Clinical Images: Transjugular Intrahepatic Portosystemic Shunt Reduction for Management of Recurrent Hepatic Encephalopathy.

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) is currently one of the major treatment modalities for complications associated with portal hypertension in patients with cirrhosis.1 The TIPS procedure entails the formation of a low-resistance conduit between the hepatic and portal veins, thereby bypassing the liver parenchyma. One of the major complications associated with TIPS, reported to occur in 15%-30% of TIPS cases,2 is new or worsened hepatic encephalopathy (HE) which can be severely debilitating, with symptoms including confusion, disorientation, lethargy, and frank obtundation. The primary treatment for recurrent HE following TIPS is similar to the treatment provided to any encephalopathic patient and begins with a search for precipitating factors such as infection, electrolyte abnormalities, bleeding, and constipation. Medical treatment with agents such as lactulose and nonabsorbable antibiotics such as rifaximin are usually successful in reversing the problem.3 However, further intervention including shunt reduction or occlusion and organ transplantation is estimated to be required in 3%-7% of patients who continue to suffer from refractory HE.3 We present a case of refractory HE post TIPS revision that was treated with shunt reduction. TIPS revision is a safe and effective procedure for restoring shunt patency if the TIPS becomes occluded. TIPS reduction is a procedure that decreases the diameter of the lumen of the TIPS and subsequently allows less flow through the shunt.