Selective Shunts Goals: Prevent variceal bleeding and encephalopathy Mechanism: Decompress Varices Maintain Portal Perfusion Maintain Portal Hypertension Key: Decompress only gastrosplenic compartment

TIPS on Portal Hypertension Distal Splenorenal Shunt

TIPS on Portal Hypertension DSRS vs Total Shunts Six randomized trials in N.A. Mean follow-up 39 mos (1-8 yrs)

TIPS on Portal Hypertension Partial Shunts Ease of portocaval Limited portal diversion Maintain some liver perfusion Short, straight PTFE graft

TIPS on Portal Hypertension Partial Shunts Sarfeh Ann Surg 200:706,1986

TIPS on Portal Hypertension Partial Shunts Randomized trial in ETOH cirrhotics 20 +/- 11 mos

TIPS on Portal Hypertension Non-Shunt Operations Options Esophageal transection Variceal ligation Devascularize +/- splenectomy Very limited role

TIPS on Portal Hypertension Liver Transplant Indicated for liver failure Not for variceal bleeding Number  > 3,500/yr in U.S. 20,000 potential recipients in U.S. 5,000 listed for transplant 24% die on waiting list

TIPS on Portal Hypertension TIPS Transjugular Intrahepatic Portocaval Shunt

TIPS on Portal HypertensionTIPS

TIPS Technically feasible Complications % Infection Intraperitoneal Bleeding Congestive Failure Subcapsular Hematoma Acute Renal Failure Hemobilia Mortality (30 day) % (1) Rossie NEJM 1994;330:165, (2) Rosch Hepatology 1992;16:884, (3) LaBerge Radiology 1993;187:913.

TIPS on Portal Hypertension Problems With TIPS Encephalopathy minimum 15% Occlusion 33 - one year Rebleeding one year (1) 4.7 months (3) (1) Rossie NEJM 1994;330:165, (2) Rosch Hepatology 1992;16:884, (3) LaBerge Radiology 1993;187:913.

TIPS on Portal Hypertension The Role For Tips Refractory bleeding Bridge to transplant Child C (all or only “D  Z” ?) ??? refractory ascites Relative contraindication: Poor f/u

Special Cases of Portal Hypertension

TIPS on Portal Hypertension Splenic Vein Thrombosis Etiology: Pancreatitis - Acute or Chronic Pancreatic Carcinoma Hallmark: Isolated Gastric Varices Treatment: Splenectomy (if bleeding)

TIPS on Portal Hypertension Portal Vein Thrombosis Etiology: Congenital - “Cavernous Transformation” Hallmark: Normal Liver Function W/ Varices Treatment: Endo Tx OR DSRS

TIPS on Portal Hypertension Budd-Chiari Syndrome Etiology Hypercoagulable: Estrogens, XRT, Myeloprolif, PNH IVC Occlusion: RA Myxoma, Pericarditis, Membrane Liver Mass High Dose ChemoTx Presentation: Classic Triad Abdominal Pain Ascites Hepatomegaly

TIPS on Portal Hypertension Budd-Chiari Syndrome Diagnosis –U/S, CT, Angio Treatment –NOT a static disease –If NO necrosis  Symptomatic Tx –If necrosis  Shunt (PCS or MAS) or Transplant

TIPS on Portal Hypertension Some Take Home Points Child A better than Child C Start Sandostatin when Dx suspected β blockade  bleeding by  C.O Banding safer than scleroTx TIPS: Encephalopathy & occlusion rate

TIPS on Portal Hypertension Some Take Home Points Selective shunt:  encephalopathy SV Thrombosis: Presentation & Tx Budd-Chiari: Classic triad Transplant for liver failure

TIPS on Portal Hypertension

Etiology Portal Hypertension Etiology PRE-HEPATIC Portal Vein or Splenic Vein Thrombosis INTRA-HEPATIC Cirrhosis (ETOH, Hepatitis, Other Toxins) POST-HEPATIC Budd-Chiari

TIPS on Portal Hypertension Complications of Portal Hypertension Ascites Encephalopathy Variceal bleeding –Initial management –Evaluation –Definitive therapy –Special cases

TIPS on Portal HypertensionEncephalopathy Etiology: ? Nitrogen compounds Induced by: InfectionDehydration ConstipationBlood in gut No test is diagnostic Therapy : HydrateCleanse gut ↓ proteinFind and treat cause

TIPS on Portal HypertensionAscites Origin: Sinusoidal pressure > colloid oncotic pressure Induced by: Physiologic Stress IV Fluids Complications: Spontaneous Bacterial Peritonitis “Hepatorenal Syndrome”

TIPS on Portal Hypertension Control of Ascites Sodium / Water Restriction Spironolactone Loop Diuretic Large Volume Paracentesis Peritoneal-Venous Shunt (?) TIPS

TIPS on Portal Hypertension VARICEAL BLEEDING General Approach Resuscitation Initial treatment Support Evaluation Definitive therapy

TIPS on Portal HypertensionVasopressin 8-Arginine Vasopressin (ADH) Intense constriction (all beds) + ’s  Mesenteric Flow  Portal Pressure Stops Bleeding in >80% - ’s Peripheral Ischemia Myocardial Ischemia NTG  ’s adverse effects

TIPS on Portal HypertensionSandostatin® Long acting STS analogue +’s  Mesenteric Flow  Portal Pressure Stops bleeding in > 85% Good as VP but  side effects -’s Cost DRUG OF CHOICE

TIPS on Portal Hypertension Portal Vein Anatomy

TIPS on Portal Hypertension Portal Vein Collaterals Five Principle Routes Veins of Retzius Umbilical Vein Hemorrhoids Adhesions Esophageal Varices

TIPS on Portal Hypertension Sclerotherapy VARICEAL BLEEDING Sclerotherapy Intra- or Para- Variceal Occludes venous channels Multiple sessions + surveillance >60% rebleed 1/3 fail treatment 30% complication rate

TIPS on Portal Hypertension Endoscopic Sclerotherapy IntravaricealParavariceal

TIPS on Portal Hypertension Complications of ScleroTx LOCAL Ulceration Stricture Perforation SYSTEMIC Fever Pneumonitis CNS

TIPS on Portal Hypertension Total Shunts Divert most (all?) portal flow Options Portocaval Shunt (E-S or S-S; +/- Graft) Interposition Shunt Central Splenorenal Shunt

TIPS on Portal HypertensionTIPS

Child’s Classification ABC Bilirubin < 22 – 3> 3 Albumin > – 3.5< 2.8 Ascites NoneControlledUn controlled Enceph NoneMinimalAdvanced Nutrition ExcellentGoodPoor

TIPS on Portal Hypertension SclTx vs TIPS Five Randomized Trials patients Mean Follow-up 15 mos (1-36) * p < 0.05 in all but one study ** p < 0.05 in all studies *** n.s. in all but one study where survival  w/ SclTx