A 52-year-old female with a history of alcoholic cirrhosis presented to the ED with complaints of hematemesis. She reported one episode of possible blood-tinged emesis followed by an episode of emesis that was clear liquid without blood. She denied blood in her stool. She did have an episode of epistaxis prior to the hematemesis. She had a prior history of massive GI bleeding from esophageal varices. A TIPS procedure (transjugular intrahepatic postosystemic shunt) had been performed a year prior because of frequent bleeding from varices. Since the procedure, she had not had any further episodes of GI bleeding.
Initial VS: BP 104/68, HR 96, T 36.5 °C (97.7 °F), RR 16, SpO2 93% on RA
Physical exam revealed a soft, non-tender, and non-distended abdomen. Rectal exam was performed, and stool was guaiac negative. There was dried blood present in the right nostril.
The ED team taking care of the patient wanted to know if the TIPS was still working so a BSUS was performed.
A RUQ view was obtained to look for ascites. See below.
No ascites was noted, which was somewhat reassuring. When a TIPS fails, the signs of portal hypertension will often become apparent again, including re-accumulation of ascites.
To evaluate the TIPS, the team started by finding the portal vein within the liver. See below.
You can see that the shunt appears hyperechoic compared to what a normal vein would look like. This is because of the synthetic shunt that is in place.
Next, color Doppler was placed over the shunt. See below.
You can see that flow is present through the shunt, indicating that it is not occluded. To assess whether or not there is stenosis within the stent, Doppler velocity studies would have to be performed and compared to previous studies. This was not done in the ED.
Labs revealed hemoglobin of 13.9, which was at her baseline.
She was admitted to the hospital for serial hemoglobin checks and GI consultation. Her hemoglobin remained stable. GI saw her and performed an EGD, which showed no residual varices. The episode of hematemesis was attributed to the epistaxis, and she was discharged on hospital day 2.
Bottom Line:
1. New ascites can be a sign that a TIPS is not working.
2. Color Doppler can easily and reliably assess for thrombosis occluding a TIPS.
