American Board of Internal Medicine (ABIM) Certification Practice Exam

When is a transjugular intrahepatic portosystemic shunt (TIPS) typically considered for patients with refractory ascites?

1. In the presence of heart failure

2. In the absence of hepatic encephalopathy

3. When the serum bilirubin level exceeds 4 mg/dL

4. In patients with severe pulmonary hypertension

The correct answer is: In the absence of hepatic encephalopathy

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure utilized to alleviate complications of portal hypertension, particularly refractory ascites. One of the most crucial considerations for TIPS candidacy is the patient's neurological status, specifically the presence or absence of hepatic encephalopathy. In patients with liver disease, hepatic encephalopathy is a significant concern because TIPS can increase the risk of worsening encephalopathy due to shunting blood away from the liver, where toxins are typically metabolized. Therefore, TIPS is generally preferred in patients who do not have hepatic encephalopathy, as treating with TIPS in these patients is more likely to be successful and less risky in terms of cognitive complications. The other factors mentioned in the incorrect options are generally either contraindications or considerations that do not align with the standard guidelines for TIPS placement in the context of refractory ascites. Heart failure, severe pulmonary hypertension, or elevated serum bilirubin levels can complicate the patient's overall condition and might influence the decision-making process against proceeding with TIPS. Therefore, the absence of hepatic encephalopathy represents a clear criterion for considering TIPS as a viable option for managing refractory ascites in patients.