TREATMENT OF REFRACTORY ASCITES USING TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) - A CAUTION

Ascites becomes refractory to medical treatment in nearly 10% of cirrh otic patients, who then require repeated large-volume paracentesis. In this prospective study we evaluated the use of transjugular intrahepa tic portosystemic shunt (TIPS) in 30 patients with refractory ascites. TIPS was successful in all and resulted in a 54% reduction in portaca val gradient (from 22.8 +/- 0.8 to 10.4 +/- 0.6 mm Hg). Ascites became easily controlled with diuretics in 26 patients following TIPS. Ascit es recurrence associated with shunt stenosis was observed during follo w-up in eight patients; revision could be undertaken in five of them a nd resulted in good control of ascites. In responders, a marked decrea se in plasma aldosterone and renin activity, a reduction in serum crea tinine, and a rise in urinary sodium excretion were observed. Creatini ne and inulin clearances improved significantly; PAH clearance remaine d unchanged. However, new-onset or worsening hepatic encephalopathy wa s seen in 14 patients. Severe disabling chronic encephalopathy occurre d in five patients; it could be reversed successfully by balloon occlu sion of the shunt in three. The cumulative survival rate was 41 and 34 % at 1 and 2 years, respectively. In summary, TIPS can control refract ory ascites in a majority of patients but is associated with a high ra te of chronic disabling HE. In addition, the survival rate is poor. Ra ndomized trials are needed to evaluate the exact role of TIPS in the m anagement of refractory ascites. It is unlikely to improve survival bu t can ameliorate quality of life in nontransplant candidates and be us eful as a bridge to transplantation, in particular, to improve denutri tion associated with longstanding tense ascites.