Rare Complication Of Portal Hypertension Research Articles

Portal vein stenting in the management of duodenal varices due to malignant obstruction: A case report and literature review.

Introduction and importanceEctopic varices of the small bowel are a rare complication of portal hypertension. There are various aetiologies that can cause portal vein hypertension such as portal vein obstruction. Each of these pathologies has their own management strategies. Currently, there is a paucity of literature demonstrating the best management for patients with malignant portal vein obstruction leading to these varices.Case presentationThis report presents a case of a 66-year-old female who presented with recurrent per-rectal bleeding. Computed tomography angiography diagnosed duodenal varices in the context of malignant obstruction of the portal vein. Due to being a poor operative candidate, she underwent trans-hepatic portal vein stenting leading to resolution of her symptoms.Clinical discussionTo date, the management of portal vein obstruction due to various aetiologies has only been reported in case reports with no significant large-scale studies providing recommendations on the most appropriate treatment. This case demonstrates the role of palliative stenting for patients with portal hypertension due to malignant portal vein obstruction.ConclusionDuodenal varices are a rare complication of portal vein obstruction. This article contributes to the literature by demonstrating that patients with complications associated with portal vein obstruction can benefit from stenting. For those with malignant obstruction, palliative stenting serves as an important therapeutic option.

Predictors of survival in portopulmonary hypertension: a 20-year experience.

Portopulmonary hypertension (PoPH) is a rare complication of portal hypertension associated with poor survival. Scarce data is available on predictors of survival in PoPH with conflicting results. We sought to characterize the outcomes and variables associated with survival in a large cohort of patients with PoPH in an American population of patients. We identified PoPH patients from the Cleveland Clinic Pulmonary Hypertension Registry between 1998 and 2019. We collected prespecified data, particularly focusing on hepatic and cardiopulmonary assessments and tested their effect on long-term survival. Eighty patients with PoPH with a mean ± SD age of 54 ± 10 years, (54% females) were included in the analysis. The median Model for End-Stage Liver Disease with sodium (MELD-Na) score was 13.0 (10.0-18.0) at PoPH diagnosis. World Health Association functional class III-IV was noted in 57%. Mean pulmonary arterial pressure was 47 ± 10 mmHg and pulmonary vascular resistance 6.0 ± 2.8 Woods units. A total of 63 (78.5%) patients were started on pulmonary arterial hypertension (PAH)-specific treatment during the first 6 months of diagnosis. Survival rates at 1-, 3- and 5-year were 77, 52 and 34%, respectively. Cardiopulmonary hemodynamics as well as PAH-specific treatment did not affect survival. In the multivariable model, MELD-Na, resting heart rate and the presence of hepatic encephalopathy were independent predictors of survival. PoPH patients have poor 5-year survival which is strongly associated to the severity of underlying liver disease and not to the hemodynamic severity of PoPH; therefore efforts should be focused in facilitating liver transplantation for these patients.

Hepatic hydrothorax in a child and its management

Hepatic hydrothorax is a rare complication of portal hypertension. The optimal treatment for this condition is liver transplantation. Liver transplantation is significantly more manageable in children who weigh more than 8 kg. Here, an implantable pleural access device was used in a 5-month-old infant for painless iterative punctures to relieve respiratory symptoms, while waiting for liver transplantation and the patient's growth. The patient underwent successful transplantation 3 months later with a more optimal weight.

