Transjugular intrahepatic portosystemic shunt: is it the ultimate solution for refractory ascites?

Management of ascites

The evaluation of ascites includes a directed history, focused physical examination, and diagnostic paracentesis with ascitic fluid analysis. Dietary sodium restriction and oral diuretics are the mainstay of therapy for the majority of patients with cirrhotic ascites. Transjugular intrahepatic portocaval shunt has emerged as the treatment of choice for selected patients with refractory ascites, although serial large-volume paracenteses should be attempted first. Early diagnosis, broad-spectrum antibiotics, and albumin infusion contribute to the successful management of spontaneous bacterial peritonitis (SBP). Referral for liver transplant evaluation should be considered at the first sign of decompensation and should not be delayed until development of ominous clinical features, such as refractory ascites and SBP.

The use and misuse of transjugular intrahepatic portasystemic shunts

Transjugular intrahepatic portasystemic shunts, or TIPS, are used to create a low-resistance channel between the hepatic vein and the intrahepatic portion of the portal vein by deployment of an expandable metal stent. TIPS function like side-to-side surgical portacaval shunts, but their placement does not require anesthesia and major surgery. This article reviews the uses and misuses of TIPS in current practice. The uses include variceal hemorrhage and ascites as well as miscellaneous indications such as Budd-Chiari syndrome, veno-occlusive disease, bleeding ectopic and rectal varices, hepatic hydrothorax, and portal hypertensive gastropathy. TIPS is not indicated for primary prophylaxis of variceal hemorrhage, prehepatic portal hypertension, correction of hypersplenism and thrombocytopenia, pulmonary hypertension and hepatopulmonary syndrome, and portal hypertension associated with polycystic liver disease or Caroli's disease. Also reviewed herein is the management of patients after TIPS placement.