Rare Medical Problems

Complications of Transjugular Intrahepatic Portosystemic Shunt Procedural complications are generally seen in 10% or fewer patients after TIPS.Severe life-threatening bleeding has been reported in 1% to 2% of cases because of either puncture of the liver capsule with resulting hemoperitoneum or inadvertent puncture of the biliary tree with resulting hemobilia. Other major complications include contrast medium induced renal failure, heart failure, stent migration, fever, infection, transient arrhythmias, and inadvertent puncture of the gallbladder or other organs adjacent to the liver. Hemolysis, which is typically self-limited and mild, is not uncommon after TIPS. Although procedural complications are relatively infrequent, hepatic encephalopathy is a common complication after TIPS, with a frequency in the range of 20% to 30%. This figure is not unexpected: TIPS represents a side-to-side portosystemic shunt that often results in complete diversion of portal flow, as well as a proporti

Indications Accepted indications Control of refractory acute variceal bleeding Prevention of refractory recurrent variceal bleeding in Child class B and C patients Refractory hepatic hydrothorax Budd-Chiari syndrome Refractory ascites Promising but unproven Hepatorenal syndrome Veno-occlusive disease Unproven Prevention of refractory variceal bleeding in Child class A patients Initial therapy of acute variceal hemorrhage Initial therapy to prevent recurrent variceal hemorrhage Prevention of initial variceal hemorrhage Reduction in intraoperative morbidity rate during liver transplantation Hepatopulmonary syndrome Contraindications Absolute contraindications Right-sided heart failure Primary pulmonary hypertension Polycystic liver disease Severe hepatic failure Portal vein thrombosis with cavernous transformation Relative contraindications Biliary obstruction Active intrahepatic or systemic infection Severe hepatic encephalopathy poorly controll

Transjugular Intrahepatic Portosystemic Shunt Attempts to devise a less invasive approach to portal decompression led to the development of a nonsurgical shunt, the TIPS. The potential advantages of this technique include avoidance of general anesthesia, decreased procedural morbidity and mortality rates, and avoidance of surgery in the region of the hepatic hilum, which may be important in potential liver transplantation candidates. A percutaneous method of creating a portosystemic shunt was first conceived in the late 1960s. Although technically successful, the shunts were short-lived, and all thrombosed within a few days. The development of expandable, implantable metallic stents provided a means, albeit imperfect, for maintaining shunt patency and allowed the widespread clinical implementation of this technique. The use of the flexible Wallstent endoprosthesis (Schneider, Minneapolis, MN) and several technical modifications have reduced procedure

Overview of the Principles and Techniques of the Major Treatment Modalities Endoscopic Therapy Endoscopy is the cornerstone of the management of gastrointestinal hemorrhage both as a diagnostic and as a therapeutic modality. Once esophageal varices are identified as the source or likely source of bleeding, endoscopic options for treatment include injection sclerotherapy and variceal band ligation. Although these techniques do not treat the underlying portal hypertension, they have been shown to be effective in controlling variceal hemorrhage. The rates of success and complications of these endoscopic techniques depend in part on the experience of the operator and the technique employed. Endoscopic Sclerotherapy A variety of techniques have been employed in performing endoscopic sclerotherapy (EST) with the goal of arresting acute bleeding and preventing recurrent bleeding through the obliteration of varices by repeated injections. Injections may be directed into the veins