Gastroenterology Education and CPD for trainees and specialists

1. Which one of the following statements regarding TIPS is false?

1. This is a end to side porto-caval shunt
2. Typically portal decompression is considered to be adequate if gradient (portal vein- IVC) falls to 15mm Hg or less ( ideally below 12mm Hg)
3. Mean pulmonary pressure of more than 45mm Hg is a contraindication for TIPS
4. 30 day mortality post TIPS is typically in the range of 10-15%.
5. The incidence of new or worsening encephalopathy following TIPS is 20-31%.

Explanation :TIPS is a side-to-side portacaval shunt that is placed by an interventional radiologist or a hepatologist usually under local anaesthesia. The purpose of a TIPS is to decompress the portal venous system and therefore prevent rebleeding from varices or stop or reduce the formation of ascites. Typically portal decompression is considered to be adequate if gradient (portal vein- IVC) falls to 15mm Hg or less ( ideally below 12mm Hg) and varices on contrast injection are no longer demonstrated. Absolute contraindications include congestive heart failure, severe tricuspid regurgitation and severe pulmonary hypertension (mean pulmonary pressures of more than 45 mm Hg) as these patients are not candidates for a liver transplant). TIPS is contraindicated only if the hepatic encephalopathy is uncontrollable. The incidence of new or worsening encephalopathy following TIPS is 20-31%.

2. Which one of the following statements regarding porto-caval shunts is true?

1. The frequency of TIPS dysfunction ranges from 5% at 12months
2. A shunt velocity of less than 0.5m/second is suggestive of shunt dysfunction and further assessment with a shunt venogram and pressure studies is then needed.
3. Selective shunts are technically easier and quicker to perform.
4. Encephalopathy following TIPS responds to standard therapy and frequently must the TIPS be occluded to control the encephalopathy
5. Portocaval shunts are preferred to mesocaval shunt for future liver transplantation operation.

Explanation :TIPS dysfunction is defined as a loss of decompression of the portal venous system due to occlusion or stenosis of the TIPS. The frequency of shunt dysfunction ranges from 30-50% at 12months to 47-68% at 24months. In selective shunt, the variceal flow is reduced while preserving portal blood flow. The distal splenorenal shunt (DSRS)- the splenic vein (which drains varices via short gastric veins) is connected to distal left renal vein. Selective shunts are technically difficult and takes longer to perform. Encephalopathy following TIPS responds to standard therapy and only rarely (less than 5%) must the TIPS be occluded to control the encephalopathy. Side-to-side mesocaval shunt connects side of superior mesenteric vein (SMV) to side wall of IVC thus preserves the portal vein (compared to porto-caval shunts) which may be important during liver transplantation.

Gastroenterology training and education

MCQ On TIPS

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