Makindo Medical Notes

🫀 Transjugular Intrahepatic Portosystemic Shunt (TIPS) is a radiological procedure creating a channel between the portal vein and hepatic vein to relieve portal hypertension. It is mainly used for variceal bleeding and refractory ascites.

🎯 Indications for TIPS

• 🩸 Variceal Bleeding: Refractory/recurrent bleeding not controlled by endoscopy.
• 💧 Refractory Ascites: Resistant to diuretics or requiring repeated paracentesis.
• 🌊 Hepatic Hydrothorax: Pleural effusion due to portal hypertension.
• 🫀 Budd-Chiari Syndrome: Venous outflow obstruction.
• 🩺 Portal Vein Thrombosis: Selected cases to restore flow.

🛠️ Procedure

• Access: Via the internal jugular vein → catheter advanced into hepatic veins.
• Shunt Creation: Needle puncture from hepatic vein into portal vein tract.
• Stent Placement: Maintains portosystemic channel, diverting blood into systemic circulation.

⚙️ Pathophysiology

• Portal Hypertension: Cirrhosis → ↑ portal pressure → varices & ascites.
• TIPS Effect: Reduces portal pressure → ↓ variceal bleed risk & ascites formation.

🚫 Contraindications

• Severe/recurrent hepatic encephalopathy.
• Advanced right heart failure.
• Severe liver failure (Child-Pugh C, MELD >15).
• Active sepsis.
• Extensive portal vein thrombosis.

🦷 Ameloblastoma is a rare, benign but locally aggressive odontogenic tumour arising from the enamel-forming epithelium. Most commonly in the mandible, it can cause significant jaw expansion and deformity if untreated.

📖 About

• Incidence: ~1% of all jaw tumours/cysts.
• Age Group: Peak 30–50 years (but any age possible).
• Location: Mandible (esp. molar & ramus region) >> Maxilla.
• Histopathology: From dental lamina, enamel organ, or odontogenic cyst lining.

🧬 Etiology

• Exact cause uncertain, but linked with:
  • Genetic mutations → esp. BRAF V600E.
  • Chronic irritation/inflammation.
  • Association with impacted teeth/odontogenic cysts.

🩺 Clinical Presentation

• Often asymptomatic in early stages → incidental finding.
• Painless jaw swelling or bony expansion.
• Facial asymmetry & displacement of teeth.
• Root resorption (seen radiographically).
• Occasional pain or paraesthesia if nerves compressed.

🩻 Radiographic Features

• Classic multilocular radiolucency → “soap bubble” or “honeycomb” appearance 💡.
• Well-defined lesion with cortical thinning & expansion.
• Root resorption of adjacent teeth.

🔬 Histological Subtypes

• Conventional (Solid/Multicystic): Most common, aggressive, higher recurrence.
• Unicystic: Single cyst-like lesion, less aggressive, younger patients.
• Peripheral: In soft tissue overlying bone, rare.
• Desmoplastic: Dense stroma with collagenisation.

🛠️ Management

• Surgery = gold standard
  • Radical resection (marginal/segmental mandibulectomy) → lower recurrence.
  • Curettage/enucleation → higher recurrence, sometimes used for small lesions.
• Reconstruction: May require bone grafts, flaps, or prosthetics for function/appearance.
• Follow-up: Lifelong surveillance → recurrences can appear years later.

📊 Prognosis

• Benign but locally invasive.
• Recurrence:
  • 5–15% after wide resection.
  • >50% after curettage alone.
• Rare malignant transformation → ameloblastic carcinoma.

📚 References

• Philipsen HP, Reichart PA. J Oral Pathol Med. 2006.
• Speight PM, Takata T. Virchows Arch. 2017.

⚠️ Complications

• 🧠 Hepatic Encephalopathy: Due to toxin bypass → confusion, altered cognition.
• 🩻 Stent Stenosis/Occlusion: May cause recurrence of ascites/bleeding.
• ❤️ Heart Failure: Increased preload can worsen existing cardiac disease.
• 🦠 Infection: Risk during/after procedure.
• 💉 Hemorrhage: Rare but serious intra-procedural bleeding.

🩺 Post-Procedural Care

• Monitor closely for encephalopathy & cardiac decompensation.
• Follow-up Doppler ultrasound (1–3 months, then 6-monthly) to assess patency.
• Lactulose/rifaximin prophylaxis for encephalopathy risk.
• Diuretics may still be required for ascites control.

📊 Prognosis

• Excellent for controlling variceal bleeding & refractory ascites.
• Outcome depends heavily on underlying liver function.
• MELD >15 = poorer prognosis → transplant referral considered.

🔄 Alternative Treatments

• Endoscopic band ligation for varices.
• Large-volume paracentesis for ascites.
• Liver transplantation = definitive cure for advanced cirrhosis.

✅ Conclusion

TIPS is a powerful tool for portal hypertension complications. Careful patient selection, complication monitoring, and long-term follow-up (including Doppler surveillance) are essential to optimise outcomes.