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. The risk of bleeding falls significantly if the HVPG can be reduced to less than 12mmHg.  The degree of reduction in HVPG to control ascites is unclear but at present a gradient of at least < 12 mm Hg has been suggested to be a reasonable goal.

Discuss the indications for TIPS?

• Control of acute variceal bleed that is refractory to medical therapy.
• TIPS is effective in the prevention of rebleeding from gastric and ectopic varices (including intestinal, stomal and anorectal varices) and is the preferred approach for the prevention of rebleeding in this group of patients.
• TIPS will decrease the need for repeated large volume paracentesis in patients with refractory cirrhotic ascites. However, given the uncertainty as to the effect of TIPS creation on survival and the increased risk of encephalopathy, TIPS should be used in those patients who are intolerant of repeated large volume paracentesis.
• TIPS may be used in the management of portal hypertensive gastropathy if there is recurrent bleeding despite the use of beta blockers.
• TIPS is effective in the control of hepatic hydrothorax but it only should be used in patients whose effusion cannot be controlled by diuretics and sodium restriction.
• TIPS may be an option in Budd-Chiari syndrome of moderate severity who have failed to respond to anticoagulation.

What tests are needed before TIPS placement?

Preceding creation of a TIPS, tests of liver and kidney function should be performed as well as cross sectional imaging of the liver to assess portal system patency and exclude liver masses. You need a pair of good kidneys in order to get rid of the excess sodium and water that will be mobilised after TIPS

What are the contraindications for TIPS?

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).
Normal cardiac function is needed as after TIPS venous return is increased (almost doubles) because of increased splanchnic/portal return and may lead to cardiac failure if pre procedure cardiac function is compromised.

Discuss the complications of TIPS?

Major procedural complications (intra abdominal haemorrhage, laceration of the hepatic artery or portal vein and right heart failure) are expected in no more than 3% of cases.
Hepatic encephalopathy and TIPS dysfunction are the two complications that have limited the effectiveness of TIPS most significantly.
Other complications include infection of TIPS, sepsis and stent migration in IVC or portal vein. Haemolysis may occur following TIPS placement and appears to be due to damage to the red cells by the stent.

Discuss TIPS dysfunction?

TIPS dysfunction is defined as a loss of decompression of the portal venous system due to occlusion or stenosis of the TIPS. Recurrence of the complication of portal hypertension (bleeding or ascites) for which the TIPS was performed indicates TIPS dysfunction. Occlusion of the TIPS can either be due to thrombosis or hyperplasia of the intima. Thrombosis of the TIPS usually occurs early and can happen within 24 hours of TIPS
creation. Thrombosis of the TIPS is identified by Doppler ultrasound and patency re-established by repeat catheterization.
Documentation of patency can only be achieved with certainty by re-catheterization of the shunt. An abnormal Doppler ultrasound is predictive of occlusion or stenosis whereas a normal ultrasound does not exclude TIPS dysfunction. The recurrence of symptoms in the face of a ‘normal’ ultrasound does not eliminate the need for TIPS venography.
The development of covered stents has reduced the frequency of TIPS dysfunction.

Discuss TIPS and encephalopathy?

• TIPS is contraindicated only if the hepatic encephalopathy is uncontrollable.
• The incidence of new or worsening encephalopathy following TIPS is 20-31%.
• Encephalopathy following TIPS responds to standard therapy and only rarely (less than 5%) must the TIPS be occluded to control the encephalopathy. A TIPS also can be reduced in calibre, should excessive encephalopathy prove difficult to control and yet allow for continued portal decompression.
• It is important to note that if the encephalopathy was precipitated by variceal bleeding then prevention of rebleeding should make it less likely that the patient will have recurrent encephalopathy.

Discuss TIPS surveillance?

Doppler ultrasound should be performed at specified intervals following the procedure and on the yearly anniversary of the TIPS thereafter

Ref

1. AASLD Practice Guidelines: The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the Management of Portal Hypertension

• Obtain informed consent prior to the procedure.
• The procedure should be performed with strict sterile conditions.
• Routine use of fresh-frozen plasma (FFP) or platelet concentrates is not recommended.
• All ascitic fluid should be drained to dryness in a single session as rapidly as possible over 6-8 hours. The drain should not be left in overnight.
• Plasma volume expansion should be given once paracentesis is complete.
• Albumin (8 g albumin/ litre of ascites removed) should be used for volume expansion after large volume paracentesis (> 5 litres).
• Paracentesis of <5 litre of uncomplicated ascites should be followed by plasma expansion with a synthetic plasma expander (150–200 ml of gelofusine or haemacel) and does not require volume expansion with albumin.
• Diuretics should be reintroduced within 1-2 days after paracentesis at a usual dose of spironolactone 200mgs a day.

