Acute endotoxemia following transjugular intrahepatic stent-shunt insertion is associated with systemic and cerebral vasodilatation with increased whole body nitric oxide production in critically ill cirrhotic patients.

BACKGROUND & AIMS: Transjugular intrahepatic stent-shunt (TIPSS) insertion, in patients with uncontrolled gastro-intestinal bleeding, often results in worsening of the systemic hemodynamics which can be associated with intracranial hypertension but the underlying mechanisms are unclear. This study explored the hypothesis that TIPSS insertion results in acute endotoxemia which is associated with increased nitric oxide production resulting in systemic and cerebral vasodilatation. METHODS: Twelve patients with cirrhosis who were undergoing TIPSS for uncontrolled variceal bleeding were studied prior to and 1-h after TIPSS insertion. Changes in cardiac output (CO) and cerebral blood flow (CBF) were measured. NO production was measured using stable isotopes using l-[guanidino-(15)N(2)] arginine and l-[ureido-(13)C;5,5-(2)H(2)] citrulline infusion. The effect of pre- and post-TIPSS plasma on nitric oxide synthase (NOS) activity on human endothelial cell-line (HUVEC) was measured. RESULTS: TIPSS insertion resulted in a significant increase in CO and CBF. Endotoxin and induced neutrophil oxidative burst increased significantly without any significant changes in cytokines. Whole body NO production increased significantly and this was associated with increased iNOS activity in the HUVEC lines. The change in NO production correlated with the changes in CO and CBF. Brain flux of ammonia increased without significant changes in arterial ammonia. CONCLUSIONS: In conclusion, the insertion of TIPSS results in acute endotoxemia which is associated with increased nitric oxide production possibly through an iNOS dependent mechanism which may have important pathophysiological and therapeutic relevance to understanding the basis of circulatory failure in the critically ill cirrhotic patient.

Bleeding ectopic varices in cirrhosis: the role of transjugular intrahepatic portosystemic stent shunts.

BACKGROUND: Bleeding from ectopic varices is uncommon but can be difficult to manage. AIM: To report our experience of the use of transjugular intrahepatic portosystemic stent shunts (TIPSS) in the management of uncontrolled bleeding from ectopic varices. METHODS: A retrospective study of patients who had TIPSS for bleeding ectopic varices. Patients were selected from a dedicated data base. RESULTS: Over 14 years, of 750 TIPSS insertions, 28 patients had TIPSS for bleeding ectopic varices (Child-Pugh score: 8.8 +/- 1.8). Varices were rectal (12), stomal (8), duodenal (4) and at other sites (4). Concomitant variceal embolization was performed in five. Portal pressure gradient fell from 18.2 +/- 6.4 to 7.2 +/- 3.5 mmHg. TIPSS achieved haemostasis in six of nine patients who presented with active bleeding. Five patients rebled from ectopic varices. This was related to shunt dysfunction in two and responded to shunt interventions. Three patients rebled despite a functional shunt. Of these, thrombin controlled bleeding in one. Eight patients developed hepatic encephalopathy post-TIPSS. CONCLUSIONS: Transjugular intrahepatic portosystemic stent shunt is a safe and effective treatment for bleeding ectopic varices. Rebleeding from ectopic varices related to shunt dysfunction responds to shunt intervention. A significant proportion of patients have rebleeding despite a patent shunt, when other adjunctive measures like thrombin injection may be tried.

Palliation for suspected unresectable hilar cholangiocarcinoma.

