What happens to ascites post TIPSS procedure?

[Clarinetta]

Hi I have a question to any members who have had a TIPS shunt: what happens to ascites after the procedure?

Father in law is being referred for assessment, as he has been having fortnightly drains for refractory ascites for many months.

I think the shunt redirects fluid to renal system so does that mean any ascites is expelled via urine? Or is there still a drain involved at some point afterwards?

Just looking for some easy to understand information so that we can make sure he is fully informed.

Many thanks

[AyrshireK]

The rationale for TIPS is to decrease the portal pressure and the filtration into the peritoneal space to a level which can be drained by the lymphatic system. Thus, in contrast to diuretics and paracentesis, TIPS may counteract the mechanisms leading to ascites formation.

Within 4 weeks after TIPS urinary sodium excretion and serum creatinine improve significantly and, in combination with diuretics, can normalise within 6–12 months (This is associated with a gradual increase in urinary volume and glomerular filtration rate).

The shunt is like a canal going through the liver to channel blood through quickly and reduce portal veinous pressure (portal hypertension) - in the cirrhotic liver blood can't get through and starts to back up into the portal vein and other minor blood vessels leading to the issues associated with portal hypertension including varices and ascites. Following TIPSS procedure this pressure is reduced andthe mechanism for ascites formation is reduced too so you shouldn't see further ascites build up. Any fluid present at time of the procedure will gradually be dealt with by diuretics and urine output.

The one downside of TIPSS to be aware of is that it very often leads to an increase in symptoms of hepatic encephalopathy because blood is now being channeled through the canal/stent and it isn't filtering through the liver and is therefore not stripped of toxins which can build up in blood and make their way to the brain. Even the blood going slowly through the damaged liver will be having some of the toxins filtered out but not so after tipss.

I see you saying about assessment - is that for possible transplant? If so then tipss may well be a good interim step to perhaps give him some more time.

Best wishes, Katie

[Clarinetta in reply to AyrshireK]

Ah ok that’s much clearer thank you Katie. 😊

Unfortunately transplant has now been ruled out due to age (72) and the poor state of his health.

To be honest we’re not certain they’ll even go ahead with the TIPS as he has not been looking after himself despite every thing his family have done to support and motivate him. We’ve been told the anaesthetist will prob have final say on that.

It’s something we’re prepared for but are still crossing fingers it goes ahead if it’s the right thing for him.

HE is definitely one of our concerns (we suspect he already has low grade HE at the mo) but he has been on lactulose 3x daily for a number of months and that will continue, plus we fortunately have a community matron involved at present via local frailty team and I *assume* he will be observed and managed through them afterwards.

Thanks again 😊

[Richard-Allen]

There is a rather nice American video I often use that explains the procedure. Hopefully this may be of some help Clarinetta: youtu.be/O2u4_hF3234(Not working as expected?)

[Clarinetta in reply to Richard-Allen]

Thanks Richard- that’s a good video and shows the procedure pretty clearly.

Appreciate you taking the time to send the link 😊

[heslinjones in reply to Richard-Allen]

Good day Richard. Thanks so much for sharing. Very informative and has helped me greatly understand what was done to me and why and why I keep getting a bit of a fuzzy head much appreciated.

[Liverandlife]

I have been assessed and rejected for both a transplant and the TIPPS procedure (old age - 74 + a number of other problems). The procedure shown in the video is amazing but although I regret not being able to have it, I am also in a way relieved as I can see why it was thought my general ill-health would mitigate against a successful outcome. I am now on a highly medicated regime which keeps me going and avoids some of the side effects such encephalitis.