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89592 tn?1391274422

TIPS Procedure

I am 70 yrs old..dxd with cirrhosis in 2012.  I have had more rectal bleeding from rectal varices.  I saw a colorectal surgeon and he doesnt want to do anything for risk of infection.  The gastro hep suggested wearing a DEPENDS and living with it as it is..bleeding alot after lots of bms...or getting TIPS done.  It seems to me that Tips is risky.  I guess my rectal varices are impressive and I have hems also. I dont know if I want to chance TIPS.  my meld is 8...  Looks like the propranolol is not doing its job with the portal hypertension.  Has anyone has Tips and how did u do?  I do not have ascites.   thank you.  
4 Responses
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683231 tn?1467323017
As you have been diagnosed with cirrhosis you really need to be under the care of a hepatologist associated with a transplant center. Such a doctor would be best able to guide you with treatment questions I’m not sure you are getting good advise. Not sure how a TIPS procedure would even be under discussion at this point seems very premature to me bearing in mind I am not a medical professional I’m just a patient like yourself.

Why are you taking a beta blocker how were you diagnosed with portal hypertension?

My MELD is 6 I was diagnosed with cirrhosis with liver biopsy in 2008. In 2012 I had developed esophageal varicies which I had banded because I could not take a beta blocker as the goal of beta blocker treatment is to reduce heart rate below 60 bpm and my heart rate is already lower than that.

Anyway my suggestion is to see a different doctor for a second opinion specifically a hepatologist who is working in a liver transplant practice. That is the kind of doctor I have been seeing.

Found some info

Reasons to have TIPS performed:

“Accepted indications for TIPS include the following:

Uncontrolled variceal hemorrhage from esophageal, gastric, and intestinal varices that do not respond to endoscopic and medical management.
Refractory ascites.
Hepatic pleural effusion (hydrothorax)”

Reasons to NOT have TIPS performed:

“Contraindications for TIPS

Primary prevention of variceal hemorrhage.
Congestive heart failure.
Severe pulmonary hypertension.
Severe tricuspid regurgitation.
Active biliary obstruction.
Sepsis.
Multiple hepatic cysts or Caroli's disease.”

Per above it is not used to prevent variceal bleeding it is used to treat uncontrolled variceal bleeding that cannot be controlled by endoscopy and medical management.

I would get a second opinion
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3 Comments
Hi Flynn..thank you for answering my question.  I do have a hepatologist at Cleveland Clinic.  His reply to me for the rectal varices bleeding is to WEAR A DEPENDS or GET THE TIPS PROCEDURE ..those are your only 2 options.  I said to him...well with the rectal varices I have bm's so thats not a good solution.  The nurse pracs reply to me when I talked to her about it was..WELL, YOU CAN TRY MAYO AND SEE IF THERE ARE ANY THINGS THEY CAN DO.  Thats when I went to see an Interventional Radiologist at another hosp and the dr suggested TIPS but knew my concern with HE.  He then said he could do an embolization...similar to BRTO..that would stop the rectal bleeding.  I was against the TIPS because of risk of HE (I live alone) right sided heart failure and worsening liver.  My meld is 8 and everything is within normal limits at the time except for a few labs..the only complication I have is the rectal varices and portal hypertension.  the radiologist is not sure if the bleeding is from the hems or the varices.  I do have portal hypertension and am taking propranolol.  Had gr 2 non bleeding esophageal varices that cc banded..my local gastro didnt think they needed banding he said they were small..but drs at CC said they were large and they band all gr 2 varices as a preventative.  I was dxd with cirrhosis in 2012. My heart rate with 110 mgs prop in am and 110 in pm is around 65-70.  I wish I could get it lower.    My only issue is with the rectal variceal bleeding.. or hems...  so I am hoping the embolization on May 3rd will help me.   though the radiologist said they will have to keep an eye out for more varicosities.    thank you.... i dont know much about the embolization..but glad there was another option. Tips seemed too soon for me.  I know dr like to eval the pt for transplant after the TIPS procedure and I am not a candidate for the tx because of my long standing rheum arth, lung disease and age.  
Ok well good you are seeing a hepatologist at CC

I’m still a little surprised they would suggest TIPS seems early to me but I’m not a doctor. Maybe you should try the Mayo Clinic if that is an option for you sounds like he doesn’t have the best bedside manner from what you described.

From my experience most doctors go with the lowest level of intervention and go up if needed so hopefully the embolization will do the trick.

I’ve have had issues in the past with  hemorrhoids I guess the best is to try to avoid them by keeping properly hydrated, getting enough fiber in your diet and maybe taking a stool softener like Docusate (dioctyl sulfosuccinate) to try to prevent reoccurrence

Even if your not eligible for transplant a doctor at such a facility is still the best level of physician to follow your case.

About liver enzyme tests, if nothing is currently injuring your liver your liver enzymes should be normal even with liver cirrhosis. Our liver enzymes were elevated when we had hep c because our livers were under attack every day from hep c.

My only blood test that isn’t normal is my platelet count which was about 80 to 90 before I was cured of hep c. A year after being cured they were about 110 and now 4 years after cure my platelet count is about 125 still below normal of 150 but improving. My low platelet count is basically a symptom of portal hypertension so I’m hoping my improving platelet count means my portal hypertension may be improving a little.


