Dear Dr. Roach: My cousin has a significant degree of liver cirrhosis from a metastatic carcinoid. The carcinoid hasn’t grown in a couple of years, but the cirrhosis continues to progress. This is from micro carcinoid tumors plugging up the flow of blood on the capillary level.
He has now developed ascites. He was recently started on furosemide and spironolactone, and has a paracentesis (6-8 liters’ worth) about twice a month. He saw a radiologist about a Denver shunt versus a TIPS procedure. Apparently, the Denver shunt would improve the ascites in relatively short order, but it wouldn’t affect the progression of the underlying liver failure. The TIPS procedure, on the other hand, has the potential to stop the liver failure in time by taking care of the portal hypertension. That said, it comes with significant risk. It could lead to irreversible terminal liver failure. His “MELD” score is 20. Can you help us make sense of this?
Dear A.: This is quite complicated, but I’ll do my best.
A “TIPS” is a “transjugular intrahepatic portosystemic shunt,” which needs to be taken piece by piece. “Transjugular” means that the procedure on the liver is done through the jugular vein in the neck, not through open abdominal surgery — that’s a major advantage. A shunt is an artificial connection between two anatomic structures, in this case the hepatic vein and the portal vein inside the liver (“intra-” denotes “within”; “hepatic” is “of the liver”).
The liver has two circulations. One is the usual systemic circulation, through the hepatic artery. This is high-pressure (it is near systemic blood pressure, ranging from about 120 mmHg at peak to 80 mmHg minimum), and it supplies the oxygen that the liver needs. The liver also gets blood from the portal vein, which comes from the intestines. The liver removes toxins from this blood. The portal vein normally has a pressure of only 5-10 mmHg.
Blood from both of these vessels will end up in the hepatic vein, which goes back to the right side of the heart to be reoxygenated in the lungs.
Many liver diseases lead to high pressure in the portal system — portal hypertension. In your cousin’s case, the cancer cells have blocked many of the small blood vessels inside the liver, raising portal vein pressure. This high pressure can make fluid “back up,” and can cause ascites, a clear fluid inside the abdominal cavity. Paracentesis is just the removal of this ascites fluid via a needle through the abdominal wall. Six to eight liters at a time is an enormous amount of fluid.
A TIPS is used to reduce pressure in the portal vein by allowing the blood to pass directly from the portal vein into the hepatic vein. This often lowers the portal pressure so much that ascites no longer develops.
Denver shunts are surgically placed direct connections from portal vein to hepatic vein. They do the same thing as a TIPS procedure. They are seldom performed anymore due to high complication rates, but one indication for having it done is persistent ascites in someone who is unable to have a TIPS. A TIPS normally is not done for someone with a MELD score (a measure of liver disease) above 18.
Email questions to ToYourGoodHealth@med.cornell.edu.