Answer the following questions about transjugular intrahepatic portosystemic shunts (TIPS):
a) What is a TIPS procedure and why is it used in patients with portal hypertension?
b) What are 2 recognised indications for this procedure?
c) Excluding mortality list 5 COMMON complications of TIPS procedure
d) Describe one classification system used in assessing severity of chronic liver disease and outline its utility.
a) What is a TIPS procedure and why is it used in patients with portal hypertension?
The hepatic vein is accessed via the internal jugular vein and IVC. A needle is then passed to connect the hepatic vein with the large portal vein near the centre of the liver, the needle tract dilated and a stent inserted to maintain the tract and form the shunt between the higher pressure portal vein and the lower pressure hepatic vein. This reduces portal hypertension.
b) What are 2 recognised indications for this procedure?
a) Variceal bleeding that has failed endoscopic and pharmacological treatment. b) Refractory ascites
c) Excluding mortality list 5 COMMON complications of TIPS procedure
• thrombosis
• occlusion of the stent
• capsular puncture
• bleeding
• encephalopathy
• stent migration
d) Describe one classification system used in assessing severity of chronic liver disease and outline its utility.
Either: Childs-Pugh score
Classified A,B or C by a composite of Total bilirubin, albumin, INR, ascites and hepatic encephalopathy. Originally used for prognostication for surgery – also used for prognostication in chronic liver disease and prediction of likelihood of complications of cirrhosis
Or: MELD score severity scoring system for assessing severity of chronic liver that uses the serum bilirubin, creatinine and INR. Initially developed to predict three month survival in patients post TIPS. Now used for prognosis of liver disease and prioritizing liver transplant recipients
The first 3 parts of this question are reasonably straightforward.
Indications for TIPS:
Technical complications of TIPS:
Complications from portal venous shunting:
The last part of the question is far from straightforward. How does one "briefly outline the utility" of something like the Childs-Pugh scoring system?
The system itself has existed since the 1970s, and it includes in its assessment the albumin level, the prothrombin time, the bilirubin, the presence of encephalopathy and the presence of ascites.
It seems the main point is prognosis. The utility of the scoring systems in general has been to estimate the expected lifespan of a cirrhosis patient, which has implications for liver transplantation. However, in the ICU, the overall mortality for cirrhosis patients is about 43%, irrespective of Childs-Pugh score. In general, SOFA and APACHE are better systems for predicting in-ICU mortality than the liver-specific scoring systems.
Thus, the answer to the "briefly outline utility" question should look like this:
Classification system:
Its utility, briefly:
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