Treating Portal Hypertension – TIPS & DIPS
Table of Content
Summary
Portal hypertension is a condition where high blood pressure develops in the blood vessels that transport blood from the digestive organs to the liver. This is usually caused by blockages that prevent normal blood flow, causing pressure to build up. The blockages force blood into other veins in the liver, stretching the walls of these vessels thin. The vessels can burst if the pressure is too high causing gastrointestinal bleeding, ascites and even kidney failure. The main cause of portal hypertension is liver cirrhosis, that causes chronic liver damage. This is usually due to alcohol abuse, hepatitis or fat buildup. Symptoms may not appear until complications arise, including jaundice, blood in the stools and cognitive impairment. Diagnosis involves blood tests, ultrasound scans and other imaging studies to evaluate blood flow and liver function. Treatment depends on the underlying cause and severity. A TIPS procedure can help treat portal hypertension by placing a stent as a by-pass from the portal vein to the hepatic vein, reducing pressure in the system. A DIPS procedure is a modification of the TIPS procedure in which the portal vein is connected to the inferior vena cava.
Introduction to Portal Hypertension
The portal vein and its branches transport blood from the stomach, intestines, pancreas, gallbladder and spleen into your liver – They form the portal venous system. The liver filters the blood delivered to it, and sends it back to the heart for recirculation. Portal hypertension is a condition caused by high blood pressure in the portal venous system. This can happen when a blockage occurs. The blockage causes more blood to divert through the other veins in the system, elevating blood pressure. The extra blood flowing through these veins stretches the walls of these blood vessels, weakening them. The vessels could burst if there is too much pressure, resulting in weakness, bleeding and leakage of fluids into the abdomen.
Causes and Symptoms of Portal Hypertension
According to liver specialists, the primary cause of portal hypertension is liver cirrhosis. This is permanent damage to the liver that results in the formation of scar tissue over many years. This scar tissue interferes with liver function and can lead to liver failure. Liver cirrhosis could be caused by hepatitis, which is inflammation of the liver. Hepatits can be induced by chronic alcohol abuse, excess fat storage in the liver, hepatitis C infection (viral) or hepatitis B infection.
Portal Hypertension could also be caused by other obstructions like blood clots and granuloma (tumours). Granuloma are masses of inflammatory cells that form during episodes of infection. The mass can obstruct blood flowing through the portal venous system, and could cause fibrosis if left untreated.
The symptoms of portal hypertension may appear only once complications have developed. However, if you have any liver disease that could cause cirrhosis, your chances of developing portal hypertension is high. The most noticeable symptoms of portal hypertension are blood in the stools, bloody vomit, bloated stomach, jaundice, swelling in the legs and feet and mental disorientation. These symptoms indicate that there is bleeding in the gastrointestinal tract, poor liver function and water retention.
Portal Hypertension – Complications
Portal hypertension is a dangerous condition if left untreated. The following complications can occur if the hypertension and liver damage aren’t treated:
Ascites – As fluid leaks into the peritoneal cavity from the enlarged, swollen portal veins, ascites begins to form. These are pockets of fluid that cause an uncomfortable swelling and feeling of bloating in the abdomen. They can suppress appetite and lead to bad digestion.
Gastrointestinal Bleeding – Enlarged veins in the portal venous system can rupture and bleed. This internal bleeding is most common in the oesophagus, as the blood vessels are close to the surface and have thin walls. The bleeding can lead to anaemia.
Hypersplenism – When there are obstructions in blood flow through the spleen, it becomes enlarged with excess blood. The enlarged spleen can become overactive, and causes blood cells to remain in the spleen, keeping them out of circulation. When this happens, the ability of the blood to clot reduces, because of low platelet count. Immunity is also compromised, as many white blood cells are held in the enlarged spleen.
Kidney Failure – Portal hypertension causes blood vessels to dilate. This can trigger narrowing of blood vessels in other parts of the body like the kidneys. According to kidney specialists, restricted blood supple can cause kidney failure, in a rate complication known as hepatorenal syndrome.
