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 TIPS?

When portal hypertension occurs and is leading to either bleeding from mouth/anus or refractory ascites (fluid in the belly which is not resolving by diuretic medications), then TIPS is advised to reduce portal pressure. In many if not all patients this leads to partial/complete resolution of the problem as well as increases the transplant free survival.

In a normal person, the blood that enters the liver via the portal vein is purified/filtered of contaminants and necessary proteins and substances are added to it. After that, the blood is transported to another vessel (hepatic vein) that takes it from the liver towards the heart known as hepatic vein. In cirrhotic patients, because of scarred liver tissue, this process becomes difficult leading to increase in portal vein pressure.

One of the solutions to this problem is to change the clogged filter (meaning the liver) and get a liver transplant done. But it is not that easy for all patients because of lack of availability of a donor and cost issues. The other relatively cheaper and easier option is TIPS.

A transjugular intrahepatic portosystemic shunt (TIPS) enables bypass of part of the portal blood straight to the hepatic vein without going through the liver. This reduced the portal pressure drastically and reduces its sequelae like bleeding or ascites.

How does the procedure work?

You will be either sedated for the procedure or given general anesthesia. The interventional radiologist will puncture a blood vessel on the right side of your neck (the internal jugular vein) with a needle and will then insert a vascular sheath over a wire into the inferior vena cava. They will take specially designed catheters and tubes to reach the hepatic vein. Then using customized equipment (special needles), the interventional radiologist will puncture the portal vein through the liver and position a wire between the two veins. After the area between them has been dilated, a stent or stent graft will be placed between the portal and hepatic vein to create a lasting connection/shunt.

What are the risks?

The major risk after the TIPS procedure is that the blood that was going through the liver would now move unfiltered into the circulation. The main contaminant that is of significance is ammonia from the intestine which maybe delivered to the brain and may result in a condition called hepatic encephalopathy, the symptoms of which range from mild (alterations in thinking) to severe (confusion and coma).

Other potential complications include liver dysfunction due to its partial blood being shunted away from it or heart stress due to sudden increase in the amount and the pressure of the blood that it usually receives.

Because a liver suffering from cirrhosis is shrunken and the liver tissue can be very hard, complications like bleeding or liver capsule puncture are also possible during the procedure. However, all these are very rare with the available techniques, guiding imaging modalities and technical expertise.

Due to the shunt, there is an increased amount of blood flowing directly to the heart, which can cause heart failure. If you experience this, your doctor will decrease the blood flow through the TIPS.