Interventional Radiology · Supplementary · from Interventional Radiology
Case 1: Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Patient Presentation
Demographics: 54-year-old male retired bartender
Chief Complaint: "I vomited a large amount of blood and feel lightheaded"
History of Present Illness: This 54-year-old male with a history of alcohol-related cirrhosis (Child-Pugh class B, MELD score 18) presents to the emergency department after an episode of large-volume hematemesis. He reports vomiting approximately 500 mL of bright red blood over 30 minutes, followed by two episodes of melena. He feels lightheaded and weak. His wife reports he appeared pale and nearly fainted while standing.
He was diagnosed with cirrhosis 3 years ago after presenting with ascites and jaundice. He has known esophageal varices that were previously banded (two sessions of endoscopic variceal ligation 18 months and 12 months ago). He was prescribed nadolol for portal hypertension prophylaxis but admits to poor compliance. He has required large-volume paracentesis every 2-3 weeks for refractory ascites over the past 4 months despite maximum diuretic therapy (spironolactone 400 mg and furosemide 160 mg daily).
He stopped drinking alcohol 8 months ago after a hospitalization for alcoholic hepatitis. He has been evaluated for liver transplantation and is currently listed as Status 3. Given recurrent variceal bleeding despite endoscopic therapy and refractory ascites, TIPS placement has been recommended.
Past Medical History:
- Alcohol-related cirrhosis (Child-Pugh B8, MELD 18)
- Portal hypertension with esophageal varices (Grade III)
- Refractory ascites requiring biweekly paracentesis
- Prior alcoholic hepatitis (8 months ago)
- Portal hypertensive gastropathy
- Splenomegaly
- Thrombocytopenia secondary to hypersplenism
- Type 2 diabetes mellitus
Medications:
- Spironolactone 400 mg daily
- Furosemide 160 mg daily
- Nadolol 40 mg daily (poor compliance)
- Lactulose 30 mL three times daily
- Rifaximin 550 mg twice daily
- Metformin 500 mg twice daily
- Pantoprazole 40 mg daily
Social History:
- Former heavy alcohol use (12-15 drinks/day for 25 years), abstinent for 8 months
- Former bartender, now retired on disability
- 20-pack-year smoking history, quit 2 years ago
- Lives with wife
- Attends AA meetings weekly
Family History:
- Father died of cirrhosis at age 60
- Mother alive with type 2 diabetes
- No family history of liver cancer
Physical Examination
- Vital Signs: BP 88/52 mmHg, HR 112 bpm, RR 22/min, Temp 36.5°C, SpO2 96% on room air
- General: Pale, diaphoretic male in moderate distress. Appears chronically ill
- HEENT: Icteric sclerae, dry mucous membranes, blood in oropharynx
- Neck: Jugular venous distension not appreciated due to body habitus
- Cardiac: Tachycardic, regular rhythm, no murmurs. Hyperdynamic precordium
- Lungs: Decreased breath sounds at bilateral bases with dullness to percussion (bilateral pleural effusions)
- Abdomen: Distended with tense ascites, fluid wave positive. Prominent caput medusae. Spleen palpable 4 cm below left costal margin. Liver edge not palpable. No tenderness
- Extremities: 2+ bilateral lower extremity pitting edema to the knees
- Skin: Jaundice, multiple spider angiomata on chest and upper back, palmar erythema, Terry's nails
- Neurologic: Alert and oriented x3. No asterixis. No focal deficits
Workup and Results
Laboratory Studies:
| Test | Result | Reference Range |
|---|---|---|
| Hemoglobin | 7.2 g/dL | 13.5-17.5 g/dL |
| Hematocrit | 21.6% | 38-50% |
| WBC | 4,800/μL | 4,500-11,000/μL |
| Platelets | 58,000/μL | 150,000-400,000/μL |
| INR | 1.8 | 0.8-1.2 |
| PT | 21.2 seconds | 11-13.5 seconds |
| Total Bilirubin | 4.2 mg/dL | 0.1-1.2 mg/dL |
| Direct Bilirubin | 2.8 mg/dL | 0-0.3 mg/dL |
| Albumin | 2.4 g/dL | 3.5-5.0 g/dL |
