GI: Surgical Treatment of Liver Cirrhosis

What is the sixth leading cause of death in patients between 35-54 years of age?

Liver cirrhosis is the sixth leading cause of death in patients between 35-54 years of age.

What is the ultimate solution to liver failure?

Liver transplantation is the ultimate solution to liver failure. It immediately normalizes portal pressure.

Most episodes of variceal hemorrhage occur when?

Most episodes of variceal hemorrhage occur < 2 years after discovery. The mortality of the first bleed is 25 to 50%.

Should surgical shunts be used for variceal prophylaxis?

No, surgical shunts should not be used for variceal prophylaxis.

Two complications of transjugular intrahepatic portosystemic shunt (TIPS) include (2):

1. shunt stenosis or occlusion (50% by two years). 2. encephalopathy.

The portal venous system is located between two capillary beds: (2).

1. splanchnic capillaries. 2. hepatic sinusoids.

Treatment for variceal hemorrhage that decrease flow and resistance include (2).

1. splanchnic vasoconstrictors. 2. portohepatic vasodilators.

Treatments for variceal hemorrhage that decrease resistance include: (2)

1. surgical portosystemic shunts. 2. percutaneous portosystemic shunts.

Reducing portal pressure reduces (2).

1. variceal wall tension. 2. the risk for variceal hemorrhage. * Variceal hemorrhage does not occur when portal pressure is reduce below 12 mmHg.

Agents that are used to control an acute variceal hemorrhage include: (5)

1. vasopressin. 2. nitroglycerin. 3. terlipressin. 4. somatostatin. 5. octreotide. Octreotide is primarily used today.

The risk of rebleeding from a variceal hemorrhage is increased within the first six weeks. However, the mortality of rebleed depends upon __________.

Child class

Child's Score

Child's Class A: 5 to 6 Child's Class B: 7 to 9 Child's Class C: 10 to 15

What is the best method by which to decrease rebleeding from varices?

Non-selective shunts are the best method by which to decrease rebleeding from varices.

How do splanchnic vasoconstrictors reduce portal pressure?

Splanchnic vasoconstrictors reduce portal pressure by decreasing portal venous blood flow.

Should TIPS be used for acute variceal hemorrhage?

TIPS is effective when medial management and/or sclerotherapy has failed.

Should TIPS be used to prevent rebleeding?

TIPS is more frequently utilized to prevent recurrent variceal hemorrhage.

Should TIPS be used for variceal prophylaxis?

TIPS should not be used for prophylaxis, as it has not been thoroughly studied.

The effectiveness of a selective shunt is diminished by ______.

collaterals (i.e. pancreatic siphon)

A major complication of non-selective shunts is _____.

encephalopathy

Any patient with cirrhosis and upper GI bleeding must have a ______.

endoscopy

Gastroesophageal hemorrhage occurs more commonly at the ________. Why?

gastroesophageal junction; In the area of the gastroesophageal junction, the veins are more superficial than in the rest of the esophagus. These varices protrude into the esophageal lumen and increase in diameter.

In jaundice, it is a bad sign when the liver becomes (texture).

hard This implies ESLD and a cirrhotic liver.

The portal vein carries blood to the liver from veins that drain the ________.

major splanchnic organs

Endoscopic therapy for variceal rebleeding is __________ effective than pharmacological management.

more

A selective shunt requires a _______.

patent splenic vein

In a patient with poor hepatic reserve:

perform a liver transplant

The treatment of cirrhosis is equivalent to the treatment of _______.

portal hypertension * Medical treatment is typically ineffective, but surgical treatment (i.e. liver transplant) is highly successful.

Portal hypertension leads to the formation of _______. What is the significance of this?

portal-systemic collaterals; Collaterals form by the dilation or pre-existing connections between the portal and systemic circulations. Under normal conditions, blood form porto-systemic connecting vessels flows into the portal venous system. This occurs because resistance in intra-hepatic However, under portal hypertension, blood flows away from the portal venous system through portosystemic collaterals. This occurs because collateral resistance in lower than that of the intrahepatic vessels.

The risk of variceal bleeding increases with _______.

size

Blood flow into the portal system is determined by _______.

splanchnic arterioles

Treatments for variceal hemorrhage that decrease portal flow include _______.

splanchnic vasoconstrictors

Cirrhosis

the fibrotic end result of a variety of mechanisms causing hepatocellular injury

Treatments for variceal hemorrhage that decrease variceal flow includes: (2).

1. selective surgical shunts. 2. endoscopic sclerotherapy.

Drawbacks of balloon tamponade include: (3).

1. rebleeding. 2. endotracheal intubation. 3. lots of complications.

How do you evaluate a patient with cirrhosis? (4)

1. Diagnose the underlying liver disease. 2. Define the portal venous anatomy. 3. Estimate functional hepatic reserve. 4. Identify the site of upper GI hemorrhage.

The treatment of variceal hemorrhage is based on methods that will decrease (2).

1. resistance. 2. flow.

