Joost PH Drenth
Portal Hypertension & TIPS
St Radboud Nijmegen
Department of Gastroenterology and Hepatology Radboud University Nijmegen Medical Center The Netherlands
UMC
UMC
Opzet
– Chirurgie – TIPS
• Klinische uitingen van portale hypertensie/ cirrhose • Therapie
– Fysiologie – Pathofysiologie
• Portale Hypertensie
– Wat is dat?
• Cirrhose
– Anatomie – Functie
• Lever
St Radboud Nijmegen
UMC
St Radboud Nijmegen
UMC
Liver
– Hepatic arteries – Portal – Venous blood
• 1.5 kg, wedge shape • 4 lobes, Right, left, Caudate, Quadrate. • Double blood supply
St Radboud Nijmegen
UMC
Laparoscopic view of the liver
St Radboud Nijmegen
UMC
Lever
Wervel
Milt
Maag
Computer Tomografie
St Radboud Nijmegen
UMC
St Radboud Nijmegen
Lever
Wervel
vet
Milt
Maag
Post-Mortem
UMC
Liver Function
•Metabolism •Carbohydrate, Fat & Protein •Secretory •Bile, Bile acids, salts & pigments •Excretory •Bilirubin, drugs, toxins •Synthesis •Albumin, coagulation factors •Storage •Vitamins, carbohydrates •Detoxification •toxins, ammonia
St Radboud Nijmegen
UMC
Liver Cirrhosis
• Cirrhosis is common end result of many chronic liver disorders • Inflammation – healing with fibrosis - Liver tissue is replaced by connective tissue • Regeneration of remaining hepatocytes form regenerating nodules • Loss of normal architecture & function. • The damage is irreversible but witholding / treating causative agent can slow or stop further damage
St Radboud Nijmegen
UMC
Causes
• Alcohol induced cirrhosis – One of two common causes of cirrhosis in the United States – Occurs in 15% of all alcoholics – ~ 3-4 /day in Men ~ 2-3 / day in Women • Hepatitis B – Most common cause of cirrhosis world wide – Passed through blood or bodily secretions – 100 more infectious than HIV – United States 1.5m – World 300m infected • Hepatitis C – Second of two common causes of cirrhosis in USA – USA 6.5m – Mostly passed through needle use (not sexually)
St Radboud Nijmegen
UMC
Normal Liver - Microscopy
St Radboud Nijmegen
UMC
St Radboud Nijmegen
Regenerating Nodule
Fibrosis
Cirrhosis
UMC
Liver Biopsy – Cirrhosis
St Radboud Nijmegen
UMC
Normal Liver vs. Cirrhosis
St Radboud Nijmegen
UMC
Portal Hypertension
• Has everything to do with the blood supply of the liver
St Radboud Nijmegen
UMC
St Radboud Nijmegen
UMC
Portal Hypertension
– Alcohol – Hepatitis B and C
• Major cause of portal hypertension is cirrhosis of the liver
– Blood will find a way to bypass the liver to reach the heart or there is too much pressure “upstream”
• Problems
– Normal pressure 5-10mm Hg – Anything over 10mm Hg is considered high
• Portal hypertension is an increase in pressure in the portal vein which is caused by obstructed blood flow through the liver
St Radboud Nijmegen
UMC
Vena mesenterica superior
Vena porta
Lever
Vena hepatica
St Radboud Nijmegen
Vena mesenterica inferior
Vena lienalis
a Ven
rica t s ga
Vena cava
Milt
Maag/Oesophagus
Normale situatie
UMC
Vena Vena mesenterica mesenterica superior superior
Vena porta
Lever
Vena Vena hepatica hepatica
St Radboud Nijmegen
Vena Vena mesenterica mesenterica inferior inferior
Vena lienalis
a Ven
rica t s ga
Vena Vena cava cava
Milt
1. Vertraging van de bloedstroom
Maag/Oesophagus
Druk in vena porta ↑
Lever Cirrhose
UMC
Vena Vena mesenterica mesenterica superior superior
Vena porta
Lever
Vena Vena hepatica hepatica
St Radboud Nijmegen
Vena Vena mesenterica mesenterica inferior inferior
Vena lienalis
a Ven
rica t s ga
Vena Vena cava cava
Milt
1. Vertraging van de bloedstroom 2. Venen zetten uit 3. Milt wordt groter
Maag/Oesophagus
Druk in vena porta ↑
Lever Cirrhose
UMC
Vena Vena mesenterica mesenterica superior superior
Vena porta
Lever
Vena Vena hepatica hepatica
St Radboud Nijmegen
Vena Vena mesenterica mesenterica inferior inferior
Vena lienalis
a Ven
rica t s ga
Vena Vena cava cava
Milt
1. Omkering van de bloedstroom 2. Venen zetten uit 3. Milt wordt groter
Maag/Oesophagus
UMC
Vena Vena mesenterica mesenterica superior superior
Vena porta
Lever
Vena Vena hepatica hepatica
St Radboud Nijmegen
Vena Vena mesenterica mesenterica inferior inferior
Vena lienalis
a Ven
rica t s ga
Vena Vena cava cava
Omkering van de bloedstroom Venen zetten uit Milt wordt groter Esophagus varices
Milt
1. 2. 3. 4.
