Some patients with ascites due to liver cirrhosis become no longer responsive to diuretics. Once other causes of ascites such as portal vein thrombosis, malignancy or infection and non-compliance with medications and ...Some patients with ascites due to liver cirrhosis become no longer responsive to diuretics. Once other causes of ascites such as portal vein thrombosis, malignancy or infection and non-compliance with medications and low sodium diet have been excluded, the diagnosis of refractory ascites can be made based on strict criteria. Patients with refractory ascites have very poor prognosis and therefore referral for consideration for liver transplantation should be initiated. Search for reversible components of the underlying liver pathology should be undertaken and targeted therapy, when available, should be considered. Currently, serial large volume paracentesis （LVP） and transjugular intrahepatic portasystemic stent-shunt （TIPS） are the two mainstay treatment options for refractory ascites. Other treatment options are available but not widely used either because they carry high morlJidity and mortality （most surgical options） rates, or are new interventions that have shown promise but still need further evaluation. In this comprehensive review, we describe the evaluation and management of patients with refractory ascites from the prospective of the practicing physician.展开更多
The transjugular intrahepatic portosystemic stent-shunt (TIPS) has successfully been used in the management of refractory variceal bleeding and ascites in patients with portal hypertension. Major drawbacks are the ind...The transjugular intrahepatic portosystemic stent-shunt (TIPS) has successfully been used in the management of refractory variceal bleeding and ascites in patients with portal hypertension. Major drawbacks are the induction of hepatic encephalopathy and shunt dysfunction. We present a 59-year-old woman with alcoholic liver cirrhosis who received a TIPS because of recurrent bleeding from esophageal varices. Stent occlusion occurred 4 mo after placement of the TIPS. Laboratory testing revealed resistance to activated protein C (APC). Combination therapy with low-dose enoxaparin and clopidogrel could not prevent her recurrent stent occlusion. Finally, therapy with high-dose enoxaparin was sufficient to prevent further shunt complications up to now (follow-up period of 1 year). In conclusion, early occlusion of a TIPS warrants testing for thrombophilia. If risk factors are confirmed,anticoagulation should be intensified. There are currently no evidence-based recommendations regarding the best available anticoagulant therapy and surveillance protocol for patients with TIPS.展开更多
Background and aims:The present treatment goal of the transjugular intrahepatic portosystemic shunt(TIPS)is a portosystemic pressure gradient of12 mmHg or its reduction by>50%.This study relates the stent diameter...Background and aims:The present treatment goal of the transjugular intrahepatic portosystemic shunt(TIPS)is a portosystemic pressure gradient of12 mmHg or its reduction by>50%.This study relates the stent diameter to the reduction of the pressure gradient and attempts to predict the appropriate stent diameter necessary to reach the treatment goal.Methods:Pressure response,super response,and poor response were investigated in 208 de-novo TIPS patients and defined as post-TIPS gradients between>6 and 12 mmHg,6 mmHg,or not reaching the goal(>12 mmHg,reduction<50%),respectively.Pressures were related to the smallest stent diameters measured by planimetry of the radiographic image.Results:Responders(65%),super responders(26%),or poor responders(9%)had comparable stent diameters of 7.21.0 mm,but different post-TIPS gradients(9.71.9 mmHg,4.51.5 mmHg,and 14.21.4 mmHg,p<0.001),relative reduction of pre-TIPS gradients(51.711.4%,73.611.1%,and 34.09.1%,p<0.001),and specific reduction per mm of stent diameter(7.52.0%/mm,10.12.0%/mm,and 4.81.4%/mm,p<0.001).Prediction of the stent diameter required to reach response was not possible.Only two super responders had a stent diameter of<6 mm.Super and poor responders differed by the increase in the right atrial pressure(+5.0 mmHg vs.+3.1 mmHg,p=0.026)and reduction in the portal vein pressure(-8.6 mmHg vs.-4.6 mmHg,p<0.001).Conclusion:Most patients reached the treatment goal with stent diameters of<8 mm.Overtreatment(super response,gradient ≤6 mmHg)can be prevented by stent diameters as small as 6 mm.The individual response was not related to the stent diameter and not predictable.Cardiac dysfunction may play an important role by its effect on the right atrial(preload)and portal pressure(afterload).展开更多
文摘Some patients with ascites due to liver cirrhosis become no longer responsive to diuretics. Once other causes of ascites such as portal vein thrombosis, malignancy or infection and non-compliance with medications and low sodium diet have been excluded, the diagnosis of refractory ascites can be made based on strict criteria. Patients with refractory ascites have very poor prognosis and therefore referral for consideration for liver transplantation should be initiated. Search for reversible components of the underlying liver pathology should be undertaken and targeted therapy, when available, should be considered. Currently, serial large volume paracentesis （LVP） and transjugular intrahepatic portasystemic stent-shunt （TIPS） are the two mainstay treatment options for refractory ascites. Other treatment options are available but not widely used either because they carry high morlJidity and mortality （most surgical options） rates, or are new interventions that have shown promise but still need further evaluation. In this comprehensive review, we describe the evaluation and management of patients with refractory ascites from the prospective of the practicing physician.