AIM: The aim of this study was to evaluate the outcome of different techniques of palliation for patients with hilar cholangiocarcinoma. METHOD: All patients treated with palliative intent between 1988 and 2004 at the Royal Infirmary of Edinburgh were reviewed. Patients were analysed on an intention to treat basis. Demographics, procedure and outcome (including re-admissions) were recorded. RESULTS: Two hundred and thirty-three patients underwent palliative treatment for suspected hilar cholangiocarcinoma. The diagnosis was confirmed histologically in 109 patients. The procedure related morbidity and mortality was 54/225 and 18/207 respectively. Seventy-one patients required re-admission. Twenty patients underwent surgical biliary bypass for jaundice. Those undergoing surgical palliation had a longer median (95% CI) time to re-admission (16 (0-36) vs.7 (2-12) weeks, p=0.001). Endoscopic retrograde cholangio-pancreatography (ERCP) and stenting was only successful in 28 patients and was associated with a significantly higher re-admission rate compared to patients in whom ERCP was not performed (60/179 vs. 4/27, p=0.050). The overall median (95% CI) survival was 145 (124-185) days. CONCLUSION: Current options for palliation of hilar cholangiocarcinoma provide good short term success but are all associated with significant early and late morbidity. Due to its low success and association with an increased re-admission rate, ERCP for definitive palliation should not be used in the first line staging and management of these patients.

Follow-up and outcomes for resection of colorectal liver metastases in Edinburgh.

AIM: The aim of this study was to assess the value of a defined follow-up protocol for patients undergoing potentially curative hepatic resection for colorectal hepatic metastases. METHODS: A standard protocol for the duration of the study consisted of clinical assessment, serum carcinoembryonic antigen (CEA) and computed tomography. Patterns of recurrence, method and timing of diagnosis and outcome were recorded. RESULTS: One hundred and ninety-one patients underwent potentially curative resection from 1989 to 2004 of whom 103 developed recurrence. The median (inter-quartile range) follow-up was 24.4 (6.5-42.3) months. The median (IQR) time to recurrence and overall survival was 25.0 (10 -not yet reached) and 45.2 (21-123) months, respectively. Seventeen patients (8.9%) underwent further surgery with curative intent. Fifty-five patients (57.9%) had recurrence diagnosed at routine follow-up with 71% (44/62) being diagnosed by CEA and CT. The CEA was elevated in 85.7% (72/84 patients) at the time of diagnosis of recurrence. CONCLUSION: Although the detection of recurrent disease is common during follow-up after hepatic resection for colorectal metastases, few patients will be suitable for further intervention with curative intent. The exact nature of the follow-up protocol remains to be determined but if it is going to be performed it should be most intensive within the first 3 years.

Review article: update on the role of transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the management of complications of portal hypertension.

In the 8 years since its introduction into clinical practice, initial enthusiasm for the transjugular intrahepatic portosystemic stent-shunt (TIPSS) has been tempered by a more critical appraisal of its role in the management of portal hypertension. TIPSS has established its role as a rescue procedure for variceal haemorrhage uncontrolled by endoscopic means and as a treatment for ectopic or recurrent variceal bleeding. Randomized trials comparing TIPSS with endoscopic methods in the secondary prophylaxis of oesophageal variceal haemorrhage have shown reduced rebleeding after TIPSS but no effect on survival. Its exact role in this situation awaits further assessment, including quality of life and cost analyses, and consideration of the current limited availability of the technique. Experience of TIPSS in patients with refractory ascites or hepatorenal syndrome has been disappointing. Little data currently exist, but results of further randomized studies comparing TIPSS with paracentesis for refractory ascites are awaited. Ideally these should be multicentre studies, and should include quality of life data for this poor prognostic group. Development of shunt insufficiency remains a major problem and occurs in approximately 50% patients at 1 year. The need for continued shunt surveillance by Doppler sonography and direct portography is the major limitation of TIPSS, but hopefully the development of covered stents will address this problem.

Differing actions of the acute administration of propranolol and isosorbide-5-mononitrate on the portal circulation.