S3031 Successful Endoscopic Resection of Portal Hypertensive Gastric Polyps

INTRODUCTION: Portal hypertension is a common complication of decompensated cirrhosis. Portal hypertensive polyposis (PHP) is a rare complication of portal hypertension with a prevalence of 0.9–1.3%. The precise etiology is unknown but portal pressure-related congestion may induce proliferation and angiogenesis in PHP. Thrombocytopenia (platelet count < 130×109/L) and Model For End-Stage Liver Disease (MELD) score >16 are independent risk factors for the development of PHP (1). Gastric polyposis related to PHP does not appear to have malignant potential and there are currently no guidelines for their management. CASE DESCRIPTION/METHODS: A 61-year-old female with decompensated cirrhosis (MELD score of 21) secondary to non-alcoholic fatty liver disease with esophageal varices and hepatic encephalopathy presented with chronic normocytic anemia. Iron studies were consistent with a combination of iron deficiency and anemia of chronic disease. The patient denied hematemesis, melena and hematochezia. Her hemoglobin was 7g/dL, INR of 1.4, and platelet count of 121 × 109/L. Upper endoscopy showed severe portal hypertensive gastropathy in the fundus, cardia and gastric body. In the antrum, there were hyperplastic appearing polyps with a maximum diameter of 5 cm (Figure 1). Portions of the polyp were ulcerated and prolapsing into the duodenal bulb. Small hyperplastic appearing polyps were also noted in the first part of the duodenum. Biopsies of the antral polyps revealed hyperplastic polyps with surface ulceration and granulation tissue. Random antral and gastric body biopsies revealed surface hyperplastic changes. After pathology results returned, repeat upper endoscopy was performed for therapeutic intervention. The 3 cm antral polyp was successfully removed using a detachable snare (Figure 2), while the 5 cm polyp was debulked piecemeal using a 10mm hot snare (Figure 3). The patient was also monitored overnight without signs or symptoms of any immediate complications or gastrointestinal bleeding. DISCUSSION: PHP, while rare, can be a cause of anemia in patients with cirrhosis and portal hypertension. Although the management of these lesions is not guideline-based at this time, this case highlights that endoscopic resection can be achieved with commonly available endoscopic tools. Patients should be counseled on risk of post-polypectomy hemorrhage.Figure 1.: Evidence of portal hypertensive gastropathy and view of gastric polyps from the proximal antrum.Figure 2.: 3cm antral polyp successfully removed using a detachable snare.Figure 3.: 5cm gastric polyp covering the pylorus debulked piecemeal using 10mm hot snare.

Management of Gastric and Ectopic Varices: The Endoscopist's Perspective

AbstractGastric and Ectopic varices are a rare complication of portal hypertension and represent a complex, heterogeneous system of vascular shunts. Bleeding from these shunts can be severe and life-threatening, with poorly standardized treatment algorithms to follow in their management. When bleeding occurs, it is important to follow standard diagnostic procedures for portal hypertensive bleeding and always obtain imaging of the underlying vascular anatomy to help guide therapy. Potential treatment methods will depend on these imaging findings as well as the location of the varix within the gastrointestinal tract. While gastric varices have more data to support specific treatment options, duodenal and rectal varices have only case reports and case series to guide their care. In addition, stomal varices are a very rare complication of portal hypertension and have limited data to support any one treatment modality. Gastric and ectopic varices are best approached in a multidisciplinary fashion after discussion with hepatologists and interventional radiologists to overcome the uncertainty in choosing a definitive therapy.

2354 Massive Hematochezia Due to Bleeding Cecal Varices in a 35-Year-Old

INTRODUCTION: Bleeding from cecal varices is a rare complication of portal hypertension. We present a case of bleeding cecal varices manifesting as massive hematochezia in a 35 year-old woman with alcoholic cirrhosis. CASE DESCRIPTION/METHODS: A 35yo woman with chronic alcoholism presented with hematochezia, hypotension, and syncope. She endorsed a 15-year history of heavy alcohol intake, with no known liver disease or prior GI bleeding. Vital signs included HR 112 bpm and BP 83/48 mmHg. Labs indicated hemoglobin 6.6 g/dL, platelet count 58 K/uL, BUN 12 mg/dL, INR 1.5. Upper endoscopy showed no esophageal varices or blood. Colonoscopy showed red blood in the entire colon causing impaired visualization of underlying mucosa. The patient had continued hematochezia and hypotension requiring massive transfusion. CT angiography revealed active bleeding in the cecum and proximal ascending colon with abnormal surrounding vascularity, consistent with bleeding cecal varices (Figure 1). Arteriography demonstrated rectal, splenic, gastric, and small esophageal varices. The patient underwent transhepatic intravenous portosystemic shunt (TIPS) with an associated portosystemic gradient decrease from 24mmHg to 14mmHg. She had no further bleeding and was started on Nadolol for further reduction in portosystemic pressure. The patient was discharged in stable condition. DISCUSSION: Bleeding colonic varices are an uncommon manifestation of portal hypertension, with an incidence of 0.07%. Specifically, bleeding cecal varices are far more rare, and have been reported in less than 20 cases in the literature. This report describes a case of bleeding cecal varices in a 35 year-old with alcoholic cirrhosis; there is only one other report of bleeding cecal varices in a younger patient. Hemorrhage from these lesions is life threatening and requires robust knowledge of diagnostic and therapeutic options. Diagnosis is often attempted with colonoscopy, however can be difficult due to visual obscuration by bleeding. Mesenteric angiography is most effective in diagnosis. Endoscopic and radiologic interventions include cyanoacrylate injection, endoscopic variceal ligation, coil embolization, balloon occluded retrograde transverse obliteration (BRTO), and TIPS. In our case, the decision to pursue TIPS was made due to complicated superior mesenteric artery anatomy precluding coil embolization. Aggressive resuscitation and collaboration between gastroenterology, surgery, and radiology made for a successful outcome for this young patient.