Mild cognitive impairment – The body responds to portal hypertension by creating new blood vessels to bypass the damaged liver. When this happens, the blood by-passing the liver doesn’t get filtered, leading to a build-up of toxins. The toxins accumulated can start to affect cognitive function, causing disorientation and reduced mental faculties.
Diagnosis of Portal Hypertension
Portal hypertension is hard to diagnose based on the patient’s symptoms alone. The doctor will begin with a medical history and check of current symptoms. Ascites or dilated veins in the abdomen and anus are important indicators of portal hypertension. Blood tests can also reveal a lot about the internal functioning of the liver. A comprehensive metabolic panel can provide data about liver and kidney function. A complete blood count can indicate if the spleen is overactive, and holding white blood cells and platelets. High levels of toxin in the blood are also a warning sign.
Doctors can use ultrasound imaging to detect blood flow through the portal vein and check the health of the stomach and spleen. They may also require a CT or MRI scan to get a clearer picture of the network of blood vessels in the liver, to identify obstructions and areas of narrowing or widening. If the patient has signs of gastrointestinal bleeding, the doctor may choose to investigate with an endoscopy. This is a procedure in which a camera attached to the end of a long tube is used to perform a visual exam of the inside of the oesophagus duodenum and stomach.
Treatment of Portal Hypertension
Portal hypertension may be reversible, if it is caused by an infection or a blood clot, by treating the root cause with medication. However, significant scar tissue in the liver, such as that caused by long-term liver cirrhosis, may cause persistent portal hypertension. In such cases, the objective of treatment is to manage the complications caused by the portal hypertension. Urgent complications are addressed first, and then a long-term management plan is devised.
If there is acute gastrointestinal bleeding, the doctor may perform endoscopic sclerotherapy. A medical solution is injected into the gastrointestinal tract during endoscopy, to reduce bleeding. Banding, i.e. tying bleeding varices with tiny rubber bands to stop bleeding, may also be performed if required. The patient will also be given medication to reduce blood pressure and dilate the blood vessels. If these techniques are not effective, the doctor may choose to perform surgical procedures to redirect blood flow through the portal venous system and relieve the pressure – TIPS & DIPS.
Transjugular Intrahepatic Portosystemic Shunt (TIPS)
The Transjugular Intrahepatic Portosystemic Shunt (TIPS) is an interventional radiological procedure in which a shunt or by-pass is put in place to connect two veins within the portal venous system. This is not an open procedure. It is a minimally invasive procedure, done using guiding visualisation from an X-ray machine. TIPS is performed through a small incision in the neck, connected to the jugular vein. The procedure is performed under anaesthesia or strong local sedation.
The procedure is performed by a radiologist with special training. The radiologist guides a catheter through the incision in the jugular vein into the liver. The catheter has a metal mesh tube (stent) with a tiny inflatable balloon within. A contrast dye is injected into the catheter for better visualisation of the blood vessels in the liver. Once in place, the balloon is inflated to place the stent. This creates a connection between the portal vein and the hepatic vein, by-passing the liver. After the stent is placed, the blood pressure in the portal vein is measured, to ensure pressure has been relieved. The catheter and balloon are then retracted, leaving the stent in place. The procedure usually takes about 60 to 90 minutes.
TIPS helps reduce the risk of internal bleeding in the stomach and oeshopahus in liver cirrhosis patients. TIPS can also reduce the accumulation of fluid in the abdomen and lungs. The procedure is minimally invasive, and hence has the benefit of a quick recovery time, compared to open surgery. However, the procedure also has certain risks. This includes the risk of infection or an allergic reaction to the material of the stent. Some patients with poor kidney function face a risk of worsening due to the use of the contrast material during X-ray. Other potential risks include fever, muscle stiffness around the incision site, and delayed stenosis. Patients with advanced liver disease have a risk of worsening liver failure after TIPS. As the liver is by-passed in this procedure, it can also lead to a build-up of toxins in the blood that disrupts normal brain function.
