WordNet

transfer to another track, of trains
a conductor having low resistance in parallel with another device to divert a fraction of the current (同)electrical shunt, bypass
implant consisting of a tube made of plastic or rubber; for draining fluids within the body
a passage by which a bodily fluid (especially blood) is diverted from one channel to another; "an arteriovenus shunt"
provide with or divert by means of an electrical shunt
avoid and stay away from deliberately; stay clear of (同)eschew

PrepTutorEJDIC

〈人・物〉‘を'わきにどかす;〈話題など〉‘を'他へそらす / (別の軌道に)〈車両〉‘を'入れ換える / 〈電流〉‘を'わきへそらす;〈分路〉‘を'置く / わきへそれる / 〈車両が〉分岐線に移行する / 〈U〉わきへそれること / 〈C〉転てつ器;(電気の)分路
…‘を'『避ける』(avoid)

Wikipedia preview

出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2017/10/28 18:55:28」(JST)

wiki en

Transjugular intrahepatic portosystemic shunt or transjugular intrahepatic portosystemic stent shunting (commonly abbreviated as TIPS or TIPSS) is an artificial channel within the liver that establishes communication between the inflow portal vein and the outflow hepatic vein. It is used to treat portal hypertension (which is often due to liver cirrhosis) which frequently leads to intestinal bleeding, life-threatening esophageal bleeding (esophageal varices) and the buildup of fluid within the abdomen (ascites).

An interventional radiologist creates the shunt using an image-guided endovascular (via the blood vessels) approach, with the jugular vein as the usual entry site.

The procedure was first described by Josef Rösch in 1969 at Oregon Health and Science University. It was first used in a human patient by Dr. Ronald Colapinto, of the University of Toronto, in 1982, but did not become reproducibly successful until the development of endovascular stents in 1985. In 1988 the first successful TIPS was realized by M. Rössle, G.M. Richter, G. Nöldge and J. Palmaz at the University of Freiburg.^[1] The procedure has since become widely accepted as the preferred method for treating portal hypertension that is refractory to medical therapy, replacing the surgical portocaval shunt in that role.

Mechanism of action

Portal hypertension, an important consequence of liver disease, results in the development of significant collateral circulation between the portal system and systemic venous drainage (porto-caval circulation). Portal venous congestion causes venous blood leaving the stomach and intestines to be diverted along auxiliary routes of lesser resistance in order to drain to systemic circulation. With time, the small vessels that comprise a collateral path for porto-caval circulation become engorged and dilated. These vessels are fragile and often hemorrhage into the GI tract. (See esophageal, gastric, rectal varices).

A TIPS procedure decreases the effective vascular resistance of the liver through the creation of an alternative pathway for portal venous circulation. By creating a shunt from the portal vein to the hepatic vein, this intervention allows portal blood an alternative avenue for draining into systemic circulation. In bypassing the flow-resistant liver, the net result is a reduced pressure drop across the liver and a decreased portal venous pressure. Decreased portal venous pressure in turn lessens congestive pressures along veins in the intestine so that future bleeding is less likely to occur. The reduced pressure also makes less fluid develop, although this benefit may take weeks or months to occur.

Implantation

Steps in a TIPS procedure: A) portal hypertension has caused the coronary vein (arrow) and the umbilical vein (arrowhead) to dilate and flow in reverse. This leads to varices in the esophagus and stomach, which can bleed; B) a needle has been introduced (via the jugular vein) and is passing from the hepatic vein into the portal vein; c) the tract is dilated with a balloon; D) after placement of a stent, portal pressure is normalized and the coronary and umbilical veins no longer fill.

Transjugular intrahepatic portosystemic shunts are typically placed by an interventional radiologist under fluoroscopic guidance.^[2] Access to the liver is gained, as the name 'transjugular' suggests, via the internal jugular vein in the neck. Once access to the jugular vein is confirmed, a guidewire and introducer sheath are typically placed to facilitate the shunt's placement. This enables the interventional radiologist to gain access to the patient's hepatic vein by traveling from the superior vena cava into the inferior vena cava and finally the hepatic vein. Once the catheter is in the hepatic vein, a wedge pressure is obtained to calculate the pressure gradient in the liver. Following this, carbon dioxide is injected to locate the portal vein. Then, a special needle known as a Colapinto is advanced through the liver parenchyma to connect the hepatic vein to the large portal vein, near the center of the liver. The channel for the shunt is next created by inflating an angioplasty balloon within the liver along the tract created by the needle. The shunt is completed by placing a special mesh tube known as a stent or endograft to maintain the tract between the higher-pressure portal vein and the lower-pressure hepatic vein. After the procedure, fluoroscopic images are made to show placement. Pressure in the portal vein and inferior vena cava are often measured.