Duodenal Varix Rupture - A Rare Cause of Fatal Gastrointestinal Hemorrhage: A Case Report and Review of Literature.

Duodenal varices are a rare complication of portal hypertension; with cirrhosis being the most common cause. Reports regarding the disease prognosis and natural history are limited. In addition to the diagnostic difficulty, ectopic duodenal varices pose a significant therapeutic challenge owing to the lack of specific management guidelines. Given the high risk of rupture, they can have devastating clinical outcomes. Rupture typically presents as a gastrointestinal hemorrhage and requires emergent interventions. We present a case of duodenal varix seen on upper endoscopy in a patient with portal hypertension and cirrhosis, together with review of the literature outlining the current understanding of this disease entity. We also highlight the pathogenetic mechanisms as well as the current diagnostic and therapeutic approaches for this potentially fatal disease.

Duodenal Variceal Bleeding: A Rare Complication of Portal Hypertension

IntroductionDuodenal varices are a rare complication of portal hypertension and are labeled as ectopic varices. These are portosystemic collaterals in locations besides the gastroesophageal region and represent 2-5% of all variceal bleeding. Duodenal varices represent 17% of these bleeds. Although they are rare, duodenal varices are challenging to treat and often fatal. Case A 57 year-old female patient with a history of decompensated alcoholic cirrhosis initially presented to an outside hospital for melena. Esophagogastroduodenoscopy (EGD) done there reported an ulcer in the second part of duodenum that was treated with three hemoclips. She was then transferred to our institution for further management. She had melena on presentation resulting in hemodynamic instability. Initial hemoglobin was 8.6, which quickly declined to 6.0. Urgent EGD showed small esophageal varices, portal hypertensive gastropathy and bright red blood in the first and second parts of duodenum without an actively bleeding source readily identifiable. Shortly after the procedure she developed additional melenic bowel movements. On review of imaging, duodenal varices were identified incidentally on computed tomography of the abdomen. She subsequently underwent emergent TIPS and coil embolization of cecal and a duodenal varices. Unfortunately, over the next eight days, she continued to have recurrent bleeding episodes despite upsizing of TIPS and cyanoacrylate injection directly into the duodenal varix. The bleeding ceased after a repeat coil embolization of residual duodenal varices. The patient subsequently developed fungemia and septic shock, shortly after which she passed away. Conclusion Duodenal varices are usually seen in either the first or second part of the duodenum. They arise due to portosystemic communication via veins of Retzius. Due to its rarity, there have been no randomized trials on the management of this condition and treatment guidelines have not been established. Case reports showed various treatment modalities including sclerotherapy, varix ligation, resection and portocaval shunt. Despite this, mortality rate remains as high as 40%. Bleeding from duodenal varices should always be considered in the differential diagnosis of a patient with portal hypertension who presents with upper gastrointestinal bleeding.1995_A Figure 1 No Caption available.1995_B Figure 2 No Caption available.1995_C Figure 3 No Caption available.

Transjugular intrahepatic portosystemic shunt in refractory hydrothorax - a contribution to an unexplored indication.

