optimal management of ascites: tips - denver, … management of ascites: tips ... the accumulation...

Optimal Management of Optimal Management of Ascites: TIPSAscites: TIPS

Michael A. Heller, MDMichael A. Heller, MDUniversity of Colorado Health Sciences CenterUniversity of Colorado Health Sciences Center

Department of Surgery Grand RoundsDepartment of Surgery Grand RoundsJanuary 22, 2007January 22, 2007

What is Ascites?What is Ascites?

The accumulation of free fluid within the abdominal The accumulation of free fluid within the abdominal cavity.cavity.

Normally < 150ml in abdomenNormally < 150ml in abdomen

PE findings:PE findings:Shifting dullness to percussion, fluid Shifting dullness to percussion, fluid wave, bulging flank.wave, bulging flank.Respiratory compromise lateRespiratory compromise late


Differential diagnosis:Differential diagnosis:Portal hypertensionPortal hypertensionHypoalbuminemiaHypoalbuminemiaMiscellaneous disordersMiscellaneous disorders


TransudativeTransudativeIncreased pressure in portal veinIncreased pressure in portal veinSAAG > 1.1SAAG > 1.1

ExudativeExudativeIncreased secretionIncreased secretionSAAG < 1.1SAAG < 1.1

Serous Albumin Serous Albumin ––Ascites Albumin = SAAGAscites Albumin = SAAG

What is Ascites? What is Ascites? -- PathophysiologyPathophysiology

Sequestration of fluid in the abdomen leads to further Sequestration of fluid in the abdomen leads to further sodium and water retention by the kidneys.sodium and water retention by the kidneys.

Ascites Ascites –– Treatment OptionsTreatment Options

Medical managementMedical managementBed rest, low sodium diet, fluid restrictionBed rest, low sodium diet, fluid restriction

15% response15% response

DiuresisDiuresisSpironolactone, furosemideSpironolactone, furosemide90% Response90% Response

Ascites unresponsive to medical management x Ascites unresponsive to medical management x 2 weeks termed 2 weeks termed Refractory AscitesRefractory Ascites

Ascites Ascites –– Treatment AlgorithmTreatment Algorithm

Refractory AscitesRefractory Ascites

10% develop spontaneous bacterial peritonitis10% develop spontaneous bacterial peritonitisCan be lethalCan be lethal

Hepatorenal syndromeHepatorenal syndromeDiscomfortDiscomfort50% survival rate at 2 years50% survival rate at 2 years

Treatment of Refractory AscitesTreatment of Refractory Ascites

Serial large volume paracentesisSerial large volume paracentesisTIPS (TIPS (transjugulartransjugular intrahepatic portosystemic intrahepatic portosystemic shunt)shunt)Surgical Surgical peritoneovenousperitoneovenous shuntsshuntsLiver transplantLiver transplant

Treatment Treatment –– Serial ParacentesisSerial Paracentesis

ProsProsImmediate reliefImmediate reliefRelatively low riskRelatively low riskCan be done as an outpatientCan be done as an outpatient

ConsConsDoes not resolve the ascitesDoes not resolve the ascitesRequires frequent follow upRequires frequent follow upDepletes protein storesDepletes protein storesIncreases risks of SBPIncreases risks of SBPDevelopment of renal failureDevelopment of renal failure

Treatment Treatment –– PortocavalPortocaval ShuntsShunts

ProsProsRelatively simple procedureRelatively simple procedureCan be done under local anesthesiaCan be done under local anesthesiaImprove renal functionImprove renal functionDecreases the need for serial paracentesisDecreases the need for serial paracentesisDecreased chance of SBPDecreased chance of SBP

ConsConsShunt stenosis and obstructionShunt stenosis and obstructionDisseminated intravascular coagulation (DIC)Disseminated intravascular coagulation (DIC)

Treatment Treatment –– PortocavalPortocaval ShuntsShunts

Effective at reducing ascites, but this comes at a Effective at reducing ascites, but this comes at a high risk.high risk.

Postoperative encephalopathyPostoperative encephalopathyNo improvement of shortNo improvement of short--term or longterm or long--term term survivalsurvivalHeart failureHeart failure

Franco et al., Arch Surg 1988

TIPSTIPS

Transjugular intrahepatic Transjugular intrahepatic portovenousportovenous shuntshuntPerformed by interventional radiologyPerformed by interventional radiologyCreates fistula between a hepatic vein and a Creates fistula between a hepatic vein and a portal vein.portal vein.

Initially created to treat recurrent variceal Initially created to treat recurrent variceal hemorrhagehemorrhage

TIPSTIPS

A sideA side--toto--side side portocavalportocaval shuntshunt

TIPS TIPS –– What Does it Do?What Does it Do?

Decreases the intrahepatic portal pressure, Decreases the intrahepatic portal pressure, thereby decreasing splanchnic vein pressure and thereby decreasing splanchnic vein pressure and decreasing ascites.decreasing ascites.