BACKGROUND: The aim of this study was to clarify the actions of propranolol and isosorbide-5-mononitrate upon the portal circulation. METHODS: Portal haemodynamics were assessed in 16 patients with transjugular intrahepatic portosystemic stent shunts. A reverse thermodilution catheter was positioned in the portal vein, and portal vein pressure and portal vein flow were measured directly. The effects of propranolol 80 mg and isosorbide-5-mononitrate 20 mg over 1 h were determined independently. RESULTS: This demonstrated that propranolol reduced both portal pressure gradient (7.7 +/- 2.3 to 5.5 +/- 2.1 mmHg, P < 0.01) and portal vein flow (925 +/- 123 to 597 +/- 99 mL/min, P = 0.01) significantly, implying a reduction in splanchnic inflow as its main effect. In contrast, isosorbide-5-mononitrate tended to increase portal vein flow (814 +/- 186 to 911 +/- 211 mL/min; P = 0.06) whilst reducing portal pressure significantly (108 +/- 12 to 92 +/- 10 mmHg P = 0.014). This suggests a fall in intrahepatic resistance and provides no evidence for baroreceptor-mediated reflex splanchnic vasoconstriction. CONCLUSIONS: These drugs act upon different variables contributing to portal hypertension and so they may have a powerful synergistic effect in combination. Direct measurement of portal vein flow is a valuable method for assessing the pharmacological modulation of portal venous inflow.

Clinical response after transjugular intrahepatic portosystemic stent shunt insertion for refractory ascites in cirrhosis.

BACKGROUND: Transjugular intrahepatic portosystemic stent shunts (TIPSS) have been used successfully to reduce portal pressure in the context of variceal haemorrhage. Recent interest has focused on the possible use of TIPSS to manage refractory ascites. AIM: To study the effect of TIPSS insertion in 18 patients with refractory ascites. RESULTS: Response rates were 33.3%, 50%, 33.3% and 26.7% at 1 week, 4 weeks, 3 months and 6 months, respectively. Overall mortality was 50% with a new or worsening encephalopathy rate also of 50%. Patients with lower serum bilirubin and serum creatinine prior to TIPSS insertion had greater response at 1 and 4 weeks, respectively. There was no improvement in either liver or renal function after TIPSS insertion by standard laboratory tests, although serum sodium increased in the responders after 1 month. CONCLUSION: TIPSS improves refractory ascites in only a minority of patients, and is associated with high encephalopathy and mortality rates.

A comparison between gastric and oesophageal variceal haemorrhage treated with transjugular intrahepatic portosystemic stent shunt (TIPSS).

BACKGROUND: Transjugular intrahepatic portosystemic stent-shunts (TIPSS) are becoming widely used in the management of oesophageal variceal haemorrhage (OVH). Their place in the treatment of gastric variceal haemorrhage (GVH), a condition with a traditionally poor prognosis, remains unclear. The aims of our study were to compare portal haemodynamics and patient outcome in patients undergoing TIPSS for either GVH or OVH. PATIENTS AND METHODS: 106 consecutive patients undergoing TIPSS at our institution for either GVH (32 patients) or OVH (74 patients) were studied. The groups were similar with regard to patient age, aetiology and severity of liver disease and number of procedures carried out as an emergency (34.4% vs. 36.5%). Episodes of shunt insufficiency, rebleeding, encephalopathy and other clinical sequela were recorded. Mean follow-up was similar in both patient groups (14.2 vs. 12.1 months). RESULTS: Baseline portocaval pressure gradient was lower in patients with GVH compared with those with OVH (13.0+/-0.9 mmHg vs. 19.0+/-0.6 mmHg) (P < 0.001). Rates of variceal rebleeding, encephalopathy and shunt insufficiency during follow-up were similar in both groups and there was no difference in survival. CONCLUSION: Patients with GVH had markedly lower portocaval pressure gradients than those with OVH, but shunt and clinical complications and survival were similar during follow-up. TIPSS appears to be an effective treatment for GVH and should be compared with endoscopic or surgical techniques in controlled trials.

Transjugular intrahepatic portosystemic stent-shunt (TIPSS): long-term follow-up.

