Better Rx for Cirrhosis-Linked Bleeding
WEDNESDAY, June 23 -- Patients with cirrhosis of the liver who suffer acute variceal bleeding have improved chances for survival if a shunt is used earlier rather than later, a new study finds.
Variceal bleeding occurs when the pressure in the portal vein -- the large vein that feeds the liver -- becomes too high and causes bleeding in the surrounding vessels. It is a common complication of cirrhosis, where the liver is damaged. The standard treatment for most patients is to give them drugs to lower the blood pressure and put bands around the bleeding vessels to control the bleeding.
"The early use of transjugular intrahepatic portosystemic shunt (TIPS) with covered stents improves survival of those patients with cirrhosis in whom the use of the current recommended therapy of acute variceal bleeding has a high probability of failure," said lead researcher Dr. Juan Carlos Garcia-Pagan, from the Liver Unit at the Hospital Clinic of Barcelona in Spain.
Until now, TIPS has only been used when the initial treatment for acute variceal bleeding fails, he noted.
"In this situation, TIPS usually controls the bleeding episode, but at that time the patient has suffered a marked deterioration in the liver function, usually has become infected and, despite the control of bleeding, the patients often die of liver insufficiency," Garcia-Pagan added.
However, using TIPS right away in these patients seems to dramatically improve outcomes, according to the report in the June 24 issue of the New England Journal of Medicine.
For the study, Garcia-Pagan's group randomly assigned 63 cirrhosis patients with acute variceal bleeding to standard treatment or TIPS.
During 16 months of follow-up, only one of the TIPS patients had uncontrolled bleeding, compared with 14 on standard therapy, the researchers found.
Moreover, the odds of not having uncontrolled bleeding at one year were 50 percent among patients on standard therapy, but 97 percent among the TIPS patients.
Survival was also better among TIPS patients. The odds of surviving at one year were 61 percent among patients receiving standard treatment, compared with 86 percent among TIPS patients, the researchers found.
"In patients at high risk of treatment failure, the early use of TIPS using covered stents needs to be considered," Garcia-Pagan said. "Centers unable to perform emergent TIPS should refer these patients to centers able to do so."
Dr. Eugene Schiff, director of the Center for Liver Diseases at the University of Miami Miller School of Medicine, said that "TIPS reduces pressure in the portal vein."
In the procedure, a catheter threaded though the jugular vein places a stent in the portal vein in the liver, Schiff explained. The stent connects the portal vein with the hepatic vein, so that blood can be shunted from the portal vein to the hepatic vein. "When you do that, you decompress the pressure in the portal vein, and the pressure drops dramatically," he said.
However, one complication of the procedure is a side effect called hepatic encephalopathy, which causes cognitive changes, because restricted blood flow in the liver allows toxins to accumulate.
"It's a neuropsychiatric state where you have anywhere from confusion to staggering to coma," Schiff said.
Schiff had expected many of the patients with early TIPS to develop this problem, but the researchers found that this side effect occurred in fewer TIPS patients (28 percent) than in patients receiving standard care (40 percent).
This study will get people to rethink the early use of TIPS, Schiff said. "Maybe, TIPS should be put in early. Now, they wouldn't do that," he said. "I think you are going to see earlier use of TIPS."
For more on cirrhosis of the liver, visit the U.S. National Institute of Diabetes and Digestive and Kidney Diseases.
Posted: June 2010