Early Transjugular Intrahepatic Portosystemic Shunt Placement in Patients with Cirrhosis and Variceal Bleeding
22 March 2018 (online)
Introduction and Content Organization Transjugular intrahepatic portosystemic shunt (TIPS) is traditionally used as a rescue treatment for recurrent uncontrolled acute variceal bleeding (AVB) in patients with cirrhosis. However, recent studies are challenging this view. Several groups have demonstrated that early TIPS (performed within 24–72 h of AVB) improves survival and reduces the rate of re-bleeding in high-risk patients compared with standard pharmacological and endoscopic therapies. Furthermore, the risk for hepatic encephalopathy, one of the most worrisome complications of TIPS, was not increased in patients who underwent early TIPS. In addition to better clinical outcomes, TIPS is also more cost effective than the current standard of care and may increase patients’ chance for liver transplantation. Patient selection for early TIPS is important, as the procedure is unlikely to benefit patients with severe end-stage liver disease and is not meant for those with mild hepatic dysfunction (Child–Pugh A). Finally, while the current results for early TIPS are promising, further prospective studies are needed to confirm these findings before early TIPS can be widely adopted.
Learning Points Studies have demonstrated that early TIPS for acute variceal bleeding in patients with cirrhosis is associated with:
Lower rates of re-bleeding
Reduced hospitalization cost
Increased likelihood for liver transplantation
No increased risk of hepatic encephalopathy compared with medical + endoscopic management