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OVERLAP OF DIAGNOSTIC AND THERAPEUTIC INTERVENTIONS IN GASTROENTEROLOGY

Several diagnostic tests commonly used by gastroenterologists also have therapeutic potential; for information about EGD, colonoscopy, ERCP, and other modalities, refer to the Diagnostics section of this chapter.

PARACENTESIS

  • Indications: 1) All patients with new-onset ascites of uncertain cause, 2) All patients with preexisting ascites in whom SBP is suspected, 3) All patients with cirrhosis and ascites who are being admitted to the hospital

  • Variations: Diagnostic (obtain small sample for testing), therapeutic (large-volume paracentesis)

  • Tests to consider: See Table 4.14

  • Relative contraindications: Fluid <2 cm deep from abdominal wall, severe thrombocytopenia (platelet count <50K/µL), DIC; no specific INR cutoff for patients with cirrhosis

  • Complications: Complications of fluid shifts (e.g., hypotension, AKI), abdominal wall hematoma, intraabdominal bleeding, wound infection, persistent leak from the puncture site

TABLE 4.14Laboratory Tests Commonly Ordered to Evaluate Ascites Fluid

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS)

FIGURE 4.10

Transjugular intrahepatic portosystemic shunt (TIPS). TIPS is a shunt or bypass used to connect two veins within the liver – the portal vein and the hepatic vein – in order to treat portal hypertension.

  • Concept: Placement of a TIPS (via angiographic techniques) creates a low-resistance channel between the hepatic vein and an intrahepatic branch of the portal vein and thus helps to reduce elevated portal pressure (Figure 4.10)

  • Indications: Bleeding related to portal hypertension, management of refractory ascites

  • Contraindications:

    • - Absolute contraindications: Congestive heart failure, severe pulmonary hypertension, severe tricuspid regurgitation, multiple hepatic cysts, active systemic infection, biliary obstruction

    • - Relative contraindications: Obstruction of all hepatic veins, hepatocellular carcinoma (especially if centrally located), portal vein thrombosis, thrombocytopenia (platelets <20K/µL)

  • Complications:

    • - Intraprocedural complications: Cardiac arrhythmias, liver capsule puncture

    • - Postprocedural complications: Hepatic encephalopathy, heart failure, liver failure, infection, TIPS dysfunction

MEDICATIONS

TABLE 4.15Key Medications in Gastroenterology

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