文摘The transjugular intrahepatic portosystemic stent-shunt (TIPS) has successfully been used in the management of refractory variceal bleeding and ascites in patients with portal hypertension. Major drawbacks are the induction of hepatic encephalopathy and shunt dysfunction. We present a 59-year-old woman with alcoholic liver cirrhosis who received a TIPS because of recurrent bleeding from esophageal varices. Stent occlusion occurred 4 mo after placement of the TIPS. Laboratory testing revealed resistance to activated protein C (APC). Combination therapy with low-dose enoxaparin and clopidogrel could not prevent her recurrent stent occlusion. Finally, therapy with high-dose enoxaparin was sufficient to prevent further shunt complications up to now (follow-up period of 1 year). In conclusion, early occlusion of a TIPS warrants testing for thrombophilia. If risk factors are confirmed,anticoagulation should be intensified. There are currently no evidence-based recommendations regarding the best available anticoagulant therapy and surveillance protocol for patients with TIPS.
文摘Background and aims:The present treatment goal of the transjugular intrahepatic portosystemic shunt(TIPS)is a portosystemic pressure gradient of12 mmHg or its reduction by>50%.This study relates the stent diameter to the reduction of the pressure gradient and attempts to predict the appropriate stent diameter necessary to reach the treatment goal.Methods:Pressure response,super response,and poor response were investigated in 208 de-novo TIPS patients and defined as post-TIPS gradients between>6 and 12 mmHg,6 mmHg,or not reaching the goal(>12 mmHg,reduction<50%),respectively.Pressures were related to the smallest stent diameters measured by planimetry of the radiographic image.Results:Responders(65%),super responders(26%),or poor responders(9%)had comparable stent diameters of 7.21.0 mm,but different post-TIPS gradients(9.71.9 mmHg,4.51.5 mmHg,and 14.21.4 mmHg,p<0.001),relative reduction of pre-TIPS gradients(51.711.4%,73.611.1%,and 34.09.1%,p<0.001),and specific reduction per mm of stent diameter(7.52.0%/mm,10.12.0%/mm,and 4.81.4%/mm,p<0.001).Prediction of the stent diameter required to reach response was not possible.Only two super responders had a stent diameter of<6 mm.Super and poor responders differed by the increase in the right atrial pressure(+5.0 mmHg vs.+3.1 mmHg,p=0.026)and reduction in the portal vein pressure(-8.6 mmHg vs.-4.6 mmHg,p<0.001).Conclusion:Most patients reached the treatment goal with stent diameters of<8 mm.Overtreatment(super response,gradient ≤6 mmHg)can be prevented by stent diameters as small as 6 mm.The individual response was not related to the stent diameter and not predictable.Cardiac dysfunction may play an important role by its effect on the right atrial(preload)and portal pressure(afterload).