We assessed the long-term efficacy of transjugular intrahepatic portasystemic stent-shunt (TIPSS) in 64 patients. Insertion was successful in 56 patients (87.5%). The reasons for its use were: variceal bleeding (49); ascites (6); portal hypertensive gastropathy (6); hypersplenism (2); and embolization of a spontaneous shunt (1). Fourteen patients were Childs A, 20 Childs B and 28 Childs C cirrhotics. Two patients were non-cirrhotic; one with amyloidosis and one with non-cirrhotic portal fibrosis. Patients were followed clinically and radiologically (Doppler ultrasonography and routine portography at 6 months). During 33 patient-years of follow-up, 22 died, 12 during index admission (two were procedure-related) and nine were transplanted. Twenty-five patients are alive, with a mean survival of 7.1 (SD 7) months. Variceal rebleeding occurred in 10 patients (22.7%), one of whom died, and was always associated with shunt insufficiency (shunt thrombosis 2, hepatic vein stenosis (HVS) 1, intimal hyperplasia (IH) 4, dislocated stent 1, inadequate stent 2). Clinical encephalopathy was induced in seven patients (17.1%) following TIPSS. All responded to medical therapy, but two required reduction in shunt size. Ascites improved after TIPSS in 36 patients (87.8%), but reaccumulated in seven (17.5%), associated with shunt dysfunction in five (SBP 2, IH 3, HVS 2). Fatal sepsis occurred in two patients, and 14 other episodes of infection required antibiotics. TIPSS is a useful treatment for variceal bleeding, resistant ascites and portal hypertensive gastropathy. Shunt dysfunction and sepsis occur frequently, and regular surveillance is necessary.

Predicting survival in patients with liver cancer considered for transarterial chemoembolization.

INTRODUCTION: Transarterial chemoembolization (TACE) has been used extensively to treat tumours confined to the liver in patients unsuitable for surgical resection. This study attempts to identify patients with liver cancer most likely to benefit from this type of treatment. PATIENTS AND METHODS: All patients undergoing TACE for liver cancer between 1989 and 2001 were included in the study. RESULTS: In a group of 137 consecutive patients undergoing TACE, univariate analysis identified a number of pre-treatment factors that were associated with poor prognosis. Multivariate analysis of these factors subsequently identified three pre-treatment factors; age greater than 60, serum alkaline phosphatase concentration >120U/l and albumin less than 35 g/l; that were independently and significantly associated with reduced survival duration. A scoring system was devised with one point allocated for each adverse factor which produced median survivals related to points scored as follows, 0 points-20 months, 1 point-12 months, 2 points-7 months and 3 points-4 months. To validate this scoring system the next 40 consecutive patients undergoing TACE were studied prospectively. These patients had median survival durations related to points scored as follows 0 points not calculable, 1 point-10 months, 2 points-7 months, 3 points-4 months. CONCLUSION: This simple scoring system can be used to predict prognosis in patients with liver cancer and may assist in clinical decision making in the selection of patients likely to benefit from TACE.

Prospective evaluation of haematological alterations following the transjugular intrahepatic portosystemic stent-shunt (TIPSS).

BACKGROUND: TIPSS is effective in reducing portal hypertension and provides access to the portal system for direct pressure measurements. OBJECTIVE: To assess the incidence and severity of haemolysis and its course following TIPSS, and also to assess changes in spleen size and any relationship to changes in the platelet and white cell count and haemoglobin concentration. DESIGN: A prospective study. MATERIALS AND METHODS: Twenty-three patients undergoing TIPSS with a mean follow-up of 8 months (SE 1.2) were studied. Male-female ratio was 13:10 and the mean age was 53.6 years (SE 1.7). Full blood count, reticulocyte count, serum haptoglobin, urinary haemosiderin, examination of the peripheral blood smear and spleen size (ultrasonography) were measured prior to and 3, 7 and 30 days after TIPSS and 6-monthly thereafter. RESULTS: Seven patients (30.4%) developed haemolysis, which was clinically significant in three (13%). This settled spontaneously within 2 weeks of TIPSS. Portal pressure gradient was reduced from a mean of 21.9 (SE 1.6) to 9.5 (SE 1) mmHg (P < 0.001) and did not change significantly thereafter. Haemoglobin concentration improved significantly from a mean of 89 (SE 16) to 113 (SE 19) g/l (P < 0.05) after TIPSS. Significant changes in spleen size and platelet count occurred, with a reduction in the former from 16.9 (SE 1.1) to 13.7 cm (SE 2.4) (P < 0.01) and an increase in the latter from 85.9 (SE 8.4) to 135.3 x 10(9)/l (SE 16.8) (P < 0.01). No significant correlations were found between the changes in the portal pressure gradient, spleen size and platelet count. There was no significant change in the white cell count. CONCLUSION: Transient significant haemolysis occurs in about 13% of patients following TIPSS. TIPSS is useful for reducing splenomegaly and improving thrombocytopenia and haemoglobin. There is no correlation between the changes in portal pressure gradient, spleen size and platelet count.