Hepatic hydrothorax is a rare complication of portal hypertension, but may be potentially severe. Although conservative therapy may be effective, it is not without risk and refractory cases are not rare. The portal decompression achieved by transjugular intrahepatic portosystemic shunts (TIPS) has shown positive results in the treatment of refractory ascites, and in that sense, the analysis of their value in other complications of portal hypertension becomes relevant. The aim of this study was to evaluate the efficacy and safety of TIPS in patients with refractory hydrothorax. This was a retrospective study including patients with refractory hydrothorax undergoing TIPS in a tertiary hospital in the period between 2000 and 2014, and evaluated the following: demographic characteristics, liver disease, and outcomes (efficacy and safety, including complications after TIPS, liver transplantation, 30-day, and 1-year mortality). Nineteen patients with hydrothorax underwent TIPS; most had previously undergone multiple thoracocentesis and all had hypoalbuminemia. In all, 57.9% of the patients were men, with a mean age 63±9 years, and 84.2% had cirrhosis of alcoholic etiology and a mean Model for End-Stage Liver Disease-16, Child-Pugh B in 42.1%/Child-Pugh C in 47.4%. TIPS was effective in 73.3% of the cases. Portosystemic encephalopathy was recorded in 66.6% of the cases. Mortality was 25% at 30 days and 42.8% at 1 year with septic complications or progression of liver disease. Two patients underwent liver transplantation. The mean follow-up duration was 704 days (3-3485 days). TIPS appears to be a relatively efficient method to control hydrothorax, making it a valid option in refractory cases despite the high risk of portosystemic encephalopathy and mortality.

Two cases of spontaneous rupture of an umbilical hernia, a rare complication of portal hypertension

Portal hypertension is a severe complication of liver cirrhosis frequently leading to formation of ascites. We describe two patients that presented with a spontaneous rupture of an umbilical hernia, a rare complication of liver cirrhosis.

Spontaneous Hemoperitoneum in Non Cirrhotic Portal Hypertension: A Case Report

Purpose: We report a rare case of non -irrhotic portal hypertension with spontaneous intraperitoneal hemorrhage. This report details patient's presentation, management and literature review. Case Report: 29-year-old Ethiopian male with history of splenomegaly and thrombocytopenia presented with sudden onset of severe diffuse abdominal pain, associated with generalized weakness. Examination was significant for mild tachycardia, diffuse abdominal tenderness without guarding and splenomegaly. Lab work was significant for Hemoglobin 9.3 (previous hemoglobin 14.7), platelets 27, WBC 2.1, normal Bun/Cr, total protein 6.0, albumin 3.4, AST 30, ALT 23, Alkaline phosphatase 62 and total bilirubin 2.3. CT abdomen with contrast was remarkable for massive splenomegaly, associated with extensive varices as well as spontaneous splenorenal shunt. Portal and splenic vein appeared to be intact. There was fluid of high density adjacent to the liver as well as within the bilateral pericolic gutters. Density was compatible with hemorrhagic fluid in nature. It was decided for initial conservative management. Upper GI endoscopy showed very large esophageal varices that were banded along with gastric varix and portal HTN gastropathy. Paracentesis was done that showed 3 million red blood cells confirming hemoperitoneum and a low albumin with a high SAAG, consistent with portal hypertension. A comprehensive evaluation for causes of liver disease including hepatitis serology, autoimmune causes, metabolic and schistosoma antibodies was done and was found negative. Liver biopsy was consistent with hepatoportal sclerosis and no evidence of cirrhosis. He remained hemodynamically stable, so conservative management was continued and he was discharged after five days of monitoring. Conclusion: Non-cirrhotic portal hypertension is diagnosed by the presence of unequivocal evidence of portal hypertension in the definite absence of liver cirrhosis and extrahepatic portal vein obstruction. The most common clinical presentation is variceal bleeding, which (in contrast to variceal bleeding in cirrhosis) is often relatively well tolerated due to the preserved liver function. Intraperitoneal rupture of ectopic varices is a rare complication of portal hypertension. Very Few case reports have been published in the literature and little is known about the best management strategy for these patients. The management is individualized according to the condition of the patient and the resources. Objectives of management include suspicion for diagnosis, aggressive resuscitation, and correction of coagulopathy, reduction of portal hypertension and if required, surgical interventions for direct control of the bleeding vessel.

Laparoscopic management of massive spontaneous external haemorrhage from the umbilical varix due to recanalisation of the paraumbilical vein in a patient with ′Child′s Class A′ liver cirrhosis

Spontaneous external haemorrhage from the umbilical varix is an extremely rare complication of portal hypertension. Bleeding is usually into the peritoneal cavity and the treatment involves urgent laparotomy and ligation of the bleeding varices. We describe a cirrhotic 38-year-old man who presented with spontaneous external haemorrhage from the umbilical varix which was successfully managed laparoscopically by in-situ distal clipping and proximal transcutaneous ligation of the recanalised paraumbilical veins. We therefore feel that laparoscopy can be safely and effectively employed to control external haemorrhage from the umbilical varix associated with liver cirrhosis. This novel technique can help avoid a laparotomy and also help preserve the umbilicus.

