Massive gastrointestinal bleeding after transjugular intrahepatic portosystemic shunt (TIPS)

Clinical presentation

A patient with end-stage liver disease secondary to haemochromatosis was transferred to our hospital for variceal bleeding. During the previous 5 months, she underwent 10 oesophagogastroduodenoscopies (EGD) with repeated endoscopic band ligations (EBL). Following the most recent EBL, she was transferred to our hospital for emergent transjugular intrahepatic portosystemic shunt (TIPS) procedure. The patient arrived on mechanical ventilator support with continuous infusion of intravenous inotropes. After multiple blood transfusions and supportive measures, she had a successful TIPS procedure (mean portal-systemic gradient decreased from 11 mm Hg to 4 mm Hg). She recovered and was transferred to the general medical ward.

Six days after the TIPS, she had another episode of hematochezia, tachycardia and worsening anaemia (haemoglobin dropped from 8.9 g/dL to 5.5 g/dL in 4 hours). The patient was in circulatory shock and was transferred back to the critical care unit. TIPS was interrogated and was found with adequate flow velocities (figure 1), with portal venous end of 87 cm/s,...

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