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Gastroenterologie up2date 2016; 12(04): 321-339
DOI: 10.1055/s-0042-117560
Leber/Galle/Pankreas
© Georg Thieme Verlag KG Stuttgart · New York

Transjugulärer intrahepatischer portosystemischer Shunt (TIPS) – Update 2016

Inge Kaare Tesdal
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Publication History

Publication Date:
22 December 2016 (online)

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Kernaussagen

TIPS bei Varizenblutungen

  • Ein Hochrisikopatient ist definiert als ein Patient in Child-Pugh-Gruppe C (bis 13 Punkte) oder ein Patient in Child-Pugh-Gruppe B mit aktiver Blutung während der Endoskopie.

  • TIPS bei Hochrisikopatienten führt zu einer signifikanten Senkung der Rezidivblutungsrate und zu einer signifikanten Verbesserung der Überlebensrate.

  • Eine angiomorphologische Klassifikation der portosystemischen Kollateralen vor und nach TIPS-Anlage ist hilfreich, um das Blutungsrisiko einzuschätzen.

  • Bei der Kombination von großen Ösophagus- und Magenvarizen und schlechter Leberfunktion (Child-Pugh > 8) steigt die Rezidivblutungsrate signifikant.

  • Die Varizenembolisation stellt weiterhin eine wichtige additive Methode dar, um die Rezidivblutungsgefahr dauerhaft zu reduzieren.

  • Es besteht eine eindeutige Indikation zur Varizenembolisation, wenn der portosystemische Gradient nach TIPS nicht ausreichend gesenkt wurde und/oder die hepatofugal perfundierten Varizen einen Konkurrenzfluss zum TIPS-Shunt darstellen.

TIPS bei anderen Indikationen

  • Die Mehrzahl der Studien zeigt, dass nach TIPS Aszites und aszitesassoziierte Komplikationen oft sistieren oder besser medikamentös therapierbar sind.

  • Die Therapie des Budd-Chiari-Syndroms sollte stufenweise erfolgen: Eine Verschlechterung der Leberfunktion muss ohne Zeitverzögerung zum Therapiewechsel führen.

  • Bei der symptomatischen Pfortaderthrombose sollte immer über eine TIPS-Anlage als Therapieoption nachgedacht werden.

Komplikationen

  • Die Komplikation mit der höchsten Morbidität und Letalität sind Blutungen. Um sie zu vermeiden, ist die prätherapeutische Abklärung der Leberdurchblutung essenziell.

  • Zur Therapie der Enzephalopathie steht die medikamentöse Beeinflussung der Darmflora durch nicht resorbierbare Disaccharide und ein darmselektives Breitbandantibiotikum im Vordergrund.

 

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