Successful treatment of a bleeding duodenal varix by endoscopic band ligation

Bleeding from duodenal varices is a rare complication of portal hypertension. Most patients with duodenal varices have extrahepatic portal hypertension [1]. Due to the limited number of cases, different treatment modalities for duodenal varices have not been compared in randomized controlled trials and most of our current knowledge is obtained from case reports and small case series. So far, endoscopic therapy (sclerotherapy, band ligation, mini-loop ligation), radiological techniques (percutaneous transcatheter embolisation, TIPS-implantation) and surgical procedures have been used [2]. Compared to other treatment options endoscopic band ligation is a relatively noninvasive therapy. However, till now, only a small number of case reports regarding the use of this technique in the duodenum have been published [3-5]. A 78-year old woman was admitted to hospital because of hematemesis and melena. Two years previously, a neuroendocrine carcinoma of the head of the pancreas had been diagnosed and treatment with lanreotide (60 mg s.c. once a month) had been started. The patient s history further included insulin dependent diabetes mellitus, arterial hypertension and ischemic stroke. On admission the patient had severe anemia (hemoglobin 7.7 g/dl). After hemodynamic stabilization, gastroscopy was performed, which revealed esophageal varices with a diameter of >0.5 cm without signs of bleeding, a considerable amount of blood in the stomach and duodenum and a single varix in the superior part of the duodenum. A small ulcer was visible on this varix, indicating recent bleeding (Fig. 1). Band ligation of the duodenal varix was successfully performed. In addition, the patient received terlipressin and antibiotics. Abdominal MRI revealed tumor progression: the tumor in the head of the pancreas had increased to a diameter 9 x 5 cm, causing thrombosis of the portal vein. In addition, one liver metastasis (diameter 4 cm), peritoneal carcinosis and ascites were detected. Six days after endoscopic treatment, a second gastroscopy was performed. At this time the duodenal varix was hardly visible anymore and at the site where the band ligation had been performed there was a small flat ulcer covered with necrotic material (Fig. 2). During two months follow-up there were no further episodes of gastrointestinal bleeding. This case brings further evidence that bleeding from duodenal varices caused by portal hypertension can be treated successfully by endoscopic band ligation.

Successful treatment of portopulmonary hypertension with the selective endothelin receptor antagonist Sitaxentan

Portopulmonary hypertension (POPH) is a rare complication of portal hypertension. Prostanoids have been shown to be effective in the treatment of POPH and have been used as a bridge to liver transplantation. More recently, case series revealed beneficial effects of both the dual endothelin receptor antagonist bosentan and the phosphodiesterase-5 inhibitor sildenafil. The efficacy of sitaxentan, a selective endothelin receptor A (ERA) antagonist in the reversal of POPH, is still unclear. We report a case of POPH that was successfully treated with oral sitaxentan. Haemodynamic and symptomatic improvements were maintained after a 12-week long-term treatment period. Additionally, hepatic vein pressure gradient significantly decreased from 12 mmHg to 8 mm after treatment with sitaxentan. This is the first reported case of a successful therapy with a selective ERA antagonist in a patient suffering from POPH. Oral sitaxentan therapy might be a promising new option for patients suffering from POPH.

Emergency embolization of multiple splenic artery pseudoaneurysms associated with portal hypertension complicating cystic fibrosis†

Cystic fibrosis (CF) is the most common potentially lethal genetic disease in the white population. Improvements in life expectancy have led to an increasing recognition of hepatobiliary complications from CF. Splenic artery aneurysms are a rare complication of portal hypertension with a high mortality due to their significant potential for rupture, resulting in life-threatening i.p. haemorrhage. The optimum treatment of ruptured splenic artery aneurysms is controversial. This case describes the successful emergency embolization of multiple splenic artery pseudoaneurysms associated with portal hypertension complicating cystic fibrosis.

Management of Bleeding Anorectal Varices in Cirrhosis

Background/Aims: Bleeding from anorectal varices (AVR) is a rare complication of portal hypertension in cirrhosis. Though rare, yet it's usually massive and life threatening. No agreement has been reached on which could be the optimal therapeutic strategy for bleeding AVR. Therefore, this study was conducted to evaluate the efficacy and safety of endoscopic band ligation (EBL) in the treatment of 12 patients with lower gastrointestinal bleeding from ruptured AVR. Methods: emergency colonoscopy was done within 24 hours of admission to confirm the diagnosis and thereafter EBL was done with a pneumatic band ligation device. A follow-up endoscopy was done one week after the initial haemostatic procedure searching for any complications. Results: successful haemostasis was achieved in all patients (100%). The only complication observed was a clean base shallow post EBL ulcers in 6 patients (50%). Recurrent bleeding was observed in 2 patients (16.6%). Conclusion: the experience reported in the present study confirms the efficacy and safety of this haemostatic modality in the treatment of this rare and frequently fatal cause of lower gastrointestinal hemorrhage.

