Physician's Assistant

Patient Details

Handover (299 days ago 17:16)

Handover Wed 11 June 2025 17:16

Last Modified: 299 days ago

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**Mr Givens** - MRN: Unknown

**Summary:** 54-year-old gentleman with decompensated cirrhosis, refractory ascites, and multiple myeloma who underwent elective TIPS procedure yesterday, complicated by post-procedure hypotension and portal vein thrombosis with active bleeding into gallbladder.

**Background:**
- Decompensated cirrhosis with refractory ascites
- Multiple myeloma on treatment with lenalidomide and dexamethasone (2mg, 3 weeks out of 4)
- Elective TIPS procedure for refractory ascites
- Current medications include spironolactone and beta-blockers

**Post-procedure complications:**
- Significant hypotension (BP dropped to 75mmHg, now 100/50mmHg)
- Required steroids, antibiotics, and fluid resuscitation (approximately 5L)
- Developed ascites secondary to fluid overload
- Portal vein thrombosis extending from portal vein into TIPS
- Active bleeding into gallbladder via cystic duct (confirmed on CT)
- Likely bile duct injury during TIPS procedure

**Investigations:**
- Ultrasound: Portal vein clots extending length of portal vein into TIPS
- CT scan (today): Active contrast extravasation into gallbladder, portal vein thrombosis, TIPS well-positioned
- Awaiting formal radiology report

**Current status:**
- Haemodynamically stable
- No anticoagulation commenced pending bleeding assessment
- TIPS functioning well with normal flow

**Management options discussed:**
1. Trans-TIPS thrombectomy (IR offering this approach)
2. Thrombolysis (contraindicated due to active bleeding)
3. ERCP with covered plastic stent to tamponade cystic duct bleeding
4. PTC with interventional stenting
5. Conservative management with monitoring

**Plan:**
- Await formal CT report
- Urgent discussion with Interventional Radiology regarding management options
- Consider ERCP with stenting to address both bleeding and biliary leak
- Continue supportive care and monitoring
- Multidisciplinary team discussion for definitive management plan

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