Maag/Oesophagus
UMC
St Radboud Nijmegen
UMC
St Radboud Nijmegen
UMC
• • • • • • •
Symptoms of Portal Hypertension
Esophageal Varices Ascites Hepatic encephalopathy Palmar erythema Spider Clubbing Caput Medusae
St Radboud Nijmegen
St Radboud Nijmegen
Esophageal Varices
– Banding – tying rubber band around bleeding veins – Sclerotherapy – injection of sclerosing agent which causes them to shrink
• Treatment:
– 8% per year for the first two years – 30% by the sixth year – Risk of bleeding is 30% in the first year after Diagnosis – 70% chance of rebleeding and some 30% of the episodes are fatal
• Chronic Liver Disease -
UMC
UMC
Esophageal Varices
• Two main inflows for esophageal varices are left coronary vein or splenic hilus through the short gastric veins • Responsible for 5-11% of gastrointestinal bleeding
– Life threatening – shock – Diagnosis by endoscopy
• Extreme dilation of the sub-mucosal veins in the lower mucosa of the esophagus and sometimes upper part of the stomach
St Radboud Nijmegen
UMC
St Radboud Nijmegen
Esophageal Varices
UMC
Bleeding Esophageal Varices
St Radboud Nijmegen
UMC
Banding
Esophageal Varices
Banding
St Radboud Nijmegen
UMC
Ascites
• Diuretics are used in treatment and safer than drainage
– Can cause fluid retention by the kidneys
• Accumulation of fluid in the peritoneal cavity • Not deadly but can lead to further complications
St Radboud Nijmegen
UMC
Ascites
Every 2-3 weeks: 12-21 liter drainage
St Radboud Nijmegen
UMC
Ascitis & Umbilical hernia
St Radboud Nijmegen
UMC
St Radboud Nijmegen
Spider naevi
UMC
• Subtle signs are usually observed in 70% of people with cirrhosis
– Impairment of brain cells because of toxic substances in the blood – Impaired cognition, tremors, and decreased levels of consciousness
• Hepatic encephalopathy
Hepatic Encephalopathy
St Radboud Nijmegen
UMC
Palmar Erythema
– Therapy – treat portal hypertension
• Palmar erythema – reddening of the skin on the hands because of capillary congestion
St Radboud Nijmegen
St Radboud Nijmegen
Clubbing
– Thought to cause vasodilation in the fingers and therefore hypertrophy of the nailbeds
• Clubbing – deformity of the fingers and fingernails
UMC
UMC
Caput Medusae
– Blood trying to circumvent the liver because of pressure
• Appearance of distended or engorged umbilical veins radiating from umbilicus
St Radboud Nijmegen
UMC
St Radboud Nijmegen
Caput Medusae
UMC
St Radboud Nijmegen
Caput Medusae
UMC
• Gynaecomastia • Jaundice
Other signs of Cirrhosis
St Radboud Nijmegen
UMC
St Radboud Nijmegen
Gynaecomastia
UMC
St Radboud Nijmegen
Jaundice
UMC
St Radboud Nijmegen
Portal Hypertension
UMC
Treatment of Portal Hypertension
– Pass blood from splenic vein to renal vein
• Splenorenal Shunts
– pass blood from portal vein to inferior vena cava
• Portacaval Shunts
– Propanolol start when varices > grade 3
• Beta adrenergic blocking agents
St Radboud Nijmegen
UMC
St Radboud Nijmegen
Portal Hypertension
UMC
End-to-side portocaval shunt
St Radboud Nijmegen
UMC
St Radboud Nijmegen
Porto-caval shunt
UMC
Side-to-side portocaval shunt
St Radboud Nijmegen
UMC
St Radboud Nijmegen
Mesocaval “C” shunt
UMC
Various portocaval shunts
St Radboud Nijmegen
UMC
St Radboud Nijmegen
Splenorenal shunt
UMC
Various Splenorenal shunts
St Radboud Nijmegen
UMC
Portocaval shunts
– Difficult for the surgeon; requires a lot of experience – High death rate – 24-53% show debilitating symptoms of hepatic encephalopathy – High rate of non-functioning shunts
St Radboud Nijmegen
UMC
catheter is extend from portal vein across liver and connects to the hepatic vein
T I P S
Treatment of Portal Hypertension
Transjugular Intrahepatic Portosystemic Shunt
St Radboud Nijmegen
St Radboud Nijmegen
TIPS
Transjugular Intrahepatic Porto-systemic Shunt
UMC
UMC
St Radboud Nijmegen
TIPS
UMC
St Radboud Nijmegen
UMC
TIPS functional side-to-side shunt
St Radboud Nijmegen
UMC
St Radboud Nijmegen
UMC
St Radboud Nijmegen
Insertion of TIPS (3)
UMC
St Radboud Nijmegen
Insertion of TIPS (2)
UMC
St Radboud Nijmegen
Insertion of TIPS (1)
UMC
2004:
2002:
2000:
1993:
St Radboud Nijmegen
Stembandknobbels verwijderd. Preoperatief onderzoek hepatomegalie en verhoogde Gamma GT, ASAT en ALAT. Niet insuline afhankelijk Diabetes Mellitus en verhoogd Gamma GT. Diabetes Mellitus met nefropathie, opname in verband met ascites, hypertensie. Second opinion in verband met refractaire ascites bij alcoholische levercirrose.
