A cirrhotic patient with MELD score 18 develops ascites refractory to maximally tolerated diuretics. He is not a transplant candidate currently. What procedure is indicated and what is the key complication to prevent pharmacologically?
- A Large-volume paracentesis (LVP) with albumin; TIPS is reserved for variceal bleeding only
- B Peritoneovenous shunt; DIC is the key complication
- C Transjugular intrahepatic portosystemic shunt (TIPS); hepatic encephalopathy is the main complication ✓
- D Surgical porto-systemic shunt; post-shunt liver failure
Correct answer: C. Transjugular intrahepatic portosystemic shunt (TIPS); hepatic encephalopathy is the main complication
Explanation
TIPS is effective for refractory ascites, reducing portal pressure and improving diuretic response. Hepatic encephalopathy (HE) occurs in 25–35% of patients post-TIPS, as portal blood (containing ammonia and other toxins) bypasses the liver. TIPS is contraindicated when MELD > 18 by some guidelines, but can be used in selected patients. LVP with intravenous albumin (8 g per litre of ascites removed) is used for episodic management, not definitive treatment of refractory ascites in transplant-ineligible patients where TIPS is more appropriate long-term.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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