Liver Cirrhosis

What is Liver Cirrhosis?

Liver cirrhosis is the end result of many different processes that damage the liver and cause it to scar and harden. The liver shrinks and loses function over time.

What problems can this cause?

Liver cirrhosis can finally result in liver failure as the liver loses normal function. This is a gradual process and actually can only be treated by liver transplantation.

Many cirrhosis patients do not have liver failure but suffer from symptoms as a result of Portal Hypertension, which is caused by an increase in resistance to blood flow through the liver. The liver is the chemical factory of the body and processes all nutrition absorbed from the intestine. To do this, it has a specialised blood supply that sends blood from the bowel to the lover where the absorbed chemicals get processed and purified so that the rest of the body is supplied with what it needs. This is called the Portal Circulation and the liver has a Portal Vein supplying blood to it for this. The liver needs oxygenated blood from the heart and that is supplied by the Hepatic Artery. The blood from the liver drains out though the Hepatic Vein to reach the heart. The process of cirrhosis increases the resistance to the portal venous flow and thus the pressure in the portal vein rises. This is portal hypertension.

What are the effects of portal hypertension?

Portal hypertension can cause two main problems that can be life threatening and very uncomfortable.

Bleeding into the bowel happens because the increased pressure in the portal system causes veins in the wall of the bowel (Oesophagus, Stomach ) to become large and tense, and eventually rupture and bleed. This bleeding can be life threatening. These dilated veins are called Varices and they can be seen on endoscopy or on radiological studies (USG, CT etc)

Accumulation of Fluid (Ascites) in the abdomen happens because the increased pressure in the veins of the bowel and other areas causes fluid to leak out in to the abdomen and collect over time. This fluid can cause discomfort, severe swelling and difficulty in breathing.

What treatments can be offered by Interventional Radiology?

Bleeding Risk can be reduced by decreasing the pressure in the portal system. In earlier era this involved major abdominal surgery with the creation of a Shunt to allow blood to flow out of the portal system into the lower pressure veins bypassing the high resistance of the liver. This obviously involved high risks. With the advent of Interventional Radiology, it is now possible to create a shunt directly from the portal vein inside the liver using small hole in the neck vein (Jugular Vein). This is called a Transjugular Intrahepatic Porto-Systemic Shunt (TIPS) and has now become the mainstay of this treatment.

As will be clear, the reduction in portal pressure that the TIPS procedure achieves, also reduces the accumulation of fluid in the abdomen, and is used for this indication as well.

The movie below shows the blood flow from the portal vein into the inferior vena cava after a TIPS shunt.

What are the risks of the TIPS procedure?

The TIPS procedure is a procedure meant to palliate symptoms. It does not change the course of liver disease.

As in in any major procedure, there are risks involving the performance of the procedure.

The major risk during the creation of the TIPS is bleeding from the liver. With modern imaging technology, this risk is minimised.

The major risk of the procedure is common to all porto-systemic bypass shunts. The shunt bypasses the liver and thus blood which is not treated by the liver reaches the rest of the body. This can cause Hepatic Encephlopathy which can affect the mental function of the patient. This is not common (0ccurs in less than 1 out of 5 patients). Post TIPS encephalopathy can often be controlled by drugs and diet. IF required, the TIPS shunt can be narrowed to increase the blood flow to the liver and this can control the encephalopathy. Uncontrolled encephalopathy can require closure of the shunt in rare cases.

Who cannot undergo a TIPS Procedure?

Patients with encephalopathy are not suitable for TIPS as the problem will worsen.

Patients with extremely poor liver function cannot tolerate the procedure and this is judged by a scoring system called the MELD Score. Patients with a high MELD score are usually considered ineligible for this procedure.

Patients with a blocked portal veins cannot undergo a standard TIPS procedure.

Patients with bleeding disorders , as often happens with liver disease, must have correction of the bleeding tendency before TIPS is carried out.

What happens after the procedure?

Patients with a TIPS procedure will need monitoring for correct function of the shunt. This is done by ultrasound and the USG images below show a normal working TIPS shunt as well as a doppler study of the flow .