Dhr FvH 61 jaar
UMC
– – – –
Sinds augustus 2002 ascites Pijnlijke druk in de buik en steken Toename van de buikomvang Moeheid & jeuk
• Anamnese
– Icterus – Abdomen: bolle buik met versterkte vaattekening. Palpabele lever (drie vingers). Demping in de flanken met shifting dulness. – Geen clubbing fingers of erythema palmare.
• Onderzoek
Anamnese & Onderzoek
St Radboud Nijmegen
UMC
Beloop
• Patiënt komt in aanmerking voor een TIPS procedure
– diuretica geen effect – Diverse drainages geen effect – Geen spontane bacteriele peritonitis
• Therapie resistente ascites
St Radboud Nijmegen
UMC
TIPS 1
St Radboud Nijmegen
St Radboud Nijmegen
TIPS 2
UMC
UMC
TIPS 3
St Radboud Nijmegen
UMC
St Radboud Nijmegen
TIPS 4
UMC
St Radboud Nijmegen
UMC
St Radboud Nijmegen
•
Subcapsular Hematoma Hemobilia
Congestive Failure
Acute Renal Failure
Mortality (30 day) 3 - 13%
Intraperitoneal Bleeding
Infection
Complications 9 - 50%
•
TIPS
Technically feasible
St Radboud Nijmegen
•
UMC
UMC
Problems With TIPS
19% @ 4.7 months
18% @ one year
• Rebleeding
• Occlusion 33 - 73% @ one year
• Encephalopathy minimum 15%
St Radboud Nijmegen
UMC
What to do with TIPS?
stents
• Polytetrafluoroethylene (PTFE) covered
– Multiple revisions!!!
• Occlusion rate well above 50% (one year)
St Radboud Nijmegen
Polytetrafluoroethylene = Teflon®
St Radboud Nijmegen
non-sticking non-reactive Implants
UMC
UMC
Polytetrafluoroethylene (PTFE) covered stents
Viatorr®
St Radboud Nijmegen
38 49
19* 33*
Complications portal hypertension Encephalopathy
36
76*
Primary patency
44
Uncovered
15*
Teflon®
Covered TIPS (Viatorr) vs uncovered stents
St Radboud Nijmegen
Shunt dysfunction
UMC
UMC
– improve long-term patency of TIPS – fewer reprocedures – prevent clinical relapses – decrease rate of encephalopathy
• Teflon® covered stents
Covered TIPS (Viatorr) vs uncovered stents
St Radboud Nijmegen
UMC
The Role For Tips
– Unreliable patient
• Relative contraindication
– Refractory ascites
– Child C livercirrhosis
– Bridge to transplant
– Refractory bleeding
• Indication
St Radboud Nijmegen
UMC
– < 1/day for women – < 2/day for men
• Preventing portal hypertension = preventing cirrhosis • Treat infectious hepatitis!!! • No alcohol
Preventing Portal Hypertension
St Radboud Nijmegen
UMC
2006:
2005:
2005:
2004:
St Radboud Nijmegen
Na TIPS afname maar niet verdwijnen van ascitis: situatie acceptabel Slikklachten: scopie esophagus carcinoom; Radiotherapie; remissie Opname elders ivm koorts: spontane bacteriele peritonitis? Recidief esophagus carcinoom: overlijden
Beloop patient
UMC
References
• Familypracticenotebook.com http://www.fpnotebook.com • Wikipedia http://en.wikipedia.org • EMedicine http://www.emedicine.com
St Radboud Nijmegen
UMC
St Radboud Nijmegen
UMC
St Radboud Nijmegen
Alcoholic Fatty Liver
UMC
St Radboud Nijmegen
Jaundice
UMC
St Radboud Nijmegen
Alcoholic Fatty Liver
UMC
St Radboud Nijmegen
UMC
PT
Normal Liver Histology
St Radboud Nijmegen
CV
UMC
St Radboud Nijmegen
UMC
St Radboud Nijmegen
UMC
St Radboud Nijmegen
TIPS
