Feenalie Patel, MD1, Benjamin L. Bick, MD2; 1Indiana University, Indianapolis, IN; 2Indiana University School of Medicine, Indianapolis, IN
Introduction: Transjugular intrahepatic portosystemic shunt (TIPS) is a first-line therapy for refractory portal hypertension. Biliary complications are rare and, when present, are noted to be due to biliary-shunt fistulas that form over time. We present an unusual complication of immediate biliary obstruction due to TIPS transecting the biliary tract, identified with the aid of digital single-operator pancreatoscopy (d-SOP).
Methods: A 19 year-old male with non-cirrhotic portal hypertension secondary to portal and splenic vein thrombosis with cavernous transformation status post TIPS, gastric esophageal varices status post coil embolization, and thrombophilia due to Factor V Leiden heterozygosity presents with jaundice. He had TIPS with prophylactic left gastric varices coil embolization without any procedural complications two days prior to admission. Since then, he has had worsening abdominal pain and jaundice. At presentation, he is found to have elevated liver enzymes with a total bilirubin of 18.4 mg/dL and direct bilirubin of 14.8 mg/dL (Table 1). CT triple phase of the abdomen/pelvis and ultrasound of the TIPS reveal patent flow through the TIPS. Due to his recent coil, he is unable to undergo magnetic resonance cholangiopancreatography (MRCP) to evaluate the biliary tract, so endoscopic retrograde cholangiopancreatography (ERCP) is performed. The cholangiogram (Figure 1) demonstrates biliary tract obstruction at the bifurcation of the right and left hepatic ducts. D-SOP is utilized to differentiate biliary compression from biliary transection, which confirms transection of the common hepatic duct from the shunt. An external and internal percutaneous biliary catheter is placed for biliary decompression, with plans for surgical repair in the future. Discussion: This case demonstrates a rare biliary complication of TIPS. Biliary complications of TIPS are typically due to biliary-shunt fistulas, which can be amenable to endoscopic therapy with biliary stenting. While nearly a dozen cases have noted biliary-fistula shunts as a complication of TIPS, only one other case has been reported in the literature of malpositioning and occlusion of the biliary tract. Unlike the other case study, our patient was unable to undergo MRCP to visualize the biliary tract. For other patients with post-TIPS biliary tract obstruction, our case presents a novel use for d-SOP in identifying this rare complication and appropriately differentiating biliary compression versus transection from TIPS.
Table 1: Trend in Liver enzymes Following Transjugular Intrahepatic Portosystemic Shunt Placement
Figure 1: Endoscopic retrograde cholangiopancreatography was performed to better visualize the biliary tract. This fluoroscopy image shows the transjugular intrahepatic portosystemic shunt (red asterisk) appearing to compress the biliary duct at the level of the hepatic bifurcation (blue arrow).
Figure 2: Visualization of the biliary tract using digital single-operator pancreatoscopy reveals bile duct compression (A) and the presence of the TIPS stent within the biliary tract (B).
Disclosures: Feenalie Patel indicated no relevant financial relationships. Benjamin Bick indicated no relevant financial relationships.