Discuss the indications for paracentesis?

Large volume paracentesis (> 5 litres) is performed in haemodynamically stable patients with tense or refractory ascites to alleviate discomfort or respiratory compromise. Serial large-volume paracenteses may be required in patients with refractory ascites or ascites that does not respond to diuretics.

Discuss the contraindications for paracentesis?

Disseminated intravascular coagulation.

Relative contraindications-

• Pregnancy
• Small bowel obstruction
• Organomegaly
• Intraabdominal adhesions

Many patients undergoing paracentesis will have baseline coagulopathy or thrombocytopenia. However, the incidence of clinically significant bleeding during paracentesis is extremely low, and routine use of FFP or platelet concentrates is not recommended. However, if thrombocytopenia is severe (40 000) most clinicians would give pooled platelets to reduce the risk of bleeding.

Explain the procedure?

Equipment- The cannula should have multiple side perforations; otherwise the end becomes blocked by bowel wall. (Bonanno Suprapubic catheter Kit is usually used).

Preparation

• Explain the procedure to the patient and obtain informed consent.
• You should discuss the risks of bleeding, infection, injury to intraabdominal organs, and post procedure hypotension.
• Place the patient supine in the bed with his or her head slightly elevated. The procedure should be performed with strict sterile conditions.
• Needle-insertion sites- right or left lower quadrant, 2 to 4 cm medial and cephalad to the anterior superior iliac spine.  You must insert the needle lateral to the rectus sheath to avoid puncturing the inferior epigastric artery.

Paracentesis

• Use the Z technique to minimize the risk of an ascitic fluid leak after the procedure.
• All ascitic fluid should be drained to dryness in a single session as rapidly as possible over 6-8 hours, assisted by gentle mobilization of the cannula or turning the patient on to their side if necessary.
• The drain should not be left in overnight.

Post paracentesis

• After paracentesis, the patient should lie on the opposite side for two hours minimize the risk of ascitic fluid leakage.
• A synthetic plasma expander (150–200 ml of gelofusine or haemacel) is used if less than 5 litres.
• Large volume paracentesis (> 5 L) should be performed in a single session with volume expansion being given once paracentesis is complete, preferably using 8 g albumin/ litre of ascites removed.

Discuss the complications of paracentesis?

• Post-paracentesis circulatory dysfunction (PPCD) – this may lead to hypotension, hyponatremia, renal failure and shortened survival.
• Haemoperitoneum
• Intraabdominal organ injury
• Inferior epigastric artery injury
• Persistent ascitic fluid leakage
• Localised infection
• Abdominal wall haematomas

Discuss the role of diuretics post paracentesis?

Following paracentesis, ascites recurs in the majority (93%) if diuretic therapy is not reinstituted, but recurs in only 18% of patients treated with spironolactone.
Reintroduction of diuretics (usually spironolactone 200mgs a day) after paracentesis (usually within 1–2 days) does not appear to increase the risk of postparacentesis circulatory dysfunction.

Ref

1. Moore KP, Aithal GP. Guidelines on the management of ascites in cirrhosis. Gut. 2006 Oct; 55 Suppl 6:vi1-vi12.
2. Thomsen TW et al. Videos in clinical medicine. Paracentesis. N Engl J Med 2006;355(19):e21, 2006.
3. Cabrera J, Inglada L, Quintero E, Jimenez W, Losada A, Mayor J, Guerra C. Large-volume paracentesis and intravenous saline: effects on the reninangiotensin system. Hepatology 1991; 14:1025-28.

