Internal Medicine

Transjugular Intrahepatic Portosystemic Shunt (TIPS) in Portal Hypertension

Portal hypertension is the increased blood pressure within the portal venous system, which can lead to serious complications like variceal bleeding, refractory ascites, and hepatic hydrothorax. TIPS reduces portal hypertension by diverting a portion of the portal blood flow directly into the systemic circulation, thereby decreasing the pressure in the portal venous system

The key indications include recurrent variceal bleeding that is unresponsive to endoscopic or pharmacological treatments, refractory ascites that does not respond to diuretics or repeated paracentesis, and hepatic hydrothorax resistant to medical therapy. Additionally, TIPS may be used in managing Budd-Chiari syndrome, where thrombosis of the hepatic veins leads to increased portal pressure.

Transducer marker pointing towards the patient’s right shoulder

Note the overall activity of the heart and any gross abnormality

Note any pericardial effusion especially below the posterior wall

Examine the cardiac segments motion and structure

What do you see here?

How to differentiate the vein from the artery:

The vein is usually:

• Oval in shape, thin walled

• Compressible with gentle pressure

• Non pulsatile

Color Flow (CF)

When applying Color Flow, the top of the box on the left of the screen will indicate the color of the flow towards the transducer, and the bottom of the box indicates the color of the flow away from the transducer. In this example the Flow towards the transducer is red, and the flow away from the transducer is blue

M-mode through the diaphragm showing its movements with deep inspiration as we discussed in our POCUS workshop

@Everyone

Pneumonia

• The lung tissue will resemble the hepatic parenchyma

• B Lines may be present

• In the case of associated pneumonia, Alveolar Consolidations with air bronchogram and possible Shred sign may be seen

@Sundus Basheer

Probe location (zone L3): 4th-10th intercostal spaces, between the anterior & posterior axillary lines.

Transducer Type & Placement

Phased Array or Curvilinear

The footprint is perpendicular to the skin with the marker pointing cephalad

Lung Sliding

Pleural line is found below the chest wall

Movement of pleura with breathing will generate the “lung sliding” sign

• Represents the sliding of the visceral pleura against the parietal pleura

• Using Color Flow (CF) can help identify the pleural line and its movement

Bat Sign: This sign is formed by the shadows of two ribs and the pleural line (looks like a bat flying towards you)

Comet Tail Artifact/B Lines

• Vertical lines, extending from the pleural line to the edge of the screen without fading

• Synchronized with lung sliding

• When present they will usually overshadow the A lines

• Represents thickening interlobular septa and extravascular lung water as in alveolar interstitial disease (pulmonary edema, ARDS...)

A Lines

Can be part of the normal lung signs

Represents normal artifact repetition(s) of the pleural line

Intervals between the A lines are equal to the distance between the skin and the original pleural line

When present without lung sliding, it may indicate the presence of pneumothorax