Variceal Bleeding Management Procedures
What are portal hypertension and variceal bleeding?
The variceal bleeding you have had is caused by portal hypertension. Portal hypertension is an increase in the pressure within the portal vein (the vein that carries blood from the digestive organs to the liver). This increase in pressure is caused by a blockage in the blood flow throughout the liver.
Increased pressure in the portal vein causes large veins (varices) to develop across the esophagus and stomach to bypass the blockage. The varices become fragile and can bleed easily. Symptoms of portal hypertension include:
- Bleeding -- black stools and/or vomiting of blood due to the spontaneous rupture and hemorrhage from varices
- Ascites -- an accumulation of fluid in the abdomen
- Encephalopathy -- confusion and forgetfulness caused by poor liver function and the diversion of blood flow away from your liver
Endoscopy, X-ray studies, and lab work confirm that you have variceal bleeding. Further treatment is necessary to reduce the risk of re-bleeding.
How is variceal bleeding treated?
Once the bleeding episode has been stabilized, treatment options are prescribed based on the severity of your symptoms and how well your liver is functioning.
FIRST LEVEL OF TREATMENT: When you were first diagnosed with variceal bleeding, you may have been treated with endoscopic therapy and/or medications. Endoscopic therapy consists of either sclerotherapy or banding. Medicines such as beta blockers or nitrates might be prescribed alone or in combination with endoscopic therapy to reduce the pressure in your varices and further reduce the risk of re-bleeding.
Because the first level of treatment has not successfully controlled your variceal bleeding, you now require decompression (reducing the pressure) of your varices.
SECOND LEVEL OF TREATMENT:
- Transjugular intrahepatic porto-systemic shunt (TIPS) -- a radiological procedure in which a stent (a tubular device) is placed in the middle of the liver to reroute the blood
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Fig 1: Portal hypertension before the TIPS procedure is performed
Portal hypertension causes veins to enlarge, and varices to develop across the esophagus and stomach from the destruction to portal vein blood flow through the liver. This causes high pressure in the portal vein. The backup of pressure also causes the spleen to become enlarged. |
What is the TIPS procedure?
During the TIPS procedure, a radiologist makes a tunnel through the liver with a needle, connecting the portal vein (the vein that carries blood from the digestive organs to the liver) to one of the hepatic veins (the three veins that carry blood from the liver). A metal stent is placed in this tunnel to keep the track open.
The TIPS procedure re-routes blood flow in the liver and reduces pressure in all abnormal veins, not only in the stomach and esophagus, but also in the bowel and the liver. Figure 2 illustrates the TIPS procedure.
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Fig 2: After the TIPS procedure is performed
A radiologist makes a tunnel through the liver with a needle, connecting the portal vein (the vein that carries blood from the digestive organs to the liver) to one of the hepatic veins (the three veins that carry blood from the liver). A metal stent is placed in this tunnel to keep the track open.
The shunt allows the blood to flow from the high pressure portal vein through the stent, bypassing liver tissue, to the hepatic vein. This reduces portal hypertension, and allows the veins to shrink to normal size, helping to stop variceal bleeding.
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The TIPS procedure is not a surgical procedure. The radiologist performs the procedure within the vessels in the X-ray room under X-ray guidance. The procedure lasts one to three hours. You should expect to stay in the hospital two to three days after the procedure.
The TIPS procedure controls bleeding immediately in more than 90% of patients, but has a late re-bleeding rate of about 20% because the shunt may narrow.
What are the potential complications of the TIPS procedure?
- Shunt narrowing or occlusion (blockage) – This could happen within the first year after the procedure. Follow-up ultrasounds are performed frequently after the TIPS procedure to detect these complications. The signs of occlusion include increased ascites or re-bleeding. This condition can be treated by a radiologist who re-expands the shunt with a
balloon or repeats the procedure to place a new stent.
- Encephalopathy -- mental changes caused by abnormal functioning of the brain that occur with severe liver disease. Encephalopathy can be worse
when blood flow to the liver is reduced by TIPS, which might result in toxic
substances reaching the brain without being metabolized first by the liver.
This condition can be treated with medicine and diet, or by revising the
shunt.
What tests are required before the TIPS procedure?
Before this procedure, you will have had the following tests to determine the extent and severity of your portal hypertension condition:
- Evaluation of your medical history
- A physical examination
- Blood tests
- Ultrasound
- Endoscopy
- 2-dimensional cardiac echocardiography
Before the TIPS procedure, your doctor might ask you to come to the Clinic for pre-operative tests. The tests might include an electrocardiogram (also called an EKG), chest X-ray, or additional blood tests. If your physician thinks you will need additional blood products (such as plasma), they will be ordered at this time.
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