Question 19

College comments

Syllabus topic/section: Section 2.1.6 Gastrointestinal Intensive Care. Topic: Hepatic Failure

Discussion: 

Most candidates answered well and had specific knowledge required for the answers. Granular details were not required in part a) considering the mark distribution in this question.
Contraindications of TIPS were well described, including Pulmonary HTN, and polycystic liver disease to name a few.
Candidates performed well if they paid close attention to the question and focussed on the systemic complications of TIPS (such as hepatic encephalopathy, liver failure and congestive cardiac failure) instead of localised or procedural complications. Many candidates who included localised or procedure related complications did not score additional marks.
 

Interpretation

Rationale:

• TIPS is the transjugular intrahepatic portosystemic shunt, a low resistance conduit for portal venous blood to bypass the ineffective liver and thereby relieve portal hypertension.

Contraindications:

• Absolute contraindications:
  • Moderate to severe pulmonary hypertension
  • Congestive heart failure
  • Multiple hepatic cysts
  • Uncontrolled sepsis
  • Uncontrolled biliary obstruction
  • Total portal vein thrombosis (in the absence of any patent intrahepatic branches)
• Relative contraindications:
  • A MELD score above 18
  • Central hepatocellular carcinoma
  • Portal vein thrombosis (in the absence of an experienced operator)
  • Hepatic vein thrombosis
  • Severe coagulopathy or thrombocytopenia

Complications:

• Technical complications:
  • Vascular access complications
  • Hepatic damage (through-and-through puncture): risk of intraperitoneal haemorrhage is 1-2%
  • Haemobilia (damage to the biliary tree)
  • Shunt stenosis or thrombosis (it happens in up to 70%)
  • Shunt migration
  • Hepatic vein stenosis (this can sabotage a future transplant)
• Complications from the shunting of portal venous blood:
  • Worsening hepatic encephalopathy
  • Shunt thrombosis or portal vein thrombosis (7-10%).
  • Bilirubin rise
  • Ischaemic hepatitis
  • Right heart failure; "unmasked" cardiomyopathy
  • Tricuspid endocarditis
  • Haemolysis
  • Shunt infection ("endotipsitis")