Use in hepatorenal syndrome

TIPS has shown some promise for patients with hepatorenal syndrome.^[3]

Complications

Procedural complications during a TIPS procedure, including bleeding and direct injury to the liver, are uncommon. In the hands of an experienced physician, operative mortality is less than 1%. On the other hand, because TIPS reduces or eliminates first-pass clearance of nitrogen from the gut, up to 25% of patients who undergo TIPS will experience transient post-operative hepatic encephalopathy.^[4] In general, this can be managed with a reduction in dietary protein and medication that reduces the absorption of nitrogen.

A less common but more difficult complication is hepatic ischemia. Portal hypertension—the condition shared by all TIPS patients regardless of etiology—generally causes compensatory hypertrophy of the hepatic artery and a decreased reliance of the liver upon the portal vein for its oxygenation. For this reason, shunting of the portal blood away from hepatocytes is usually well tolerated. In some cases, however, TIPS creation can cause an ischemic injury to the liver.^[5] Acute hepatic dysfunction after TIPS may require emergent closure of the shunt.

A rare but serious complication is persistent TIPS infection, also known as endotipsitis.^[6]

References

^ Rössle M, Richter GM, Nöldge G, Palmaz JC, Wenz W, Gerok W (1989). "New non-operative treatment for variceal haemorrhage". Lancet. 2 (8655): 153. PMID 2567908. doi:10.1016/s0140-6736(89)90201-8.
^ "What You Need to Know about the Transjugular Intrahepatic Portosystemic Shunt (TIPS).". Cleveland Clinic.
^ Guevara M, Rodés J (2005). "Hepatorenal syndrome". Int. J. Biochem. Cell Biol. 37 (1): 22–6. PMID 15381144. doi:10.1016/j.biocel.2004.06.007.
^ Rossle M, Piotraschke J. Transjugular intrahepatic portosystemic shunt and hepatic encephalopathy. Dig Dis 1996; 14:12–19.
^ Mayan H, Kantor R, Rimon U, Golubev N, Heyman Z, Goshen E, Shalmon B, Weiss P.: "Fatal liver infarction after transjugular intrahepatic portosystemic shunt procedure." Liver, 2001;21(5):361-4.
^ Mizrahi, Meir; Adar, Tomer; Shouval, Daniel; Bloom, Allan I.; Shibolet, Oren (February 2010). "Endotipsitis-persistent infection of transjugular intrahepatic portosystemic shunt: pathogenesis, clinical features and management". Liver International. 30 (2): 175–183. ISSN 1478-3231. PMID 19929905. doi:10.1111/j.1478-3231.2009.02158.x.

External links

RadiologyInfo: Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Transjugular Intrahepatic Portosystemic Shunt - eMedicine.com.

UpToDate Contents

全文を閲覧するには購読必要です。 To read the full text you will need to subscribe.

1. 経頸静脈的肝内門脈大循環短絡術：適応および禁忌 transjugular intrahepatic portosystemic shunts indications and contraindications
2. 経頸静脈的肝内門脈大循環短絡術：合併症 transjugular intrahepatic portosystemic shunts complications
3. 静脈瘤出血治療における経頸静脈的肝内門脈大循環短絡術の役割 role of transjugular intrahepatic portosystemic shunts in the treatment of variceal bleeding
4. 急性静脈瘤出血患者における止血法 methods to achieve hemostasis in patients with acute variceal hemorrhage
5. Cystic fibrosis: Hepatobiliary disease

English Journal

Parallel transjugular intrahepatic portosystemic shunt for controlling portal hypertension complications in cirrhotic patients.

He FL, Wang L, Yue ZD, Zhao HW, Liu FQ.
World journal of gastroenterology : WJG.World J Gastroenterol.2014 Sep 7;20(33):11835-9. doi: 10.3748/wjg.v20.i33.11835.
AIM: To evaluate the feasibility of a second parallel transjugular intrahepatic portosystemic shunt (TIPS) to reduce portal venous pressure and control complications of portal hypertension.METHODS: From January 2011 to December 2012, 10 cirrhotic patients were treated for complications of portal hyp
PMID 25206289

Percutaneous Mesocaval Shunt Creation in a Patient with Chronic Portal and Superior Mesenteric Vein Thrombosis.

