Rare Medical Problems

Complications of Transjugular Intrahepatic Portosystemic Shunt Procedural complications are generally seen in 10% or fewer patients after TIPS.Severe life-threatening bleeding has been reported in 1% to 2% of cases because of either puncture of the liver capsule with resulting hemoperitoneum or inadvertent puncture of the biliary tree with resulting hemobilia. Other major complications include contrast medium induced renal failure, heart failure, stent migration, fever, infection, transient arrhythmias, and inadvertent puncture of the gallbladder or other organs adjacent to the liver. Hemolysis, which is typically self-limited and mild, is not uncommon after TIPS. Although procedural complications are relatively infrequent, hepatic encephalopathy is a common complication after TIPS, with a frequency in the range of 20% to 30%. This figure is not unexpected: TIPS represents a side-to-side portosystemic shunt that often results in complete diversion of portal flow, as well as a proporti...

Indications Accepted indications Control of refractory acute variceal bleeding Prevention of refractory recurrent variceal bleeding in Child class B and C patients Refractory hepatic hydrothorax Budd-Chiari syndrome Refractory ascites Promising but unproven Hepatorenal syndrome Veno-occlusive disease Unproven Prevention of refractory variceal bleeding in Child class A patients Initial therapy of acute variceal hemorrhage Initial therapy to prevent recurrent variceal hemorrhage Prevention of initial variceal hemorrhage Reduction in intraoperative morbidity rate during liver transplantation Hepatopulmonary syndrome Contraindications Absolute contraindications Right-sided heart failure Primary pulmonary hypertension Polycystic liver disease Severe hepatic failure Portal vein thrombosis with cavernous transformation Relative contraindications Biliary obstruction Active intrahepatic or systemic infection Severe hepatic encephalopathy poorly controll...

Transjugular Intrahepatic Portosystemic Shunt Attempts to devise a less invasive approach to portal decompression led to the development of a nonsurgical shunt, the TIPS. The potential advantages of this technique include avoidance of general anesthesia, decreased procedural morbidity and mortality rates, and avoidance of surgery in the region of the hepatic hilum, which may be important in potential liver transplantation candidates. A percutaneous method of creating a portosystemic shunt was first conceived in the late 1960s. Although technically successful, the shunts were short-lived, and all thrombosed within a few days. The development of expandable, implantable metallic stents provided a means, albeit imperfect, for maintaining shunt patency and allowed the widespread clinical implementation of this technique. The use of the flexible Wallstent endoprosthesis (Schneider, Minneapolis, MN) and several technical modifications have reduced procedure...

Overview of the Principles and Techniques of the Major Treatment Modalities Endoscopic Therapy Endoscopy is the cornerstone of the management of gastrointestinal hemorrhage both as a diagnostic and as a therapeutic modality. Once esophageal varices are identified as the source or likely source of bleeding, endoscopic options for treatment include injection sclerotherapy and variceal band ligation. Although these techniques do not treat the underlying portal hypertension, they have been shown to be effective in controlling variceal hemorrhage. The rates of success and complications of these endoscopic techniques depend in part on the experience of the operator and the technique employed. Endoscopic Sclerotherapy A variety of techniques have been employed in performing endoscopic sclerotherapy (EST) with the goal of arresting acute bleeding and preventing recurrent bleeding through the obliteration of varices by repeated injections. Injections may be directed into the veins ...

Indications for liver biopsy Percutaneous liver biopsy has a small but inherent risk even in the most experienced hands, and it should therefore only be performed when the benefits of knowing the histology outweigh the risks to the patient (in terms of altering treatment or defining disease outcome). These benefits should be continually re-evaluated as new treatment options become available such as has occurred with the new antiviral therapies in viral hepatitis and in liver transplantation. Acute hepatitis of unknown etiology, including possible drug related hepatitis, has long been an indication for per cutaneous liver biopsy, but liver biopsy in typical acute viral hepatitis is usually not necessary. The usefulness of liver biopsy in chronic viral hepatitis was once hotly debated; however, with the advent of new antiviral therapies there is no doubt of the value of histology in assessing those patients who will benefit from treatment and assessing their response to it. Patients with...

Transjugular intrahepatic portosystemic shunts Only a few studies have reported on the effects of transjugular intrahepatic portosystemic shunts (TIPS) in patients with type 1 HRS. This procedure consists of insertion of an intrahepatic stent between the portal and hepatic veins by a transjugular approach. The main effect is to lower portal pressure. In type 1 HRS, TIPS improve circulatory function and reduce the activity of vasoconstrictor system.These effects are associated with a slow, moderate to strong increase in renal perfusion and GFR and a fall in serum creatinine concentrations in about 60% of patients. Median survival after TIPS in type 1 HRS is between 2 months and 4 months.As with vasoconstrictor drugs, the improved renal function probably, but not definitely, results in longer survival. Information currently available on the use of TIPS in type 1 HRS has been obtained in a very selected population of patients and may not be appli...

Liver transplantation The treatment of choice for patients with cirrhosis and type 1 HRS who are suitable for the procedure is liver transplantation, because it allows both the liver disease and the associated renal failure to be cured. The most common contraindications for transplantation in HRS are advanced age, active alcoholism, and infection. The main problem in the use of liver transplantation for type 1 HRS is that many patients die before transplantation is possible because of the short survival expectancy and long waiting times in most transplant centres. The issue can be solved by assigning these patients a high priority for transplantation from a cadaveric donor. This approach was used with the former method of organ allocation used by the United Network for Organ Sharing in the USA, which classified patients with HRS in the 2a status, with a median waiting time of about 7 days. Now this system has been changed and livers are allocated on the basis of the MELD (...

Hepatorenal syndrome The hepatorenal syndrome refers to renal failure of unknown etiology that occurs in a fully hydrated patient with severe, often progressive, liver disease. Urine biochemistry is characteristic and renal histopathology unremarkable. The pathogenesis of the hepatorenal syndrome appears to involve intense intrarenal vasoconstriction and alteration in renal cortical blood flow, possibly due to an imbalance of prostaglandins and thromboxane. Early clinical experience suggested that only orthotopic liver transplantation was able to reverse the hepatorenal syndrome, although more recent evidence has reported up to 50 per cent survival in hepatorenal failure following paracetamol (acetaminophen) overdose. Renal failure is reversed after liver transplantation, suggesting that it is due to circulating or systemic factors. Excessive use of diuretics, sepsis, abdominal paracentesis, and gastrointestinal hemorrhage are all associated with an increased risk...