How is a variceal rebleed prevented? (2)

1. Endoscopic therapy has been shown to prevent rebleeds. However, multiple sessions may be required to obliterate varices. 2. Propranolol is an acceptable alternative. * This combination is more effective than sclerotherapy alone. 3. Further therapy should be considered in patients with one episode rebleeding with hypovolemic shock or two episodes that cause a decrease HgB > 2 g/dl. If a patient has good liver function, a shunt can be used. If a patient has poor liver function, then TIPS can be used as a bridge to liver transplant.

What is the differential diagnosis of upper GI bleeding in a patient with portal hypertension? (6)

1. Esophageal Varice (80%) 2. Gastric Varices (20%) * About 90% of upper GI bleeding in patients with portal hypertension is due to portal hypertension. 3. Mallory-Weiss Tears (10%) 4. Gastric/Duodenal Ulcers 5. Portal Hypertension Gastropathy 6. Portal Colopathy

What are the two most common causes of death in patients with cirrhosis?

1. Hepatic Failure 2. Variceal Hemorrhage

What are the two major phenomena that contribute to liver cirrhosis?

1. Hepatocellular Failure 2. Portal Hypertension: Cirrhosis leads to increased hepatocellular resistance, which leads to portal hypertension. Portal hypertension can lead to variceal hemorrhage, hepatic encephalopathy, ascites, and hypersplenism.

How is the first variceal hemorrhage prevented?

1. Identify the patients at risk. 2. Counsel alcohol cessation. 3. Prescribe propranolol. No sclerotherapy or shunt.

What are two forms of endoscopic therapy for varices?

1. Injection Sclerotherapy 2. Variceal Band Ligation: Ligation is new, equally effective, and with significantly fewer complications.

What three pathological responses are required for cirrhosis to form?

1. Necrosis 2. Fibrosis 3. Nodular Regeneration

What are the five major treatments for variceal hemorrhage?

1. Pharmacological Agents 2. Endoscopic Therapy 3. Balloon Tamponade 4. Transjugular Intrahepatic Portosystemic Shunts (TIPS) 5. Surgical Intervention (Esophageal Transection, Portosystemic Shunt, or Liver Transplantation)

What are three types of non-selective shunts?

1. Portocaval Shunt: Without large liver reserve, a portacaval shunt can produce liver failure and encephalopathy. 2. Proximal Splenorenal with Splenectomy 3. Mesocaval Shunt: A mesocaval shunt is a shunt between the superior mesenteric vein and the IVC. One advantage of this shunt allows for easier liver transplantation due to maintenance of the hilum.

What are the three sites of resistance in portal hypertension?

1. Prehepatic: i.e. isolated venous thrombosis (portal vein or splenic vein) 2. Intrahepatic: i.e. cirrhosis 3. Posthepatic: i.e. hepatic vein occlusion (Budd-Chiari)

What are two curative surgical treatments for portal hypertension?

1. Splenectomy: This is used in cases of isolated splenic vein thrombosis. 2. Liver Transplant: This is used for intrinsic liver disease.

How is an acute variceal hemorrhage treated? (3)

1. The goal is to control the acute bleed and prevent the rebleed. So, endoscopic therapy (i.e. sclerotherapy or band ligation) is preferred. 2. Octreotide can be prescribed if endoscopy is delayed. Further, it reduces risk of rebleeding after initial sclerotherapy. 3. If not controlled, then a balloon tamponade, TIPS, or shunt should be considered.

Symptoms of Cirrhosis (7)

1. Weight Loss 2. Malaise 3. Weakness 4. Palmar Erythema 5. Spider Angiomas 6. Testicular Atrophy 7. Gynecomastia

Laboratory studies for portal hypertension may reveal (9):

1. anemia. 2. leukopenia. 3. thrombocytopenia. Thrombocytopenia is a predictor of varices. 4. coagulopathy. 5. hypoalbuminemia. 6. hypokalemia. 7. hyperbilirubinemia. 8. hyponatremia. 9. metabolic alkalosis.

Patients with cirrhosis may have a history of (3).

1. chronic alcoholism. 2. hepatitis. 3. complicated biliary disease.

Risk factors for variceal hemorrhage include: (8)

1. continued EtOH abuse. 2. level of liver decompensation. 3. large varices. 4. red wale markings on varices. 5. presence of gastric varices. 6. reversal of portal flow. 7. ascites. 8. Child class C.

Current indications for TIPS include: (3)

1. continued variceal hemorrhage following sclerotherapy/banding. 2. prevention of rebleeding in patients awaiting liver transplant. 3. prevention of rebleeding in a patient. who is neither a candidate for a surgical shunt nor liver transplant due to expected short survival.

Gastroesophageal varices are formed by dilation of (2).

1. coronary (esophageal) veins. 2. short gastric veins.

Shunts should be considered in patients:

1. distant from tertiary care center. 2. intolerant/refractory/noncompliant with pharmacologic or endoscopic therapy. 3. with gastric varices/portal hypertensive gastropathy.

Complications of sclerotherapy include: (2)

1. esophageal ulcers 2. esophageal strictures.

According to Ohm's law, the portal pressure is increased by (2).

1. increased portal blood flow (Q) (i.e. fistula). 2. increased resistance to portal blood flow (R).