Bercu ZL1, Sheth SB, Noor A, Lookstein RA, Fischman AM, Nowakowski FS, Kim E, Patel RS.
Cardiovascular and interventional radiology.Cardiovasc Intervent Radiol.2014 Sep 5. [Epub ahead of print]
The creation of a transjugular intrahepatic portosystemic shunt (TIPS) is a critical procedure for the treatment of recurrent variceal bleeding and refractory ascites in the setting of portal hypertension. Chronic portal vein thrombosis remains a relative contraindication to conventional TIPS and op
PMID 25189666

Reduction in portal venous pressure by transjugular intrahepatic portosystemic shunt for treatment of hemorrhagic stomal varices.

Deipolyi AR1, Kalva SP, Oklu R, Walker TG, Wicky S, Ganguli S.
AJR. American journal of roentgenology.AJR Am J Roentgenol.2014 Sep;203(3):668-73. doi: 10.2214/AJR.13.12211.
OBJECTIVE. Stomal varices can cause life-threatening gastrointestinal hemorrhage in patients with portal hypertension. Optimal therapy is not well defined. The purpose of this study was to determine the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation for the trea
PMID 25148174

Japanese Journal

TIPSを行った肝内びまん性動脈門脈短絡を合併したアルコール性肝硬変の2症例

福田健,楢原義之,金沢秀典,糸川典夫,近藤千紗,張本滉智,松下洋子,城所秀子,小林玲樹,厚川正則,中塚雄久,坂本長逸
肝臓 52(10), 662-670, 2011-10-25
… 性胸腹水．肝動脈造影で肝内全域に肝動脈門脈短絡（APシャント）による遠肝性門脈血流が描出された．難治性胸腹水に対して経頸静脈的肝内門脈大循環短絡術（transjugular intrahepatic portosystemic shunt：TIPS）を施行し胸腹水は消失した．症例2：70歳男性，アルコール性肝硬変，難治性腹水．肝動脈造影で肝内全域にAPシャントを認め，門脈血流は遠肝性に描出され …
NAID 10029822438

Remission of Hepatic Hydrothorax after OK-432 Pleurodesis

GOTO Taichiro,OYAMADA Yoshitaka,HAMAGUCHI Reo,SHIMIZU Kumi,KUBOTA Masako,AKANABE Kumi,KATO Ryoichi
Annals of thoracic and cardiovascular surgery 17(2), 208-211, 2011-04-01
… OK-432 pleurodesis is relatively safe and may provide an effective alternative to peritoneovenous shunt, transjugular intrahepatic portosystemic shunt or surgical pleurodesis. …
NAID 10029686846

Related Pictures

★リンクテーブル★

リンク元	「食道静脈瘤」「腹水」「経頚静脈肝内門脈大循環短絡術」「TIPS」
関連記事	「shunt」「transjugular」「intrahepatic」

「食道静脈瘤」

Transjugular intrahepatic portosystemic shunt
	Fluoroscopic image of TIPS in progress. A catheter has been passed into the hepatic vein and after needle puncture, a guidewire was passed into a portal vein branch. The tract was dilated with a balloon, and contrast injected. A self-expandable metallic stent has yet to be placed over the wire.
ICD-9-CM	39.1
MeSH	D019168
	[edit on Wikidata]

　　[★]

英: esophageal varix, esophageal varices
関: 胃静脈瘤、variceal bleeding、門脈圧

病態

門脈圧亢進を背景として粘膜下層～粘膜固有層の静脈叢に静脈瘤が形成される。
好発部位：下部食道
静脈瘤の形成には左胃静脈、短胃静脈、後胃静脈が関与している。

検査

上部消化管内視鏡検査

日本では形態(form, F)F2以上や発赤所見(red color sign, RC)RC2以上が危険な静脈瘤として予防的治療の適応となっている(SSUR.645)
青色静脈瘤、連珠状静脈瘤(F2)以上、red color sign陽性は治療対象(QB.A-341)

