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Inpatient Management of Portal Hypertension: Decompensation and the Preemptive TIPS Revolution in Hospitalized Patients
In this episode of Hospital Medicine Unplugged, we tackle portal hypertension in hospitalized cirrhosis—find it fast, control bleeding, dry the belly, clear the brain, and pick the right patients for TIPS and transplant.
We open with the diagnosis play: suspect it in cirrhosis with splenomegaly/ascites/varices. Gold standard is HVPG; CSPH = ≥10 mmHg. In real life, lean on liver stiffness + platelets for risk (rule-in ≥25 kPa or rule-out <20 kPa with high platelets), and confirm with varices on endoscopy or collaterals on imaging.
When blood hits the basin—acute variceal bleed—move fast:
• Do first: large-bore access, type & cross, start vasoactive agent immediately (octreotide/terlipressin), give prophylactic IV antibiotics—prefer ceftriaxone, and restrict transfusion to Hgb ~7 g/dL (unless extenuating).
• Endoscopy with band ligation within 12–24 hours.
• Early TIPS for the high risk: Child-Pugh C ≤13 or Child-Pugh B with active bleeding, or if endoscopy/meds fail. This cuts rebleeding and improves survival.
• Avoid routine plasma/platelets; correct coagulopathy only for procedures or active bleeding.
Between bleeds, prevent the next one:
• Primary prophylaxis: NSBBs (propranolol, nadolol, carvedilol preferred for large varices) or banding if NSBB-intolerant.
• Secondary prophylaxis: combo NSBB + band ligation after a bleed.
Ascites management that sticks:
• Sodium <2 g/day.
• Diuretics: spironolactone + furosemide, titrate carefully.
• Large-volume paracentesis for tense/refractory ascites with albumin replacement.
• Consider TIPS for refractory ascites in appropriate candidates.
• Watch for hyponatremia and renal injury—dose-adjust and protect the kidneys.
Encephalopathy, SBP, and kidneys:
• HE: find triggers, lactulose to 2–3 soft stools/day, add rifaximin for secondary prevention.
• SBP: ceftriaxone plus IV albumin (1.5 g/kg day 1, 1 g/kg day 2); consider secondary prophylaxis after recovery.
• HRS-AKI: albumin + vasoconstrictor (terlipressin or norepinephrine), catheterize to trend UOP; evaluate for TIPS in select cases and early transplant referral.
Imaging & surveillance you shouldn’t skip:
• US with Doppler to look for portal vein thrombosis and to screen for HCC (pair with AFP per local protocol).
• Endoscopic surveillance individualized by risk and noninvasive markers rather than one-size-fits-all scopes.
Who gets a shunt (and who doesn’t):
• TIPS controls bleeding and ascites—great in the right patient, risky in the wrong one. Beware high MELD, severe liver failure, or significant cardiac disease (relative/absolute contraindications). Monitor post-TIPS for encephalopathy and shunt dysfunction.
Medication & system pitfalls:
• Don’t over-transfuse—it raises portal pressure.
• Start ceftriaxone early in variceal bleed.
• Carvedilol can drop BP—titrate to tolerance.
• Albumin after paracentesis when >5 L removed.
• Avoid nephrotoxins (NSAIDs, IV contrast when possible).
• Build order sets: vasoactive + antibiotic bundle for bleed, CRP/renal checks, and a TIPS early-evaluation pathway for high-risk bleeders.
We close with the big picture: portal hypertension is the engine of decompensation—catch it, treat bleeds aggressively, use NSBBs/banding wisely, control ascites, and pull the TIPS lever early in the patients who benefit. And never forget the destination for many: timely transplant evaluation once major-index complications appear.
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By Roger Musa, MDIn this episode of Hospital Medicine Unplugged, we tackle portal hypertension in hospitalized cirrhosis—find it fast, control bleeding, dry the belly, clear the brain, and pick the right patients for TIPS and transplant.
We open with the diagnosis play: suspect it in cirrhosis with splenomegaly/ascites/varices. Gold standard is HVPG; CSPH = ≥10 mmHg. In real life, lean on liver stiffness + platelets for risk (rule-in ≥25 kPa or rule-out <20 kPa with high platelets), and confirm with varices on endoscopy or collaterals on imaging.
When blood hits the basin—acute variceal bleed—move fast:
• Do first: large-bore access, type & cross, start vasoactive agent immediately (octreotide/terlipressin), give prophylactic IV antibiotics—prefer ceftriaxone, and restrict transfusion to Hgb ~7 g/dL (unless extenuating).
• Endoscopy with band ligation within 12–24 hours.
• Early TIPS for the high risk: Child-Pugh C ≤13 or Child-Pugh B with active bleeding, or if endoscopy/meds fail. This cuts rebleeding and improves survival.
• Avoid routine plasma/platelets; correct coagulopathy only for procedures or active bleeding.
Between bleeds, prevent the next one:
• Primary prophylaxis: NSBBs (propranolol, nadolol, carvedilol preferred for large varices) or banding if NSBB-intolerant.
• Secondary prophylaxis: combo NSBB + band ligation after a bleed.
Ascites management that sticks:
• Sodium <2 g/day.
• Diuretics: spironolactone + furosemide, titrate carefully.
• Large-volume paracentesis for tense/refractory ascites with albumin replacement.
• Consider TIPS for refractory ascites in appropriate candidates.
• Watch for hyponatremia and renal injury—dose-adjust and protect the kidneys.
Encephalopathy, SBP, and kidneys:
• HE: find triggers, lactulose to 2–3 soft stools/day, add rifaximin for secondary prevention.
• SBP: ceftriaxone plus IV albumin (1.5 g/kg day 1, 1 g/kg day 2); consider secondary prophylaxis after recovery.
• HRS-AKI: albumin + vasoconstrictor (terlipressin or norepinephrine), catheterize to trend UOP; evaluate for TIPS in select cases and early transplant referral.
Imaging & surveillance you shouldn’t skip:
• US with Doppler to look for portal vein thrombosis and to screen for HCC (pair with AFP per local protocol).
• Endoscopic surveillance individualized by risk and noninvasive markers rather than one-size-fits-all scopes.
Who gets a shunt (and who doesn’t):
• TIPS controls bleeding and ascites—great in the right patient, risky in the wrong one. Beware high MELD, severe liver failure, or significant cardiac disease (relative/absolute contraindications). Monitor post-TIPS for encephalopathy and shunt dysfunction.
Medication & system pitfalls:
• Don’t over-transfuse—it raises portal pressure.
• Start ceftriaxone early in variceal bleed.
• Carvedilol can drop BP—titrate to tolerance.
• Albumin after paracentesis when >5 L removed.
• Avoid nephrotoxins (NSAIDs, IV contrast when possible).
• Build order sets: vasoactive + antibiotic bundle for bleed, CRP/renal checks, and a TIPS early-evaluation pathway for high-risk bleeders.
We close with the big picture: portal hypertension is the engine of decompensation—catch it, treat bleeds aggressively, use NSBBs/banding wisely, control ascites, and pull the TIPS lever early in the patients who benefit. And never forget the destination for many: timely transplant evaluation once major-index complications appear.