Best of luck
Hi Flynn..so glad you wrote.  the hosp that is doing the embolization is Cleve Clinic Akron General. I dont think my hep has a good bedside manner either.  I kept apologizing since he called me (I asked for the call) and when I got off the phone, then I thought he was a bit rude.  I kept saying..well, its a big decision, I live alone..and wondered why I was apologizing.  I was shocked they would go right to the TIPS also.  i have asked gastros, the hep and np about other options before getting the TIPS done.  cc np said to go to Mayo..maybe they can find something that will work for you.  I imagine they were sick of hearing about all my bleeding of the hems or varices or both.  The interventional radiologist and also Dr S from NY suggested the embolization.  I dont know alot about it but will do some searching.      
It doesnt matter if I add fiber or have loose stools...I will bleed after many bms.   Have used metamucil, questran, imodium, miralax, colace, etc etc  I hope the embol will help me.  
I am hoping the hep now will retire and I am able to see someone else at CC.  Not sure how hard that would be since I am not happy with the care I receive from him.  
My platelets stay around 110 to about 120...  my issue is that my albumin is lowering but could be many reasons for that.  why is your plat count improving?  because the hep c is gone?  I wish I could get my albumin in a normal range and the platelets also..though plats sometimes do hit normal once in awhile.  I have rheum arth too and take xeljanz and prednisone for it.  36 plus years with r/a so I am a mess.  mtx did a number on my liver also....
do you know much about embolization?  
Hope you're having  a good day.....   sunshine in Ohio.  
683231 tn?1467323017
My doctor believes the improving platelet count is a sign my liver is improving post treatment. I don’t personally know anything about embolization.

You don’t have to wait for your doctor to retire. You are the customer if you don’t like your doctor vote with your feet is my suggestion. If you have bad service at a store or restaurant do you go back?

Or just go to the Mayo if that is an option then you are at an entirely different practice.

You don’t have to accept a doctor you don’t like working with. Just my thoughts....
Helpful - 0
1 Comments
Hi Flynn..I am wondering how hard it would be to switch to another hep at cleveland clinic.  I am not able to go to Mayo.   its  a little different with drs.  I  switched to another rheumy in the same practice and it was difficult but i will look into doing it with this hep.  so glad you platelets are going up..thats wonderful to hear.    Good for you... best wishes.
I so appreciate your replies..thank you so much.
683231 tn?1467323017
I found numerous articles on treating rectal varicies none of which reference TIPS

Try googling retail varicies treatment.

I would change to the Mayo
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5 Comments
I am going to CC AKRON GENERAL HOSP.  The interventional radiologist is suggesting the embolization which I will have on May 3rd.  I am not going to have the TIPS.  They wanted to schedule it for April 24th and I said no.    I've read so many articles on the rectal varices and bookmarked all the treatments...which is why I was so shocked by the suggestion of TIPS by the hepatologist.  I cant go to Mayo..I dont have the means to do that.  I have asked my hep about the embolization, sclerotherapy, banding, brto, etc a year or so ago.  I am not going to jump into the tips procedure at this time.  I will let you know how the embolization went after I have it done.  thank you so much....
Darn I was hoping Mayo was an option for you. You don’t have to stick with current hepatologist if it’s not working for you. Basically he is your employee you pay him for services rendered.

Best of luck with the procedure please stay in touch
Hey flyinlynn.
As you know, I am 72yo and also have emphysema and a heart stent. Would I be eligibly for a transplant. I was thinking about a donor transplant also. I have 1 sister and 2 half sisters but they are all older than me. My whole sister also has medical issues.
Hey Harry my answer below was intended for you but I didn’t realize you weren’t the original poster on the conversation so I was referencing some of their information re MELD score. But most of the comments I made would apply to anyone seeking a transplant.

Do you know your MELD score Harv? Have you found the link to start your own new question?
Darn spell auto correct I was trying to type Harv but I  just noticed my phone corrected to Harry
683231 tn?1467323017
Well that would be a good question for your doctor associated with a transplant center. But I kind of think maybe no. They want your likely good of survival of the procedure to be likely for several years post.

You need a MELD of at least 15 to be listed and then you go through a health, psychological, and social assessment. Health as to the rigors of the procedure, psychological to assess the psychological impact on you of the procedure and the likelihood of your being capable of  and willingness to be compliant with a lifetime of anti rejection drugs. And social you need to have a family member available full time during your initial recovery post treatment. Not all those with a MELD above 15 will be listed because of the above.

Also most transplants occur with a MELD score around 30 or higher due to the availability of organs. Transplants are allocated to the sickest patients first. So centers will have lower average scores depends on the availability of organs. I have read that at any given time there are about 6,000 people waiting for transplant and only about 1,600 performed annually. Sadly people die waiting for transplant.

With a MELD of  8 you are not eligible to be on the list. They want your odds of dying from liver disease to be higher than your odds of dying from the transplant.

At this point you want to work on being as healthy as possible our goal is to die from something other than liver disease. With cure of hep c we do have the possibility of our livers improving with time. They say about 50% of people with cirrhosis before curing hep c may regress to lower fibrosis scores. It all depends on how much damage had already occurred before cure and how we treat our livers post hep c. So like for myself my BMI is a little high and I’m getting indications of fatty liver I need to get down to a normal weight to prevent additional liver damage from fatty liver. So a good diet and exercise as tolerated and allowed by our doctors is what we need to do if we want to live a normal life span. Of course this is just general information and may not apply to your situation.
Helpful - 0
3 Comments
Thats a great meld score Flynn.....
Well mine is 7 due to my INR of 1.1 if my INR was 1.0 my MELD would be the lowest possible of 6

Yours is good at 8 also.

One can’t get on the transplant list with a MELD of less than 15do I guess we are both healthy... sort of
mine was 7 till last labs and then went to 8  darn inr.  guess we are doing good..for now.    glad yours is at 7  hope we stay here for awhile..  Blessings!!
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