CASE PRESENTATION DR NADIA SHAFIQUE

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.

LABORATORY TEST  Hb 9.6,TLC 10900,PLT count  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.

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.

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

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.

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

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.

 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

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

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

 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.

COMPARISON OF TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT WITH LARGE VOLUME PARACENTESIS

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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