Direct measurement of post-prandial portal haemodynamics in cirrhotic patients with a transjugular intrahepatic portosystemic stent-shunt.

OBJECTIVE: Portal haemodynamics vary in response to eating and other stimuli, but any increase in portal venous pressure (PVP) in cirrhotic patients may be a risk factor for variceal bleeding. We directly assessed post-prandial splanchnic haemodynamics in cirrhotic patients with a transjugular intrahepatic portosystemic stent-shunt (TIPSS) in situ. METHODS: A thermodilution catheter was inserted via the patent TIPSS into the portal vein in 12 cirrhotic patients. PVP,portal venous flow (PVF) (thermodilution method), portal vascular resistance (PVR), porto-atrial pressure gradient (PPG), heart rate, mean arterial pressure (MAP) and right atrial pressure (RAP) were measured. A 505 kcal meal was given and all haemodynamic measurements were repeated at 15 min intervals for 60 min. RESULTS: Following the meal, there was a significant rise in PVP from 11.2 +/- 1.5 to 14.0 +/- 1.9 mmHg at 15 min, and 14.0 +/- 1.8 mmHg at 30 min (P < 0.001); in PPG from 9.5 +/- 1.4 to 12.7 +/- 2.2 mmHg at 15 min and 12.7 +/- 2.1 mmHg at 30 min (P < 0.005); and in PVF from 1110.2 +/- 141.1 to 1543.2 +/- 227.6 ml/min at 30 min (P < 0.01). PVR feil from 0.08 +/- 0.01 to 0.05 +/- 0.01 RU at 30 min (P < 0.05). Heart rate increased from 77 +/- 4.1 to 80.5 +/- 5.4 bpm at 15 min (p < 0.05), but MAP and RAP remained unchanged. CONCLUSION: In cirrhotic patients with TIPSS, significant changes in portal haemodynamics occur at 15-30 min following a meal, with minimal effect on systemic haemodynamics. This model offers a new technique to directly assess the causes for and possible treatments of post-prandial splanchnic hyperaemia in cirrhosis.

Transjugular intrahepatic portosystemic stent-shunt (TIPSS) insertion as a prelude to orthotopic liver transplantation in patients with severe portal hypertension.

OBJECTIVE: To investigate the impact of preoperative transjugular intrahepatic portosystemic stent-shunt (TIPSS) on patients undergoing liver transplantation. DESIGN: A retrospective non-randomized comparative clinical study. SETTING: Tertiary referral institution. PATIENTS, PARTICIPANTS: Twenty-four patients with liver cirrhosis, portal hypertension and gastro-oesophageal varices who underwent liver transplantation. INTERVENTIONS: TIPSS insertion had been performed preoperatively in 12 patients. MAIN OUTCOME MEASURES: Operative dissection times and blood transfusion requirements during liver transplantation. Postoperative complication rate. Cumulative patient and graft survival. RESULTS: There were no significant differences in outcome measures between patients with and without previous TIPSS insertion with respect to recipient hepatectomy times (mean 192 min (126-280) versus 196 min (145-254)), total operating time (mean 484 min (330-690) versus 486 min (370-580)), intraoperative blood transfusion (mean 11 units (2-29) versus 12 units (2-30)), intraoperative fresh frozen plasma transfusion (mean 9 units (1-16) versus 11 (2-23) units), patient survival (83% versus 92% cumulative 1-year survival), graft survival (80% versus 83% cumulative 1-year survival), or postoperative complication rates. CONCLUSION: TIPSS insertion is feasible and relatively safe as a 'bridge to transplantation' in patients who have had a variceal haemorrhage. There is little evidence that preoperative TIPSS insertion directly affects the performance of liver transplantation as TIPSS neither, hinders nor facilitates surgery or post operative survival. Although it is important that the potential hazards of TIPSS extension into the inferior vena cava or superior mesenteric vein be recognized, liver transplant surgeons need not be unduly concerned about the overall impact of TIPSS as it becomes more universally available in the management of variceal haemorrhage.

