Internal bleeding from high blood pressure in the veins of the liver usually occurs in the esophagus or stomach.
Medication and endoscopic techniques, such as sclerotherapy, banding, and balloon tamponade, are the first action to stop venous bleeding.
If endoscopic techniques cannot stop the bleeding, minimally invasive or surgical shunt procedures are used.
The goal of portal hypertension treatment is to reduce high blood pressure in the portal vein, the blood vessel that connects the intestines and the liver, and prevent abdominal bleeding. Portal hypertension usually results from various types of cirrhosis (scarring in the liver).
Portal hypertension can cause tiny, thin-walled veins at the base of the esophagus and in the stomach to break and bleed. At this point they are referred to as varices. Physicians usually choose to control varices with medications or endoscopy. Endoscopy involves the insertion of a fiber-optic viewing tube into the gastrointestinal tract. Once the source of variceal bleeding is located, physicians use one of the following endoscopic techniques to control the varices:
Sclerotherapy, the injection of hardening agents;
Latex banding; and
Endoscopic techniques stop bleeding in 90 percent of patients. When medical and endoscopic treatments have failed to control bleeding, portal hypertension surgery may be indicated. The surgery creates an alternate pathway for venous blood flow, called a shunt, to relieve portal hypertension and bleeding varices. The surgical procedure that is most commonly used is called distal splenorenal shunt (DSRS).
Alternatively, a minimally invasive treatment called transjugular intrahepatic portosystemic shunt (TIPS) may be appropriate for some patients.
Although surgery and TIPS can relieve the complications of portal hypertension, liver transplantation offers the only way to halt the progression of liver disease.
WHEN IS IT INDICATED?
Portal hypertension surgery is indicated in patients who have severe hemorrhaging, or internal bleeding, due to varices that cannot be controlled.
Before treating portal hypertension, physicians order a variety of tests, including:
Computed tomography (CT) scan;
The physician will also order a blood test to determine whether the patient has coagulopathy, the failure to adequately form blood clots.
Patients may receive intravenous antibiotics, fluids, blood, or platelets if necessary.
WHO IS ELIGIBLE?
Surgery is not recommended for patients with severe liver disease who experience jaundice, loss of consciousness, and other liver failure problems.
Patients whose varices have not yet begun to bleed are also ineligible for portal hypertension surgery.
RISK FACTORS FOR POSSIBLE COMPLICATIONS
Risk factors for possible complications include:
Severe liver malfunction;
Cirrhosis because of alcoholism; and
WHAT TO EXPECT
In DSRS, a patient receives general anesthesia. A surgeon makes an incision in the abdomen to access the blood vessels around the liver and joins the splenic and left renal vein. This action reduces blood pressure in any esophageal varices.
The DSRS procedure generally takes 4 to 6 hours. The procedure has a 90 percent success rates at preventing bleeding from recurring.
POST TREATMENT GUIDELINES AND CARE
Following DSRS, the patient usually remains in the hospital for 7 days following surgery.
In the weeks and months following the procedure, the patient will receive blood tests to assess liver function and abdominal ultrasound to check for clotting in the shunt.
The physician may place the patient on a diet that is low in salt and protein and prescribe a laxative known as lactulose to minimize the accumulation of blood toxins.
Complications of shunt surgery for portal hypertension are common. Since the operation usually treats people with advanced liver disease, the expected mortality rate is from 20 to 75 percent, depending on the severity of the liver damage. Complications include:
Rebleeding of varices;
Bleeding from the surgical site;
Ascites (excess fluid in the abdomen);
Clotting in the shunt; and
Encephalopathy (a brain disease causing mild or severe delirium).
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