In a patient with good hepatic reserve: (2)

1. initially perform sclerotherapy. 2. rescue with a shunt or devascularization or transection.

Signs of hepatic functional decompensation or advanced portal hypertension include: (6)

1. jaundice. 2. ascites. 3. firm irregular liver edge. 4. dilated abdominal wall veins. 5. impairment mental status. 6. presence of asterixis.

Agents that are used to prevent variceal hemorrhage include: (4)

1. non-specific β-blockers (i.e. propranolol). 2. nitrates. 3. spironolactone. 4. low Na+ diet.

Agents that are used to prevent variceal rebleed include: (2)

1. β blockade. β blockade is as effective as sclerotherapy. 2. β blockade and nitrates. This combination is more effective than sclerotherapy.

What is a non-selective shunt?

A non-selective shunt is a surgical therapy for varices that completely decompress the entire portal system and diverts all portal flow away from the liver.

Should surgical shunts be used for acute variceal hemorrhage?

A portocaval shunt used to be the first line therapy for an acute variceal hemorrhage, as these shunts effectively controlled variceal hemorrhage. However, the mortality rate is high (20-55%) and these patients often had accelerated death from liver failure that correlates with the Child's class.

What are three perks of a selective shunt (distal splenorenal shunt)?

A selective shunt: 1. preserves hepatic portal perfusion. 2. stops variceal bleeding. 3. minimizes progression of liver failure/encephalopathy by compartmentalizing the portal venous circulation. This maintains portal venous flow to the liver.

What is necessary for gastroesophageal varices to form?

A threshold of portal pressure is necessary for gastroesophageal varices to form. Patients with gastroesophageal varices have a hepatic pressure gradient > 10 mmHg, and patients with bleeding gastroesophageal varices have a hepatic pressure gradient > 12 mmHg.

Should surgical shunts be used for variceal hemorrhage rebleeding?

An elective shunt can be used to prevent recurrent variceal bleeding. In appropriately selected patients, surgical shunts reduce risk of recurrent bleeding, maintain stable liver function, and obviate repeated endoscopic procedures.

What is the most lethal complication of portal hypertension?

Hemorrhage from gastroesophageal varices is the most lethal complication of portal hypertension.

How does a selective shunt work?

In a selective shunt, the splenic vein is divided and connected to the renal vein. This compartmentalizes the varices.

What is the use of injection sclerotherapy?

Injection sclerotherapy is effective in acute bleeding and prevention of re-bleeding. However, the complication rate of sclerotherapy is high (18% with a 2.7% death rate).

When does rupture of a varix occur?

Rupture of a varix occurs when the expanding force exceeds the vessel's maximal wall tension.

How are patients awaiting liver transplatation treated?

Since there is an unpredictable waiting period, alternative measures will have to be used to arrest variceal hemorrhage by optimizing the medical condition for the patient. In patients in which liver transplant is not required for several years (Child's A), a surgical shunt can be used. In patients in which liver transplant is required for several years (Child's B and C), TIPS can be used as a bridge.

What is the definitive therapy for patients with advanced liver disease (Child's B and C)?

The definitive therapy for patients with advanced liver disease (Child's B and C) is liver transplant.

MELD/PELD Score

The higher the MELD score, the faster the transplant.

What is the major challenge in the treatment of cirrhosis?

The major challenge in the treatment of cirrhosis is determining which patients require palliative care and which patients require definite care (i.e. liver transplant).

What is the most common mechanism by which the portal pressure increases?

The most common mechanism by which the portal pressure increase is usually by conditions that increase resistance to blood flow (i.e. cirrhosis).

What is a transjugular intrahepatic portosystemic shunt (TIPS)?

Transjugular intrahepatic portosystemic shunt (TIPS) is a non-selective side to side portacaval shunt plus a shunt to the suprahepatic IVC. It has been used extensively and has drastically reduced the number of surgical shunts performed.

What is the effect of an increase in portal blood flow on portal pressure in normal patients compared to cirrhotic patients?

Under normal conditions, an increase in portal blood flow produces small or no increase in portal pressure. This is due to passive dilation of low-resistance intra- and extrahepatic vessels. However, in cirrhosis, small increases in portal flow through the liver produces large increases in portal pressure. This occurs because intrahepatic vessels are unable to dilate as in the normal liver, and the extrahepatic vessels are maximally dilated.

What is the most common manifestation of portal hypertension promoting liver transplant evaluation?

Variceal hemorrhage is the most common manifestation of portal hypertension prompting liver transplant evaluation.

Can endoscopic therapy be used for variceal hemorrhage prophylaxis?

Yes, endoscopic therapy be used for variceal hemorrhage prophylaxis. However, sclerotherapy increases ulceration. So, prophylactic sclerotherapy is not used.

Portal pressure reduction by a splanchnic vasoconstrictor is potentiated by adding _______.

a venodilator (i.e. nitroglycerin) * The vasoconstrictor acts by reducing blood flow while the vasodilator acts by reducing resistance.

A selective shunt is contraindicated in patients with ______.

ascites