Ectopic Varices in Colonic Stoma: MDCT Findings

Ectopic stomal varices are an unusual cause of gastrointestinal hemorrhage. The term "ectopic stomal varices" means abnormally dilated veins that have developed in the stomal mucosa. We describe the 2D reformatted and 3D volume rendered images by MDCT in a patient with an episode of acute bleeding from the colonic stoma. This case indicates that the 2D reformatted and 3D volume rendered images are useful to detect this rare complication of portal hypertension, and they help to tailor adequate treatment for the patients with bleeding from stomal varices.

The liver-lung-heart connection

Pulmonary hypertension is a rare complication of portal hypertension in children. In an article by Condino and others from Denver Children's Hospital the clinical presentation, cardio-pulmonary abnormalities, and clinical courses of seven children with portopulmonary hypertension are reported. The symptoms are subtle, and may be overlooked, and therefore children with portal hypertension who develop a new heart murmur, dyspnea, syncopy, or who are being considered for liver transplantation should be evaluated for portopulmonary hypertension by echocardiogram and cardiology evaluation. This article is commented on in an editorial entitled “The Many Faces of Portopulmonary Hypertension” by Michael J. Krowka, MD from the Mayo Clinic. Many Faces of Portopulmonary HypertensionThe Journal of PediatricsVol. 147Issue 1PreviewYears of portal hypertension, dyspnea with exertion, a new murmur, syncopal episodes, and sudden death. These elements comprise only part of our experiences in caring for patients with the entity characterized as portopulmonary hypertension (POPH)—the evolution of pulmonary artery hypertension as a consequence of portal hypertension pathophysiology.1 Sadly, we are reminded in this issue of The Journal of Pediatrics by Condino et al2 that POPH is not an exclusive syndrome affecting only adults with liver disease and portal hypertension. Full-Text PDF

Hemoperitoneo secundario a la rotura espontánea de la vena umbilical

Patients with ascites can develop spontaneous hemoperitoneum after injury or as a complication of diagnostic or therapeutic techniques. Spontaneous rupture of intra-abdominal varices is a rare complication of portal hypertension and an infrequent cause of hemoperitoneum that causes high mortality (75%). We present a new case of spontaneous hemoperitoneum secondary to umbilical vein rupture in a male patient with liver cirrhosis and review the cases previously described in the literature.

The successful treatment of symptomatic, refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt.

Hepatic hydrothorax is a rare complication of portal hypertension. Conservative therapy may be successful but refractory hepatic hydrothorax is not uncommon. Management of refractory hydrothorax is usually ineffective and can result in a worsened clinical status. Transjugular intrahepatic portosystemic shunts (TIPS) lower portal pressure and have been used in the treatment of refractory ascites. The aim of this study was to determine the efficacy of TIPS in the treatment of symptomatic refractory hepatic hydrothorax. A TIPS was placed in 24 consecutive cirrhotic patients with symptomatic refractory hepatic hydrothorax. Five patients (20.8%) were Child's/Pugh class B and 19 (79.2%) were class C. All had undergone multiple thoracenteses and were hypoalbuminemic. Mean follow-up was 7.2 months (range, 0.25-49 months). Fourteen (58.3%) of 24 patients had complete relief of symptoms after shunt placement and did not require further thoracentesis. Five (20.8%) additional patients required fewer thoracenteses. Five (20.8%) patients developed worsening liver function and died within 45 days. In eight (66.7%) of 12 patients with > or = 60 days of follow-up, the serum albumin increased by a mean of 1.2 g/dL (range, 0.1-2.2 g/dL). The Child's-Pugh score improved in 7 (58.3%) of these 12 patients and two patients improved from class C to class A. These two patients no longer require liver transplantation. This study shows that TIPS can be effective in the management of symptomatic, refractory hepatic hydrothorax. Clinical and laboratory improvement may be seen and liver transplantation may become unnecessary.