内視鏡所見の分類

参考3

F:form 形態	F0 静脈瘤として認められないもの F1 直線的な細いもの F2 連珠状、中等度 F3 結節状、腫瘤状
C: color 色調	Cw (白色静脈) Cb (青色静脈)
RC:red color sign 発赤所見	Red color sign(RC) ミミズ腫れ所見 red wale marking (RWM) サクランボ様発赤 cherry red spot様所見 (CRS) 血マメ所見 hematocystic spot (HCS)

F3, red color sign [show details]

治療

SSUR.649-

バルーンタンポナーデ法

ゼングスターケン・ブレークモア管 Sengstaken-Blakemoreチューブ

薬物療法

(緊急出血)バソプレシン・ソマトスタチン：門脈の流入血流を減少させ、門脈圧を減少させる。肝機能悪化リスクあり。
(予防)プロプラノロール・ナドロール：非選択的βブロッカーを使うことで、β2受容体を介した血管拡張がblockされα1受容体を介した血管収縮が優位となり、腸管の細動脈の収縮により門脈の血流が減少、門脈圧が低下する。さらに多く用いれば、β1受容体を介した心拍出量の低下により脾動脈血流量が減少し、門脈圧がより低下する。(参考2)

内視鏡的治療

interventional radiology, IVR

経皮経肝的経静脈瘤塞栓術 PTO、経回腸静脈的静脈瘤塞栓術 TIO
経皮的肝内門脈シャント術 transjugular intrahepatic portosystemic shunt TIPS
バルーン下逆行性経静脈的塞栓術 balloon-occluded retrograde transvenous obliteration B-RTO

手術療法

適応：内視鏡的硬化薬注入量法(EIS)、内視鏡的静脈瘤結紮術(EVL)で止血不可能な例、再発・出血を繰り返す例

直達手術：

食道離断術
ハッサブ手術

シャント手術
肝移植術

予後

予後不良

血小板減少：止血が困難となるため
肝硬変：総ビリルビン4mg/dl以上では硬化療法が選択できないため

参考

フリーPDF有り

1. 食道静脈瘤内視鏡所見記載基準 (日本門脈圧亢進症研究会)

井口潔
日本消化器外科学会雑誌 13(4), 338-340, 1980-04-01
NAID 110001359486

2. [charged] Primary prophylaxis against variceal hemorrhage in patients with cirrhosis - uptodate [1]
3. 消化器基本画像集

大変勉強になる資料です！！

http://www.pariet.jp/alimentary/picture.html

「腹水」

　　[★]

英: ascites, abdominal dropsy, hydroperitonia
同: 腹腔内貯留液 intraperitoneal fluid
関: 波動

概念

腹腔内液体貯留

分類

	滲出性	漏出性
外観	混濁	清明
蛋白質濃度(g/dl)	>4.0	>2.5
Rivalta反応	＋	－
比重	>1.018	<1.015
疾患	癌性腹膜炎	肝硬変
	化膿性腹膜炎	心疾患
	結核性腹膜炎	ネフローゼ
		Budd-Chiari症候群

血清蛋白質濃度は6.5-8.0g/dLが正常範囲

腹水の性状

血性腹水：癌性腹膜炎、腹腔内出血
膿性腹水：細菌性腹膜炎
乳糜性腹水：フィラリア症、腸リンパ管拡張症
粘液性腹水：腹膜偽粘膜腫、腹膜中皮腫
胆汁性腹水：胆汁性腹膜炎

比重、蛋白濃度による分類

漏出性腹水
滲出性腹水

病因

1. 門脈圧・静脈圧亢進
2. 膠質浸透圧の低下
3. リンパ液のうっ滞
4. 血管透過性の亢進

病態生理

肝硬変における腹水 HIM.1978

肝硬変→門脈高血圧→内臓の血管拡張→

1. →内臓の血管内圧の上昇→腹水
2. →動脈血の減少→血管収縮機構と抗ナトリウム利尿機構の亢進→ナトリウム保持→血漿量の増加→腹水

貯留しやすい部位(QB.Q-205)

ダグラス窩直腸子宮窩
モリソン窩：肝右葉と右腎の間
傍結腸溝：下行結腸、上行結腸の外側で腹壁との間の溝
肝表面：肝右葉と横隔膜の間

検査

500ml以上の貯留があれば、腹部超音波検査、腹部CT、腹部MRIで検出できる。

腹部単純X線写真

腸骨稜徴候

治療

食塩制限
安静
利尿薬
アルブミン性製剤
腹水穿刺
腹腔静脈シャント
経頚静脈肝内門脈大循環短絡術 transjugular intrahepatic portosystemic shunt TIPS

