Transjugular intrahepatic portosystemic shunt (TIPS)

Abstract

Portal hypertension results from increased resistance to portal venous flow in patients with chronic liver disease and cirrhosis. Clinical manifestations of portal hypertension include ascites and gastro-oesophageal varices. Patients may also present with hepatic encephalopathy. The first line of management for ascites in chronic liver disease consists of medical therapy including diuretics (e.g. spironolactone) and dietary salt restriction followed by large volume paracentesis if conservative measures alone are unsuccessful. Management of gastro-oesophageal varices on the other hand is directed at reducing risk of bleeding and this is accomplished through the use of beta-blockers (e.g. propanolol) and prophylactic endoscopic banding of varices. In patients presenting with acute variceal haemorrhage, emergency resuscitation, urgent endoscopic ligation and use of vasoactive agents such as terlipressin or octreotide are the mainstay of initial management. Occasionally, local tamponade of the varices using a Sengstaken-Blakemore tube may be required pending more definitive management. TIPS is a complimentary, minimally invasive procedure performed to reduce portal venous pressures and involves the creation of an artificial shunt between the portal and systemic venous circulation (portosystemic shunt) in patients with portal hypertension. In particular, TIPS has a major role to play in the treatment of refractory ascites or hydrothroax, where medical therapy has failed and variceal haemorrhage, in both prophylactic and acute settings.