CASE PRESENTATION

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CASE PRESENTATION

• DR NADIA SHAFIQUE

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CASE SUMMARY

• 38 yrs old female GULSHAN diagnosed case of HCV
  related DCLD (child class C) CTP score
  11presented with c/o increasing abdominal
  distention for 3 months, off and on gum bleeding
  and vomiting for 3 days.
• On examination she was pallor, jaundiced ,
  bilateral pitting pedal oedema and marked
  ascities. Rest of the clinical examination was
  unremarkable.

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LABORATORY TEST

• Hb 9.6,TLC 10900,PLT count 145000.
• PT 26/13 sec ,APTT 51/3417sec
• S.bili 2.7mg/dl,ALT 30U/l, Alk Phos 256 U/L
• Urea 73mg/dl, creatinine 2.5mg/dl
• Ascitic fluid analysis showed TLC of 250/cmm,
  neutrophils 88 and lymphocytes 12, protein 1.0
  g/dl
• Endoscopy showed F2 oesophageal varicies and
  moderate portal gastropathy.

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TREATMENT

• She was managed with dietary restriction of
  sodium to and water restriction of
  1.5litres/day.
• Lactulose, spironolactone (400mg/dl ) furosimide
  ( 120mg/dl),omeprazole ,propranolol for 8 weeks.
• FFPs were transfused and large volume
  therapeutic paracentesis was done five times
  (upto 10 litres fluid tapped at intervals)under
  cover of haemaccel.cannot afford i/v albumin due
  to affordability reason.

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OUTCOME

• She did not respond to dietry restriction of
  sodium ,water and maximum dose of diuretics.
• Labelled as having refractory ascities.

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REFRACTORY ASCITIES

• Refractory ascites defined as failure to respond
  to sodium restriction of 50 mmol/d, a combination
  of spironolactone 400 mmol/d and frusemide 160
  mg/d or bumetanide 4 mg/d, evidenced by weight
  loss of less than 200 g/d and urine sodium below
  50 mmol/d over 4 days of intense diuretic
  therapy, or recurrance of ascites within 4 weeks
  of medical therapy of paracentesis which cannot
  be prevented by medical therapy.

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TREATMENT OPTIONS

• Salt (85mmol/day) and water restriction(1.5
  litres/day)
• Diuretics
• Large volume paracentesis
• TIPSS
• Portovenous shunt
• Liver transplant

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TRANSJUGULAR INTRAHEPATIC PORTO SYSTEMIC SHUNT

• Transjugular intrahepatic portosystemic shunts
  (TIPS) are an effective method for reducing
  portal vein pressure.
• TIPS creation is a percutaneous method of
  reducing portal vein pressure wherein a
  decompressive channel is created between a
  hepatic vein and an intrahepatic branch of the
  portal vein.

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• Creating a TIPS involves several steps
• Catheterization of the hepatic veins and hepatic
  venography
• Passage of a long curved transjugular needle from
  the chosen hepatic vein through the liver
  parenchyma into an intrahepatic branch of the
  portal vein.
• Direct measurement of the systemic and portal
  vein pressures through the transjugular access.
• Balloon dilation of the tract between the hepatic
  and portal veins.
• Deployment of a metallic stent within the tract
  to maintain it against the recoil of the
  surrounding liver parenchyma.
• Angiographic and hemodynamic assessment of the
  resultant pressure reduction.
• Serial dilation of the stent until satisfactory
  pressure levels have been reached.
• Variceal embolization when indicated

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INDICATIONS

• Uncontrollable variceal hemorrhage.
• Recurrent variceal hemorrhage despite endoscopic
  therapy.
• Portal hypertensive gastropathy.
• Refractory ascites.
• Hepatic hydrothorax.
• Budd-Chiari syndrome

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CONTRAINDICATIONS

• Elevated right or left heart pressures.
• Heart failure or cardiac valvular insufficiency.
• Rapidly progressive liver failure.
• Severe or uncontrolled hepatic encephalopathy.
• Uncontrolled systemic infection or sepsis.
• Unrelieved biliary obstruction.
• Polycystic liver disease.
• Extensive primary or metastatic hepatic
  malignancy.
• Severe, uncorrectable coagulopathy

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• Comparison of paracentesis and transjugular
  intrahepatic porto systemic shunting in patients
  with ascities.( june 8 ,2000 NEJM)
• The probability of survival without liver
  transplantation was 69 percent at one year and 58
  percent at two years in the shunt group, as
  compared with 52 percent and 32 percent in the
  paracentesis group
• At three months, 61 percent of the patients in
  the shunt group and 18 percent of those in the
  paracentesis group had no ascites . The frequency
  of hepatic encephalopathy was similar in the two
  groups.

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COMPARISON OF TRANSJUGULAR INTRAHEPATIC
PORTOSYSTEMIC SHUNT WITH LARGE VOLUME
PARACENTESIS
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COMPLICATIONS

• Transient or permanent contrast induced renal
  failure
• Fever
• Hepatic infarction
• Entry site hematoma
• Muscle stiffnes
• Occlusion of stent
• Hepatic artery puncture
• Encephalopathy
• Heart arrythmias
• Sub capsular hematoma
• Abdominal bleeding
• Death(very rare)

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• THANKYOU