jects. However, it is self-limited and rarely requires SEE EDITORIAL ON PAGE 177. intervention. Potential mechanisms of such hemolysis are discussed. TIPS is also not recommended as a means of improving platelet counts in patients with Transjugular intrahepatic portosystemic shunts (TIPS) severe hypersplenism. (HEPATOLOGY 1996;23:32-39.) are a recent innovation in the management of portal hypertension. In 1992, we had previously described an
Cirrhosis is associated with a number of hematologic instance of severe hemolysis associated with this procedure. This study was undertaken to define and quan-abnormalities. [1][2][3] Anemia may result from gastrointestify the true incidence of TIPS-associated hemolysis tinal bleeding and iron deficiency 4 or directly as a conand its clinical spectrum, as well as to test the hypothesequence of severe liver disease. Anemia due to liver sis that portal decompression by TIPS would ameliodisease is characterized by macrocytosis 5 and the develrate hypersplenism in patients with portal hypertenopment of target 5,6 and spur cells. [7][8][9] In some patients sion. A total of 60 patients undergoing TIPS for with alcoholic liver disease, an acute hemolytic anemia prevention of recurrent variceal hemorrhage (n Γ
40) may also develop. 10 Additionally, the cause of liver disor refractory ascites (n Γ
20) were studied. Forty paease may also be associated with anemia, e.g., alcoholtients with cirrhosis who were followed concurrently induced bone marrow suppression. 11 Finally, portal hyserved as controls. At entry, both groups were compapertension, a principal complication of cirrhosis, leads rable with the exception of increased ascites in the TIPS group. A total of 7 instances of intravascular he-to splenic engorgement with consequent enlargement molysis were identified in 60 TIPS patients, whereas and hypersplenism. 4,12 none occurred in controls. Of these, 4 patients were Although hypersplenism may cause pancytopeasymptomatic and detected on routine laboratory testnia, 13,14 thrombocytopenia frequently dominates the ing. Hemolysis led to a greater than 4-g/dL decrease in clinical presentation. Whereas the degree of thrombohemoglobin in 2 patients, 2-to 3-g/dL decrease in 2 cytopenia only occasionally leads to severe spontaneous others and a 3-to 4-gm/dL decrease in 1 patient. Two mucosal bleeding, it has other important clinical consepatients were able to compensate for hemolysis and quences. Specifically, it may contribute to the bleeding did not develop anemia. In all but 1 case, the findings diathesis 4 after even minor surgery, e.g., tooth extracof hemolysis subsided by 12 to 15 weeks; in 1 patient, tion, as well as during episodes of variceal hemorrhage.
orthotopic liver transplantation was associated with resolution of the hemolysis. Overall, no significant Thrombocytopenia also precludes therapy with interchanges in white blood cell or platelet counts were feron-a 2 in some patients with hepatitis C and otherobserved in patients undergoing TIPS despite adewise well-compensated cirrhosis. Lastly, splenic quate portal decompression. We conclude that TIPSenlargement may be complicated by abdominal discominduced hemolysis occurs in approximately 10% of subfort, anorexia and malnutrition, and painful episodes of splenic infarction.
Surgical portal decompression has traditionally been
Abbreviations: TIPS, transjugular intrahepatic portosystemic shunts; Hbg, the definitive therapy for portal hypertension and hemoglobin; MCV, mean corpuscular volume; WBC, white blood cell.