Mechanisms of changes in renal handling of sodium following transjugular intrahepatic portal systemic stent-shunt (TIPSS).

BACKGROUND AND AIMS: Transjugular intrahepatic portosystemic stent-shunt (TIPSS) reduces the portal pressure gradient and leads to better control of ascites. The aim of this study was to evaluate (1) changes in renal handling of sodium following TIPSS and (2) the mechanism of these changes. DESIGN: Prospective study. SETTING: Tertiary referral centre for liver diseases. METHODS: Eighteen patients with ascites undergoing TIPSS for recurrent variceal haemorrhage (16) (3 or more hospital admissions because of variceal haemorrhage whilst being treated endoscopically) or refractory ascites (2) were studied. Urinary sodium (UNa), creatinine clearance (CrCl), plasma renin activity (PRA), atrial natriuretic peptide (ANP), cyclic guanosine monophosphate (cGMP), Angiotensin II (AII) and lithium clearance (LiCl) were measured before and 3 months after TIPSS when portography was performed and the portal pressure gradient (PPG) also measured. All patients were haemodynamically stable and had received no diuretics for at least 1 week before blood sampling. RESULTS: Improvement in ascites was achieved in all patients in whom TIPSS was inserted successfully (reduction in PPG to < 12 mmHg). PPG was reduced from a mean of 19 (+/-6) to 8.8 (+/-3.4) mmHg (P < 0.001). Urinary sodium and creatinine clearance improved significantly following TIPSS (P < 0.001, P < 0.001, respectively). PRA, All, cGMP and LiCl were abnormal before TIPSS and improved significantly following TIPSS (P < 0.007, P < 0.001, P < 0.001 and P < 0.01, respectively). ANP was not significantly different from normal controls and did not change significantly following TIPSS. Changes in UNa did not correlate with the Pugh score or the change in PPG. CONCLUSION: The results of this study show that TIPSS is associated with significant improvement in UNa, CrCl, PRA, AII, cGMP and LiCl. The change in UNa following TIPSS was independent of the severity of underlying liver disease or the change in PPG.

Transjugular intrahepatic portosystemic stent-shunt insufficiency and the role of diabetes mellitus.

BACKGROUND/AIMS: Maintenance of long-term patency of transjugular intrahepatic portosystemic stent-shunts (TIPSS) has proved problematic. Various prognostic variables have been assessed as predictors, but the role of diabetes mellitus, which induces vascular endothelial cell dysfunction, has not been assessed. METHODS: We analysed the records of 248 patients who underwent TIPSS between July 1991 and July 1997, followed-up through to August 1998. Patients with at least one shunt assessment by portography and available blood glucose levels were eligible (177 patients; median follow-up, 15.0 months). Fourteen patients had a pre-procedural diagnosis of diabetes (one insulin dependent, seven oral hypoglycaemic treated and six diet controlled). In another 14 patients, diabetes was diagnosed at TIPSS insertion, giving a 28/177 (15.8%) prevalence of diabetes in our patients. Fifty-nine patients were excluded from the final analysis (including five diabetics), as they either died or had early shunt insufficiency (within 1 month of stent placement), leaving 118 patients (including 23 diabetics) to be included in the final analysis. RESULTS: Mean age, sex distribution, median follow-up (months) and pre-shunt portal pressure gradient were comparable in the two groups (diabetics versus non-diabetics). Child-Pugh classes A and B were more common in the diabetic group (P < 0.01), and the mean inserted stent diameter was larger in the diabetic group (P < 0.05). The presence of diabetes was associated with a higher incidence of delayed shunt insufficiency (P = 0.02), but there was no evidence of an association between presence of diabetes and variceal haemorrhage post TIPSS. Kaplan-Meier analyses revealed earlier insufficiency in diabetic patients compared with those without diabetes (P = 0.04). Age, gender and presence of diabetes are included in the final logistic regression model. Individuals who have diabetes are more likely to experience shunt insufficiency independent of age and gender. CONCLUSIONS: Diabetes mellitus is common in patients undergoing TIPSS and is associated independently with increased incidence of primary delayed shunt insufficiency.

