Cirrhosis - Bleeding Episodes

Balloon Tamponade for Uncontrolled Bleeding

Balloon tamponade has been available for years but is now used only for bleeding not controlled by drugs or endoscopy. It employs a tube inserted through the nose and down through the esophagus until it reaches the upper part of the stomach. A balloon at the tube's end is inflated and positioned tightly against the esophageal wall. It is usually deflated in about 24 hours. Serious complications can occur, the most dangerous being rupture of the esophagus. Recurrence of bleeding is common.

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Shunt Procedures for Uncontrolled Bleeding

Shunts are used for patients who are still bleeding in the esophagus after endoscopic sclerotherapy or who are bleeding in the stomach. Choices include the following:

Transjugular intrahepatic portosystemic shunt (TIPS).
A surgical shunt.

Shunt operations usually eliminate variceal bleeding, but encephalopathy and shunt failure are frequent complications. Experts do not recommend shunts as elective surgery for high-risk patients who are candidates for liver transplantation, since shunts makes this operation more difficult.

Transjugular Intrahepatic Portosystemic Shunt (TIPS). A transjugular intrahepatic portosystemic (or portal-systemic) shunt involves the following:

The patient only requires a local anesthetic and a sedative.
A long needle is inserted into the jugular vein in the neck and passed down through the vena cava, a large vein that conducts blood back to the heart. This serves to widen the vein.
The surgeon makes an incision in the hepatic vein in the liver and creates a connection to the portal vein.
A cylindrical wire-mesh stent is inserted into this connecting vein.
The stent now acts as a shunt, which reroutes blood around the scarred liver.

TIPS is a good choice for bleeding that is not controlled by endoscopy, particularly when it is performed shortly after a bleeding episode. It also reduces ascites.

It is not useful as the first choice for stopping an initial bleeding episode or for preventing rebleeding, however, since it poses a high risk for encephalopathy. This complication outweighs its benefits compared to endoscopy for initial treatment and to beta-blockers for preventing recurrence. Blockage or closure of the shunt can develop over time.

TIPS is generally recommended only for the following patients:

Cannot tolerate sclerotherapy.
Are unlikely or unable to comply with the repeated procedures necessary for sclerotherapy.
Have poor blood circulation.

Surgical Shunts. There are two types of surgical shunts:

A portal shunt, or portal systemic shunt. It was introduced in 1945 and was the first significant treatment for bleeding varices. It relieves pressure in the portal vein by surgically joining it to the inferior vena cava, a large vein that conducts blood back to the heart. It poses a high risk for encephalopathy and does not appear to improve survival, so is not used often.
A variation called the H-graft portacaval shunt is a partial shunt that is proving to be effective for treating bleeding. It controls bleeding in 90% of patients and has a lower encephalopathy rate than the complete portal shunt or TIPS. In fact, early studies report that it may have lower rates for transplantation and death than TIPS.
A distal splenorenal shunt (DSRS) preserves blood flow through the portal vein while relieving pressure on the varices by joining the left kidney vein to the splenic vein. (The splenic vein returns blood from the spleen and is one of two veins that form the portal vein.) Studies show that DSRS has similar mortality rates compared to the portal shunt but lower rates of encephalopathy afterwards. Patients with alcoholic cirrhosis fare worse with DSRS than nonalcoholic patients. It is probably best used as an elective operation in patients with good liver function who continue to bleed in spite of endoscopy.

Liver Transplantation

Liver transplantation may be indicated in the following patients:

Those who have developed life-threatening cirrhosis and who have a life expectancy of more than 12 years.
Patients with liver cancer that has not spread beyond the liver may also be candidates.

Survival rates after transplantation are similar among those who have hepatitis B, hepatitis C, or alcoholic liver disease. Current five-year survival rates after liver transplantation are between 60% and 80%. Patients also report improved quality of life and mental functioning after liver transplantation. Patients should seek medical centers that perform more than 50 transplants per year and produce better-than-average results.

At the time of this report, more than 17,000 patients were waiting for a liver transplant. Only slightly more than 5,000 transplants were performed in 2002. And, given the large number of people with hepatitis C, this situation will almost certainly worsen over the following years.

Liver Transplantation in Patients with Hepatitis. One of the primary problems with many hepatitis patients is recurrence of the virus after transplantation.

One study of patients with hepatitis C reported five-year risks of 80% for viral recurrence and 10% for cirrhosis. A 2004 study found that the hepatitis C virus recurs with more severity with liver donations from living donors than livers taken from cadavers.
Viral recurrence is also high in hepatitis B patients. Recurrence in hepatitis B has been significantly reduced with the use of monthly infusions of hepatitis B immune globulin (HBIg), with or without lamivudine. Life-long administration may be necessary. Lamivudine may also be helpful in preventing recurrence of hepatitis B after liver transplantation in children as well as adults.

Liver Transplantation in Autoimmune Liver Diseases. Patients who require transplantation for primary biliary cirrhosis are those who develop major complications of portal hypertension and liver failure or who have poor quality of life and short survival without the procedure. Patients with primary biliary cirrhosis may be at higher risk for early rejection of the transplanted organ than patients with other forms of cirrhosis.

Rejection is also high after transplantation for autoimmune hepatitis. In one study three-quarters of the patients experienced organ rejection, and half required retransplantation within a year in one study. Autoimmune hepatitis recurred in 25% of patients studied.

Liver Transplantation in Alcoholism. There is considerable controversy over whether liver transplantation should be performed in alcoholics with cirrhosis who are unlikely to abstain. One French study reported no differences in survival, transplant rejection, and other indicators of success and failure after transplantation between alcoholics and non-alcoholics and between alcoholics who abstained and those who relapsed after the procedure.