TIPS
Formal Definition
A percutaneous procedure creating a low-resistance shunt between the portal and hepatic veins, bypassing the cirrhotic liver parenchyma to reduce portal hypertension; indicated for refractory variceal bleeding and refractory ascites; reduces portal pressure and thereby decreases hydrostatic pressure in esophageal and gastric varices, but carries risk of hepatic encephalopathy (20-30%) and shunt stenosis requiring revision.
How It's Used on the Ward
"TIPS" — a shunt placed radiologically between the portal vein and hepatic vein to reduce portal pressure; it stops variceal bleeding when endoscopic and medical therapy has failed, and it dries up ascites that won t respond to diuretics; the trade-off is hepatic encephalopathy because blood with toxins from the gut now bypasses the liver s filter.
Example
""63-year-old with alcoholic cirrhosis, MELD 18, 3 prior variceal band ligations with recurrent bleeding, two ICU admissions in 6 months. On nadolol and band ligation but continues to have melena, Hgb 7.8, 4 units pRBC in last month. Urgent EGD shows large esophageal varices with red wale sign. Diagnosis: refractory variceal hemorrhage. TIPS procedure performed via right internal jugular vein — 10mm PTFE-covered stent placed between right hepatic vein and right portal vein branch. Post-procedure: portal pressure reduced from 18 to 8 mmHg. Hepatic encephalopathy prophylaxis with lactulose started. Patient discharged on rifaximin.""
Clinical Context
Indications: refractory variceal bleeding (failed endoscopic + medical management), refractory ascites (diuretic-resistant, requiring frequent paracentesis). Contraindications: severe hepatic failure (MELD >19 predicts poor post-TIPS outcomes), CHF, severe pulmonary hypertension, multiple hepatic cysts, active infection. Procedure: interventional radiology, jugular vein access, stent deployment under fluoroscopy. Post-TIPS complications: hepatic encephalopathy (20-30% — treat with lactulose, rifaximin), shunt stenosis (30-50% at 1 year with bare metal stents; covered stents reduce this), hemolysis. Must reduce or discontinue beta-blockers post-TIPS (target portal pressure is now lower). Pre-TIPS workup: cardiac echo (assess pulmonary pressures), hepatology review, MELD score calculation.