What is cirrhosis?

Cirrhosis is a condition when healthy liver tissue is replaced by scar tissue. This hampers the normal liver function. It is a long-term / chronic condition. The damage to your liver builds up over time. When you have cirrhosis, scar tissue slows the flow of blood through the liver. Over time, the liver can’t work the way it should. In severe cases, the liver gets so badly damaged that it stops working. This is called liver failure. When this stage is not reached, the liver goes through various phases of compensation and decompensation.

What are the common causes of cirrhosis?

The most common causes of cirrhosis are:

• Hepatitis and other viruses
• Long-term alcohol abuse
• Nonalcoholic fatty liver disease (this happens from metabolic syndrome and is caused by conditions such as obesity, high cholesterol and triglycerides, and high blood pressure)

There are multiple other less common causes of cirrhosis rangin from rare autoimmune diseases to biliary problems and toxic chemicals. Some of these are even hereditary like alpha1-antitrypsin deficiency and cystic fibrosis.

How is cirrhosis diagnosed?

The healthcare provider reviewing the patient can diagnose cirrhosis by combination of clinical examination, blood tests (LFT, INR, Viral markers), Fibroscan and radiological investigations.

How is cirrhosis treated?

Cirrhosis is a progressive liver disease that happens over time. It is rarely reversible completely by treatment. Most of the treatment aims to slow down the buildup of scar tissue and prevent its sequelae.

Your treatment usually includes a healthy diet plan, medications to destroy underlying viruses, withholding consumption of alcohol or illegal drugs and managing any health problems that happen because of cirrhosis

However, if the cirrhosis has progressed to severe proportions or hepatic failure has ensued, liver transplantion may be needed.

What are possible sequelae or complications of cirrhosis?

Cirrhosis can cause other health problems such as:

• Portal hypertension:- One of the main functions of the liver is to purify the contaminated blood that comes from spleen (an organ on the left side of the abdomen below the ribs) and intestines. The portal vein (main blood vessel of the liver) carries blood from your intestines and spleen to your liver. Cirrhosis slows the normal flow of blood. This raises the pressure in the portal vein. And is known as portal hypertension.The effect of portal hypertension is seen in two ways; 1) Ascites – Free fluid filling your belly and causing distension. 2) Varices- natural collateral blood vessels formed to relieve the raised pressure of portal vein. But unfortunately these are not used to handling such large flow pressure and sometimes burst resulting in blood loss via vomiting or stool route
• Kidney disease or failure.
• Easy bruising and severe bleeding:- his happens when the liver stops making proteins that are needed for your blood to clot.
• Liver cancer:-Patients with cirrhosis and specially hepatitis virus be screened with an imaging test (for instance, ultrasound) and sometimes blood tests and Triphasic liver CTs, every 6 months as these patients are more prone than normal individuals to develop liver cancer (known as HCC- hepatocellular cancer).

What is BRTO?

One of the major possible complications of portal hypertension is gastric variceal bleeding. Gastric variceal bleeding describes the bleeding that occurs when dilated vessels in the stomach rupture, and is associated with high morbidity and mortality rates. While TIPS does work for many of these patients, there are areas where it doesn’t. Even reducing portal pressure does not reduce these low pressure shunts as they become accustomed to working at lower pressures. Hence inspite of TIPS, they may not reduce. For such patients, the eastern World invented this alternative technique BRTO.

BRTO is a minimally invasive technique that is used to treat gastric variceal bleeding. The procedure involves blocking the dilated vessels, reducing the risk of rupture. It can be used in addition to or as an alternative to TIPS for treatment of such gastric varices. While it may not treat the root cause of the varices (high portal pressure), it may sometimes be the only alternative in elective/emergency situations.

How does the procedure work?

The interventional radiologist will insert a balloon catheter (a thin, flexible tube with a tiny balloon at one end) through a vein in your thigh or neck and guide the catheter to one of the large blood vessels (inferior vena cava) using fluoroscopy for guidance. This vessel gets blood from all the lower organs of the body including liver and kidneys. The catheter is then directed to the gastrorenal or gastrocaval shunt and the balloon is expanded to block the shunt.

The interventional radiologist will then perform a venography, which is a type of imaging technique in which X-rays are used to see the vessels clearly. This will allow the interventional radiologist to confirm exactly which vessels need to be treated and if there are any other abnormal or dilated vessels which have not previously been identified. A medication will then be injected into the dilated vessels through the catheter, until they are completely filled. This medication will remain in the vessel for a short period of time, and will then be removed under fluoroscopy.

Another venography will then be performed, to confirm that the blood flow in the shunt has stopped. Finally, the balloon will be deflated and the interventional radiologist will withdraw the catheter.

Why perform it?

You may be advised to undergo this procedure if you are at risk of or already have gastric variceal bleeding and hepatic encephalopathy as well as a gastrorenal shunt. Hepatic encephalopathy refers to the worsening of brain function that is caused by a damaged liver.

Although TIPS has been considered the standard therapy for gastric varices that have been unresponsive to other treatments, recent reports have stated that BTRO is a less invasive and more effective way to manage varices than shunt surgery or TIPS. TIPS does not always cause the disappearance of gastric varices, while BRTO can in most cases completely destroy these vessels.

BRTO has tended to be used to prevent gastric variceal bleeding. It is also an effective therapy for sclerosis (narrowing) of new portosystemic shunts with the additional complication of hepatic encephalopathy. One of the greatest advantages of BRTO is its preservation of liver function. Moreover, the increase of blood flow in BRTO can also improve liver function in cases where the patient has cirrhosis (scarring of the liver).

What are the risks?

Procedure-related complications are minor and include bleeding and infection. In rare cases, the blockage of the blood to the gastric varices can further increase the pressure on the liver, causing damage to the liver.

The most serious complications of the procedure, however, are related to the medication used to block the vessels, which are called sclerosants. Inflow of a relatively large amount of sclerosant can lead to serious complications. These complications include pulmonary embolism (blockage in a lung’s main artery), fluid in or around the lungs, hypersensitivity, fever, problems with blood flow to the heart and the formation of small blood clots in vessels throughout the body. Few sclerosants can also cause haemolysis, which is the rupturing of red blood cells. To prevent this from occurring, only a low dose of the medication is used.