Makindo Medical Notes

Definition:

Transjugular Intrahepatic Portosystemic Shunt (TIPS) is a procedure that creates a connection between the portal vein and hepatic vein within the liver to reduce portal hypertension. It is mainly used to treat variceal bleeding and refractory ascites.

Indications for TIPS:

• Variceal Bleeding: Refractory or recurrent bleeding that is not controlled by endoscopic therapy.
• Refractory Ascites: Ascites that does not respond to diuretics or repeated paracentesis.
• Hepatic Hydrothorax: Pleural effusion secondary to portal hypertension.
• Budd-Chiari Syndrome: Obstruction of hepatic venous outflow.
• Portal Vein Thrombosis: To restore portal blood flow in selected cases.

Procedure:

• Access: The internal jugular vein is accessed to guide a catheter into the hepatic veins.
• Catheter Placement: A needle is used to create a tract between the hepatic and portal veins.
• Stent Placement: A stent is placed to maintain the shunt, allowing blood flow from the portal vein to the systemic circulation, bypassing the liver.

Pathophysiology:

• Portal Hypertension: Increased pressure in the portal vein due to cirrhosis. TIPS reduces this pressure by creating a pathway for blood to bypass the liver and flow directly into the systemic circulation.
• Reduction in Portal Pressure: Reduces the risk of variceal bleeding and ascites formation by lowering portal vein pressure.

Contraindications:

• Severe hepatic encephalopathy.
• Severe right heart failure.
• Severe hepatic failure (Child-Pugh C, MELD >15).
• Uncontrolled sepsis.
• Extensive portal vein thrombosis.

Complications:

• Hepatic Encephalopathy: Blood bypassing the liver can cause toxin buildup, leading to confusion and cognitive impairment.
• Stent Stenosis/Occlusion: The stent may become narrowed or blocked, leading to recurrent symptoms.
• Heart Failure: Increased blood flow to the right heart can worsen heart failure.
• Infection: Risk of infection during or after the procedure.
• Hemorrhage: Rare but serious bleeding can occur during the procedure.

Post-Procedural Care:

• Monitor for signs of hepatic encephalopathy and heart failure.
• Follow-up imaging with Doppler ultrasound or CT to assess the patency of the TIPS shunt.
• Medications such as lactulose or rifaximin to prevent hepatic encephalopathy, and diuretics may still be required for ascites management.

Prognosis:

• Significant improvement in variceal bleeding control and ascites management.
• Long-term outcomes depend on liver function and comorbid conditions.
• Patients with a MELD score above 15 may have worse outcomes.

Alternative Treatments:

• Endoscopic Band Ligation: Endoscopic treatment for oesophageal varices.
• Paracentesis: Repeated drainage of ascites fluid.
• Liver Transplantation: Definitive treatment for severe liver disease where TIPS is not sufficient.

Conclusion:

TIPS is an effective procedure for reducing portal hypertension and controlling complications such as variceal bleeding and refractory ascites. Careful patient selection, management of complications, and close monitoring are essential for optimizing outcomes.