| AST | 68 U/L | 10-40 U/L |
| ALT | 42 U/L | 7-56 U/L |
| Creatinine | 1.6 mg/dL | 0.7-1.3 mg/dL |
| Sodium | 128 mEq/L | 136-145 mEq/L |
| Ammonia | 62 μmol/L | 15-45 μmol/L |
| Lactate | 3.8 mmol/L | 0.5-2.0 mmol/L |
| MELD-Na Score | 24 (calculated) | -- |
| Hepatic Venous Pressure Gradient | 22 mmHg (pre-TIPS) | <5 mmHg (normal), >12 mmHg (variceal bleeding risk) |
Imaging/Additional Studies:
- Doppler ultrasound of the liver: Patent portal vein with hepatopetal flow. Cirrhotic liver morphology with nodular contour. Large-volume ascites. Splenomegaly (18 cm)
- CT abdomen/pelvis with contrast: Cirrhotic liver, patent portal vein (13 mm diameter), large esophageal and gastric varices, splenomegaly, large-volume ascites. No hepatocellular carcinoma identified
- Upper endoscopy (emergent): Four columns of grade III esophageal varices with active oozing from one varix. Successful band ligation of bleeding varix. Portal hypertensive gastropathy in the fundus
- Echocardiogram: Normal LVEF 60%, no evidence of pulmonary hypertension (RVSP 28 mmHg), no diastolic dysfunction
Clinical Image
Diagram illustrating the TIPS procedure showing the transjugular approach, creation of an intrahepatic shunt between the hepatic vein and portal vein, and placement of a covered stent to decompress the portal system. Source: Educational illustration.
Diagnosis
Acute Variceal Hemorrhage Secondary to Portal Hypertension from Alcohol-Related Cirrhosis with Refractory Ascites — Indication for TIPS Placement
Key Diagnostic Criteria:
- Recurrent variceal bleeding despite endoscopic therapy and beta-blocker prophylaxis
- Refractory ascites requiring biweekly paracentesis despite maximum diuretic therapy
- Hepatic venous pressure gradient >12 mmHg confirming clinically significant portal hypertension
- Patent portal vein on imaging confirming feasibility of TIPS
Treatment Plan
- Acute resuscitation: IV crystalloid and packed red blood cell transfusion (target hemoglobin >7 g/dL), octreotide infusion (50 μg/h), IV pantoprazole, IV ceftriaxone 1 g daily for SBP prophylaxis
- Emergent upper endoscopy: Band ligation of bleeding varices (completed)
- TIPS procedure: Performed within 72 hours of admission. Access via right internal jugular vein under ultrasound guidance. Hepatic venous catheterization, transhepatic needle pass from right hepatic vein to right portal vein branch. Tract dilation and placement of 10 mm covered (ePTFE) stent-graft. Post-TIPS portal pressure gradient reduced from 22 mmHg to 8 mmHg
- Post-TIPS management: Doppler ultrasound at 1 month, 3 months, 6 months, and every 6 months thereafter to monitor shunt patency. Lactulose and rifaximin continued for hepatic encephalopathy prophylaxis. Diuretics weaned as ascites resolves. Dietary sodium restriction maintained
- Liver transplant evaluation: Continue transplant workup with updated MELD score. TIPS serves as bridge to transplantation
- Continued alcohol abstinence: Maintain sobriety program and AA attendance
Key Learning Points
- TIPS is indicated for recurrent variceal bleeding refractory to endoscopic and pharmacologic therapy, and for refractory ascites unresponsive to maximum diuretic therapy
- The target post-TIPS portal pressure gradient is <12 mmHg (ideally 8-10 mmHg) to prevent rebleeding while minimizing encephalopathy risk
- Covered (ePTFE) stent-grafts have significantly improved TIPS patency rates compared to bare metal stents (>80% primary patency at 2 years vs. <50%)
- Hepatic encephalopathy is the most common complication of TIPS, occurring in 20-30% of patients; prophylaxis with lactulose and rifaximin is standard
- TIPS is contraindicated in patients with severe hepatic encephalopathy, right heart failure, severe pulmonary hypertension, and MELD >18-20 (relative contraindication due to high post-procedure mortality)