Initially became popular in the early 1990s, and Initially became popular in the early 1990s, and has since been tailored for specific patient has since been tailored for specific patient populations.populations.

TIPS ContraindicationsTIPS Contraindications

Initially high complication rates led more discrimination Initially high complication rates led more discrimination for those undergoing TIPS.for those undergoing TIPS.

AbsoluteAbsolute RelativeRelativePrimary prevention of variceal bleedingPrimary prevention of variceal bleeding HepatomaHepatoma

CHFCHF Obstruction of all hepatic veinsObstruction of all hepatic veins

Multiple hepatic cystsMultiple hepatic cysts Portal vein thrombosisPortal vein thrombosis

Unrelieved biliary obstructionUnrelieved biliary obstruction Platelets < 20Platelets < 20

Severe pulmonary HTNSevere pulmonary HTN Moderate pulmonary HTNModerate pulmonary HTN

Uncontrolled systemic infection or sepsisUncontrolled systemic infection or sepsis INR > 5INR > 5

Boyer & Haskal, Hepatology 2005

TIPS TIPS –– How ItHow It’’s Dones Done

TIPS vs. ParacentesisTIPS vs. Paracentesis

5 large scale randomized control trials 5 large scale randomized control trials completed to compare TIPS to paracentesiscompleted to compare TIPS to paracentesisRecent META analyses x2Recent META analyses x2


Albillos et al., Journal of Hepatology 2005


50% of TIPS patients 50% of TIPS patients were free of ascites at were free of ascites at one year, versus 12% of one year, versus 12% of patients who underwent patients who underwent paracentesisparacentesis

Deltenre et al, 2005


Mortality overall is unchanged by TIPS.Mortality overall is unchanged by TIPS.Salerno, 2004, included the largest population of Child C Salerno, 2004, included the largest population of Child C cirrhoticscirrhotics

No increase in liver No increase in liver related mortalityrelated mortality


Criticisms of current literatureCriticisms of current literatureNo double blinded studyNo double blinded studyHeterogeneous study populationHeterogeneous study populationMay be mortality difference based upon ChildMay be mortality difference based upon Child’’s s classificationclassificationQuality of life and cost has not yet been fully Quality of life and cost has not yet been fully evaluated.evaluated.


Overall cost of TIPS may be higherOverall cost of TIPS may be higher

Gine et al, 2002

TIPS TIPS vsvs Surgical ShuntSurgical Shunt

Surgical (Surgical (LaVeenLaVeen or Denver Shunt) considered or Denver Shunt) considered 33rdrd line treatmentline treatment

Direct comparison of TIPS Direct comparison of TIPS vsvs Surgical shunt shows Surgical shunt shows superiority of TIPSsuperiority of TIPS

Better control of ascitesBetter control of ascitesBetter longBetter long--term term patencypatencyFewer shuntFewer shunt--associated infectionsassociated infectionsNo difference in mortalityNo difference in mortality

Rosemurgery et al, Annals of Surgery, 2004

TIPS TIPS vsvs Surgical ShuntSurgical Shunt

Surgical shunting provides more immediate relief from Surgical shunting provides more immediate relief from ascites, while TIPS provides better longascites, while TIPS provides better long--term control.term control.

0

20

40

60

80

100

1 mo 3 mo 6 mo 12 mo 36 mo 60 mo

TIPS

Denver Shunt

p = 0.006 @ 60 months

Percent of Patients with Controlled Ascites

Rosemurgery et al, Annals of Surgery, 2004

TIPS TIPS –– Future DirectionsFuture Directions

New PTFENew PTFE--coated stent.coated stent.

Bureau et al, 2004

Current Current stentsstents have a have a 50% dysfunction rate 50% dysfunction rate at 1 year.at 1 year.New PTFENew PTFE--coated coated stent thought to stent thought to greatly reduce the rate greatly reduce the rate of dysfunctionof dysfunction

TIPS TIPS –– Future DirectionsFuture DirectionsProbability of Remaining Free of Shunt Dysfunction

TIPS TIPS –– Future DirectionsFuture Directions

Bureau et al, 2004

Probability of Shunt Dysfunction Probability of Developing Encephalopathy

Historical PerspectiveHistorical Perspective

GoretexGoretex use as a vascular graft done first here at use as a vascular graft done first here at the University of Colorado in animalsthe University of Colorado in animals

Arch Arch SurgSurg.. 1982 Oct;117(10):13671982 Oct;117(10):1367--7070

ConclusionsConclusions

TIPS is a relatively safe treatment for refractory TIPS is a relatively safe treatment for refractory ascites, though it does not affect overall survival ascites, though it does not affect overall survival and increases the risk of encephalopathy.and increases the risk of encephalopathy.The next generation of PTFE The next generation of PTFE stentsstents may may broaden the appeal of TIPS since it decreases broaden the appeal of TIPS since it decreases the risk of stent dysfunction.the risk of stent dysfunction.

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