23rd July 2023

A 66-year-old patient is admitted with confusion, drowsiness and abdominal distension

A 66-year-old patient is admitted with confusion, drowsiness and abdominal distension.

They have a history of cirrhosis secondary to alcohol excess, as well as ischaemic heart disease and chronic obstructive pulmonary disease.

On examination, he is drowsy but rousable to voice. His speech is not coherent. There is a hepatic flap and abdominal distension, with tense ascites.

Blood tests show a normal FBC and coagulation profile. AST and ALT are elevated, but bilirubin is normal.

You arrange for a diagnostic and therapeutic large volume paracentesis, after which the ascitic fluid reaccumulates. You wonder whether this patient may benefit from a transjugular intrahepatic portosystemic shunt (TIPSS).

Which of the following is an accepted contraindication to TIPSS?

Select the SINGLE most appropriate option from the list below. Select ONE option only.