Case report: inferior vena caval thrombosis following severe liver trauma and perihepatic packing--early detection by intraoperative ultrasonography enabling treatment by percutaneous mechanical thrombectomy.

Patients with severe liver trauma present a major challenge in management. We report the successful treatment of a patient presenting with a severe liver injury. The detection of major inferior vena caval thrombosis by intraoperative ultrasonography enabled the use of a percutaneous thrombectomy device to facilitate dissolution of the thrombus.

The role of duplex and colour Doppler ultrasound in the follow-up evaluation of transjugular intrahepatic portosystemic stent shunt (TIPSS).

Transjugular intrahepatic portosystemic stent shunt (TIPSS) is an effective means of controlling acute variceal haemorrhage. Shunt occlusion or stenosis occurs in up to 30% of patients within 6 months. It is important to detect these patients and intervene to prevent rebleeding. We have compared non-invasive Doppler ultrasound with the portal pressure gradient (PPG) at portography at 3 month follow-up in 23 patients. All patients with a shunt peak velocity greater than 90 cm s-1 (7 of 17 analysable results) had normal shunt function at portography (PPG < 12 mmHg). Portography may therefore be avoided in this group, although the majority of patients will still require portography for TIPSS follow-up assessment.

Case report: computed tomography features of complete splenic infarction, cavitation and spontaneous decompression complicating pancreatitis.

Splenic infarction is a rare complication of pancreatitis. We present the case of a 34-year-old woman, who had undergone previous drainage of a pancreatic pseudocyst, and who represented with left upper quadrant pain. Absence of enhancement of the splenic parenchyma during contrast enhanced computed tomography (CT) allowed confident diagnosis of complete splenic infarction. A later CT scan revealed splenic cavitation with spontaneous decompression into the stomach. The aetiology of these unusual complications of pancreatitis is discussed.

Transjugular intrahepatic portosystemic stent shunt.

The transjugular intrahepatic portosystemic stent shunt (TIPSS) is essentially a side-to-side portocaval shunt performed by interventional radiological methods which connects the hepatic vein to the portal vein via the liver parenchyma. It can be performed successfully in 85% to 95% patients. The procedure mortality is low (1% to 2%) and is mainly from intraperitoneal bleeding. Major indications for TIPSS are in patients in whom sclerotherapy for bleeding varices has failed, those who have recurrent variceal haemorrhage after sclerotherapy or band ligation and in patients with refractory ascites, hypersplenism and portal gastropathy. It has also been used in some patients with the Budd-Chiari syndrome, portal vein thrombosis and cirrhotic hydrothorax. TIPSS is followed by variceal rebleeding and encephalopathy in about 10% to 20% of cases, deterioration in liver function in about 25% to 35% and shunt dysfunction in 15% to 60%. Further research should be directed at developing newer types of stents to prevent shunt dysfunction.

Colonic stricture in cystic fibrosis unmasked by successful transjugular intrahepatic portosystemic stent shunt (TIPSS).

TIPSS was successfully performed in a 10-year-old female cystic fibrosis (CF) patient with bleeding gastric varices due to portal hypertension; precipitation of portosystemic encephalopathy later unveiled the presence of a latent colonic stricture associated with high potency pancreatic enzymes. The unusual sequence of events resulting from the co-existence of two CF pathologies are described, and the implications of treatment discussed.