WEDNESDAY, June 23 (HealthDay News) -- 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
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
"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 ...