Direct Intrahepatic Portosystemic Shunt (DIPS)
The Direct Intrahepatic Portosystemic Shunt (DIPS) is a modified version of the TIPS procedure. It is a procedure to place a stent from the portal vein to the interior vena cava. This procedure is performed when the hepatic vein is inaccessible due to scar tissue, or if a prior TIPS procedure has failed. The DIPS procedure is also recommended to patients suffering from Budd Chiari syndrome, a condition in which veins carrying blood away from the liver become narrow or blocked.
The DIPS procedure uses a direct puncture method to create a connection between the inferior vena cava and the portal vein. The procedure is performed under the guidance of ultrasound fluoroscopy. The stent placement allows blood to by-pass the liver and its complex scar tissue formations and flow directly into systemic circulation in the inferior vena cava.
The DIPS procedure is more effective than TIPS in cases where the liver has suffered damage around the hepatic vein. It also creates a more direct path from the portal venous system to the inferior vena cava, relieving portal hypertension. However, the procedure has some risks as well. Bypassing the liver reduces the body’s ability to filter the blood and keep it free of toxins, leading to brain dysfunction. The procedure can also result in internal bleeding in the liver. Since it is a more invasive procedure, DIPS can also cause an infection to develop in the surgical wound.
For expert care in managing portal hypertension, trust the multidisciplinary team at Kauvery Hospital. With branches in Chennai, Hosur, Salem, Tirunelveli, and Trichy, we offer advanced treatments and compassionate care tailored to your needs. Reach out to us today for comprehensive support.
Frequently Asked Questions
What is portal hypertension?
Portal hypertension is high blood pressure in the portal venous system, which carries blood from the digestive organs to the liver. It is usually caused by liver cirrhosis or blockages in the liver’s blood vessels.
What are the common symptoms of portal hypertension?
Symptoms include gastrointestinal bleeding (vomiting blood or black stools), bloating (ascites), jaundice, swelling in the legs, and confusion due to toxin buildup.
How is portal hypertension diagnosed?
Doctors use blood tests, ultrasound, CT or MRI scans, and endoscopy to evaluate liver function and detect complications like varices or ascites.
What is the difference between TIPS and DIPS procedures?
TIPS (Transjugular Intrahepatic Portosystemic Shunt): A stent is placed to connect the portal vein to the hepatic vein, reducing blood pressure in the liver.
DIPS (Direct Intrahepatic Portosystemic Shunt): A modification of TIPS where the stent connects the portal vein directly to the inferior vena cava, used when TIPS is not feasible.
Who is the candidate for TIPS or DIPS?
Patients with severe portal hypertension, recurrent variceal bleeding, or ascites that do not respond to medication may be candidates. A specialist will determine suitability based on liver function and overall health.
What are the risks of the TIPS and DIPS procedures?
Potential risks include infection, liver failure, encephalopathy (brain dysfunction due to toxin buildup), internal bleeding, and allergic reactions to the stent material.
How long does it take to recover after a TIPS or DIPS procedure?
Most patients recover within a few days, but regular follow-ups are needed to monitor liver function and ensure the stent remains effective.
Can portal hypertension be prevented?
Maintaining liver health by avoiding alcohol, managing hepatitis infections, eating a balanced diet, and getting regular medical check-ups can reduce the risk of portal hypertension.
Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai (Alwarpet & Vadapalani), Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and pediatric trauma care.
Chennai Alwarpet – 044 4000 6000 • Chennai Vadapalani – 044 4000 6000 • Trichy – Cantonment – 0431 4077777 • Trichy – Heartcity – 0431 4003500 • Trichy – Tennur – 0431 4022555 • Hosur – 04344 272727 • Salem – 0427 2677777 • Tirunelveli – 0462 4006000 • Bengaluru – 080 6801 6801