HIM.1978

軽度の腹水：食事療法でナトリウム制限を行う。
中等度の腹水：利尿薬で治療を行う。スピロノラクトン、さらに必要があればフロセミドを重ねる。
refractory ascites：利尿薬と食事療法でコントロールできない腹水。この場合、LPV(large volume paracentesis)やTIPS(transjugular intrahepatic portosystemic shunt)を考慮する。

「経頚静脈肝内門脈大循環短絡術」

　　[★]

英: transjugular intrahepatic portosystemic shunt TIPS, transjugular intrahepatic portasystemic shunt
同: ティップス、経頚静脈性肝内門脈大循環短絡術、経頸静脈的肝内門脈大循環短絡術、経頸静脈肝内門脈大循環短絡術、経頚静脈肝内門脈大循環短絡術、経頚静脈的肝内門脈大循環短絡術、経皮的肝内門脈静脈短絡術、経頚静脈性肝内門脈大循環シャント、経頸静脈的肝内門脈大循環シャント、経頸静脈肝内門脈大循環シャント、経頚静脈肝内門脈大循環シャント、経頚静脈的肝内門脈大循環シャント、経皮的肝内門脈静脈シャント

[show details]

経頸静脈肝内門脈大循環短絡術 : 93 件
経頚静脈肝内門脈大循環短絡術 : 9 件

経頸静脈性肝内門脈大循環短絡術 : 16 件
経頚静脈性肝内門脈大循環短絡術 : 40 件

経頸静脈的肝内門脈大循環短絡術 : 81 件
経頚静脈的肝内門脈大循環短絡術 : 37 件

経皮的肝内門脈静脈短絡術 : 約 50 件

経頚静脈性肝内門脈大循環シャント : 9 件
経頸静脈的肝内門脈大循環シャント : 8 件
経頸静脈肝内門脈大循環シャント : 9 件
経頚静脈肝内門脈大循環シャント : 4 件
経頚静脈的肝内門脈大循環シャント : 1 件
経皮的肝内門脈静脈シャント : 7 件

transjugular intrahepatic portosystemic shunt : 約 48,900 件
transjugular intrahepatic portasystemic shunt : 約 5,360 件

「TIPS」

　　[★] 経頚静脈肝内門脈大循環短絡術、経皮的肝内門脈静脈短絡術、経頸静脈的肝内門脈体循環シャント、transjugular intrahepatic portosystemic shunt

「shunt」

　　[★]

vt.

～をそらす

n.

短絡、分路、(医療)吻合術、シャント、

→シャント

「transjugular」

　　[★]

adj.

経頚静脈的な、経頸静脈的な、経頚静脈性の、経頸静脈性の

「intrahepatic」

　　[★]

adj.

肝内の、肝臓内の

[pmid2567908-1] Rössle M, Richter GM, Nöldge G, Palmaz JC, Wenz W, Gerok W (1989). "New non-operative treatment for variceal haemorrhage". Lancet. 2 (8655): 153. PMID 2567908. doi:10.1016/s0140-6736(89)90201-8.

[2] "What You Need to Know about the Transjugular Intrahepatic Portosystemic Shunt (TIPS).". Cleveland Clinic.

[3] Guevara M, Rodés J (2005). "Hepatorenal syndrome". Int. J. Biochem. Cell Biol. 37 (1): 22–6. PMID 15381144. doi:10.1016/j.biocel.2004.06.007.

[4] Rossle M, Piotraschke J. Transjugular intrahepatic portosystemic shunt and hepatic encephalopathy. Dig Dis 1996; 14:12–19.

[5] Mayan H, Kantor R, Rimon U, Golubev N, Heyman Z, Goshen E, Shalmon B, Weiss P.: "Fatal liver infarction after transjugular intrahepatic portosystemic shunt procedure." Liver, 2001;21(5):361-4.

[6] Mizrahi, Meir; Adar, Tomer; Shouval, Daniel; Bloom, Allan I.; Shibolet, Oren (February 2010). "Endotipsitis-persistent infection of transjugular intrahepatic portosystemic shunt: pathogenesis, clinical features and management". Liver International. 30 (2): 175–183. ISSN 1478-3231. PMID 19929905. doi:10.1111/j.1478-3231.2009.02158.x.

匿名

検索

案内

transjugular intrahepatic portosystemic shunt