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The transjugular intrahepatic portosystemic shunt for the management of cirrhotic refractory ascites

Nature Clinical Practice Gastroenterology & Hepatology volume 3, pages 380–389 (2006)Cite this article

Abstract

Cirrhotic ascites results from sinusoidal hypertension and sodium retention, which is secondary to a decreased effective arterial blood volume. Transjugular intrahepatic portosystemic shunt (TIPS) placement is currently indicated in cirrhotic patients with refractory ascites who require large-volume paracentesis (LVP) more than two or three times per month. TIPS placement is associated with normalization of sinusoidal pressure and a significant improvement in urinary sodium excretion that correlates with suppression of plasma renin activity, which is, itself, indicative of an improvement in effective arterial blood volume. Compared with serial LVP, placement of an uncovered TIPS stent is more effective at preventing ascites from recurring; however, increased incidence of hepatic encephalopathy and shunt dysfunction rates after TIPS placement are important issues that increase its cost. Although evidence suggests that TIPS placement might result in better patient survival, this needs to be confirmed, particularly in light of the development of polytetrafluoroethylene-covered stents. Favorable results apply to centers experienced in placing the TIPS, with the aim being to decrease the portosystemic gradient to <12 mmHg but >5 mmHg. This article reviews the pathophysiologic basis for the use of a TIPS in patients with refractory ascites, the results of controlled trials comparing TIPS placement (using uncovered stents) versus LVP, and a systematic review of predictors of death after TIPS placement for refractory ascites.

Key Points

  • In most patients with cirrhosis, ascites responds to diuretic therapy

  • TIPS placement corrects the mechanisms that lead to ascites formation and has been compared with LVP for the treatment of patients with ascites refractory to diuretics

  • TIPS placement is more effective than LVP at preventing the recurrence of ascites, but is accompanied by a higher rate of encephalopathy, despite no difference in mortality

  • Serum bilirubin is the best predictor of death in patients who undergo TIPS placement for the treatment of refractory ascites

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Figure 1: The pathogenesis of cirrhotic ascites and its management by the TIPS.
Figure 2: Results of meta-analysis of five randomized, controlled trials of the TIPS versus large-volume paracentesis plus albumin in the treatment of refractory ascites.
Figure 3: Log-odds ratio for mortality according to serum bilirubin levels in a meta-regression analysis of five randomized, controlled trials of the TIPS versus large-volume paracentesis plus albumin in the treatment of refractory ascites.

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Authors and Affiliations

  1. Internal Medicine at Yale University School of Medicine, New Haven, CT

    Guadalupe Garcia-Tsao

  2. Chief of the Digestive Diseases Section and Program Director of the Hepatitis C Resource Center at the Connecticut-Veterans Administration Healthcare System, West Haven, CT, USA

    Guadalupe Garcia-Tsao

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  1. Guadalupe Garcia-Tsao
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Correspondence to Guadalupe Garcia-Tsao.

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Garcia-Tsao, G. The transjugular intrahepatic portosystemic shunt for the management of cirrhotic refractory ascites. Nat Rev Gastroenterol Hepatol 3, 380–389 (2006). https://doi.org/10.1038/ncpgasthep0523

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