1. What are the contraindications of liver biopsy
2. What you need to do before you start the actual procedure
3. How to locate the site for the biopsy
4. The trolley- what you need on it
5. The actual procedure
6. The aftercare

What are the contraindications of liver biopsy

1. Ascites
2. Uncorrected coagulopathy or thrombocytopenia
3. Uncooperative patient

What you need to do before you start the actual procedure

1. Check Platelet count and clotting and must have group and save
   • Within 7-10 days of the procedure- in most outpatient cases where liver disease is stable or within last 24-48hours if inpatient with fluctuating clotting/platelets
   • Safe platelet count if >60,000/mm3. Will need platelet transfusion if count is <40,000/mm3
   • PT if <4sec prolonged it is ok, if >4sec prolong then use FFP to bring it down
2. Will need fasting for 6hours. Can take medications with sips of water.
3. Take written informed consent
   • Potential benefit should outweigh the risk.
   • There should be clear understanding on both side the need for the biopsy
   • Mortality <0.1%, significant hemorrhage ( Hb drop of more than 2g/dL) <0.3%, pain 30% and puncture of other viscus 0.01-0.1%
4. Prophylactic antibiotic to be given to patients with valvular heart disease or those at risk of bacteraemia
5. Anxious patient might need sedation with midazolam ( rarely needed)

How to locate the site for the biopsy

1. Percuss in the Mid Axillary line with deep breath in and look for liver dullness – so you know how far down the lung can go. And then go one intercostals space down to avoid causing a pneumothorax.
2. This is normally 7/8/9 intercostal space
3. Mark rib space ( pressure impression of a plastic needle cover)
4. In some hospitals radiologist will mark the spot after a quick ultrasound screen
5. If patient is known to have abnormal area in the liver or you want to biopsy an area of interest – then the biopsy has to be done by the radiologist ( real-time)

The trolley- what you need on it

1. Menghini needle ( 1.9x 120mm) and a 20ml syringe for suction



Picture1 and 2: The Menghini needle inside the pack: The needle and the stopper( the other two pieces are not used normally)

2. Biopsy pot and histology form
3. Local anaesthesia ( 1%Lignocaine, 10ml syringe, one green needle and one orange needle)


Picture3: Local anaesthesia

4. Scalpel
5. Sterile gloves
6. Dressing pack

The actual procedure

1. Patient lies flat
2. Lift the bed high enough so that you can do the biopsy standing
3. Clean the area with antiseptic solution
4. Infiltrate L/A with a orange needle first – raise a skin bleb- then go perpendicularly down – remember to suck before you inject to avoid injecting into blood vessels
5. Change to a green needle and advance needle perpendicularly ( remember the neurovascular bundle runs along the lower edge of the rib and avoid that)
6. Then you might feel that the needle is scratching the liver capsule ( withdraw then) or sometime your needle tip will actually be in the liver ( gently supporting the needle will show the syringe to swing side to side with normal respiration- again withdraw)
7. Judge that distance ( normally to reach liver capsule it requires three quarter of the length of the green needle and add another 3-4cm to be in actual liver parenchyma
8. Mark the required depth on the Menghini needle
9. Actual action –
   • Put the metal stopper inside the needle( prevents the tissue to be sucked up inside the syringe)
   • A tiny incision with the scalpel before you go in with the Menghini needle
   • Say ‘take a deep breath in, deep breath out and hold it, hold it, hold it and while you are saying this- introduce the needle
   • Introduce up to the mark as judged before ( put your index finger at the mark which will act as reminder) into the liver
   • Suck up to 10ml ( remember the tissue is cut with the needle but you need strong suction to break it off from the parenchyma)
   • Come out still saying ‘hold it hold it’
10. You need a decent core of tissue- 2-3cm in length. Make up to three passes to achieve this. When in doubt whether you have obtained liver tissue or just blood/fat- remember liver tissue will sink at the bottom of the pot.


Picture4: Decent core of liver tissue

11. Air flush the needle into the biopsy pot- that should expel the tissue from the inside of the needle into the pot
12. Don’t forget to write accurate and relevant clinical history for the histopathologist- particularly mentioned about alcohol, drugs, viral profile, serological profile and your exact clinical question



Picture5: Pot and the form

The aftercare

1. Patient lies on right lateral position for 1 hour and then on back
2. Prescribe prn Paracetamol/codeine
3. Vital signs to be checked every 15mts for two hours post biopsy, thwn every 30mts for another two hours and then hourly for a total of six hours
4. Patient can go home after 6hours if ok
5. Should have a responsible person to stay with on the first post biopsy night and should be able to return to hospital within 30mts if need arise

Liver- The photo is centered on a normal liver lobule taken by core needle biopsy.