TIPS Encephalopathy Management — RACP Adult Medicine MCQ

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HardGastroenterology & HepatologyTIPS Encephalopathy ManagementRACP Adult Medicine

A 62-year-old woman with cirrhosis and refractory ascites undergoes TIPS placement. Post-procedure, her ascites improves but she develops worsening hepatic encephalopathy refractory to lactulose and rifaximin. What intervention may be needed?

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Correct answer: A — TIPS stent reduction (narrowing the shunt diameter)

Worsening hepatic encephalopathy after TIPS is the most common complication (~25–30% of patients). If encephalopathy is refractory to maximal medical therapy (lactulose + rifaximin), TIPS stent reduction (either balloon-assisted or parallel stent placement to reduce flow) can decrease the shunt volume and improve encephalopathy while maintaining some portal decompression benefit. In extreme cases, TIPS occlusion may be necessary but sacrifices the portal decompression effect. Liver transplant assessment should be ongoing.

Reference: eTG – 2025 – Gastrointestinal; EASL – 2018 – Decompensated Cirrhosis; AASLD – 2019 – TIPS