My father has hepatitis C and is retaining water around the liver and abdominal area. The doctor who removed the last batch of fluid told him of a new procedure that might help. My father is not eligible for a transplant because of advanced heart disease. This new procedure is called TIPS and sounds like some kind of liver bypass. Do you have any information on this?
A TIPS is a relatively recently developed shunt used for treating some of the complications of cirrhosis. It stands for transjugular intrahepatic portosystemic shunt. Understanding how it might be effective for your father requires a little background in the anatomy of the liver, and what happens when one develops cirrhosis.
There are several different kinds of cirrhosis, and the hepatitis C you mention has become one of the more common causes world-wide. Although cirrhosis from various causes may look different when seen on the surface of the liver or in a biopsy under the microscope, the complications that cirrhosis produces are much the same in each of the types. A build-up of fluid in the abdomen, termed ascites, is a common complication. Bleeding from varicose veins in the esophagus, which may be massive, is another, and TIPS is commonly used to treat this latter complication.
Cirrhosis is a type of fibrosis or scarring that develops in the liver after it has been damaged. The damage can be from alcohol, hepatitis, autoimmune hepatitis, hemochromatosis or other less common causes. As the fibrosis progresses, it slowly shrinks and hardens the liver, and tends to reduce the blood flow passing through it from the intestines. This blood flow, which comes from the spleen as well as the intestines, is called portal blood flow, since it passes through the portal vein. It probably developed to allow the liver the first crack at metabolizing and detoxifying foods that we eat, since all of the blood from the intestines passes through the portal vein into the liver before being pumped out to the rest of the body.
Constricting that blood flow raises the pressure in the portal system; and since the blood is not able to maintain a high volume flow through the liver, it establishes other connections to the regular venous system returning blood from the body to the heart. This regular system, the veins from your arms, legs, kidneys and so on, is termed the systemic venous system. These new connections occur in areas where there are already small connections between the portal and the systemic systems. These are in the esophagus and in the rectum.
These small connections become massively enlarged to accommodate the blood flow, and this produces varicose veins. Varicose veins in the esophagus are particularly prone to pop and bleed. A portosystemic shunt is an opening that allows a large volume flow to pass easily from the portal system into the systemic blood system, reducing the pressure in the portal system, and therefore reducing the likelihood of bleeding from the varicosities.
Portosystemic shunts used to be done with open surgery, by connecting the splenic vein, part of the portal system, to the vena cava, part of the systemic system. The TIPS technology allows a device to be introduced through the jugular vein, and passed down into the liver and forced into a large branch of the portal vein, thus establishing the shunt. This is much less invasive than the old surgical shunts, and therefore better suited for someone who is at high risk.
Whether this would be the best treatment for your father, I really couldn’t say. A standard text mentions doing a TIPS for ascites only if medical treatment or removing fluid through a needle has not been successful. The standard medical treatment would be to restrict salt and water, and if that doesn’t cause the excess fluid to be excreted, to give spironolactone. If spironolactone alone doesn’t do the job, a diuretic such as furosemide is added. In many centers large volumes of the fluid may be removed through a needle in the abdomen, followed by albumin (a protein of the blood plasma) given intravenously, since such patients often have low levels of albumin in the blood which contributes to the development of the ascites.
In difficult cases a different kind of shunt called a peritoneovenous shunt may be considered. This is a tube with a one way valve connecting the peritoneal space where the fluid is collecting to a systemic vein. Fluid goes from the abdomen into the blood, and is then excreted by the kidneys. The one-way valve prevents blood from flowing back into the peritoneal space.
These techniques are usually tried before a TIPS is placed because a TIPS can produce serious complications. Ten to thirty percent of people who have a TIPS placed will develop hepatic encephalopathy, a type of pre-coma/coma produced by toxins that the liver is unable to remove from the blood stream, and treatment is unable to reverse this in about five percent of cases. In about thirty to fifty percent of cases the shunt closes down within a year. Although the peritoneovenous shunt can also close down and require revision, it does not increase the risk of encephalopathy. In someone who has bled from esophageal varices, one may have no alternative to placing a TIPS; but, for ascites, there are alternative treatments that can be tried first.
Because of this complication, you should certainly talk with your father’s doctors about the other treatments being pushed to the limit before proceeding with the TIPS, since as far I can tell, your father has not had bleeding from varices.