Written by Peter Liu
Spoon Feed
Transjugular intrahepatic portosystemic shunt (TIPS) placement within 72 hours after acute variceal bleeding (AVB) led to reduced rebleeding and improved mortality.
Early TIPS for variceal bleeding improves rebleed and mortality risk
Treatment of esophageal variceal hemorrhage involves initiation of vasoactive medications (octreotide or somatostatin), proton-pump inhibitor therapy, endoscopy, prophylactic antibiotic administration, and blood transfusions.
In today’s landmark RCT, a strong case was made that early TIPS should be considered in patients with high risk for recurrent bleeding. In a study of 63 patients with Childs Pugh C (score 10-13, excluding scores >13) or Childs Pugh B with active bleeding during EGD, early-TIPS (≤72h) significantly reduced rebleeding or uncontrolled bleeding (3% vs. 50%, P<0.001) and mortality at one year (14% vs. 39%, P=0.01) compared to standard medical therapy (endoscopic band ligation and nonselective beta blocker). Other adverse events, including hepatic encephalopathy (HE), were similar between the groups.
So why hasn’t early TIPS in this patient population become a standard practice? Since this study, many findings have not been reproduced like a mortality benefit for patients with Childs Pugh B and early TIPS, and contrary to published findings, subsequent RCTs show an increased incidence of HE after TIPS. Second, implementing early TIPS for AVB in a real-world setting is not easy. Outside facility and health system constraints, finding patients sick enough to benefit from early TIPS but healthy enough to tolerate a TIPS is challenging. As a consequence, studies have inconsistent exclusion criteria and risk-stratification strategies. A MELD score > 18 or utilization of a Childs Pugh C-C1 appears to better predict mortality after AVB, although a MELD greater than 19 is associated with a high post-TIPS mortality. Lastly, many early TIPS studies with AVB did not optimize with carvedilol. Despite these issues, it is clear that many patients presenting with AVB have significant benefit from early TIPS within 72 hours of presentation, and it should be considered for many high-risk patients.
How does this change my practice?
After reviewing the evidence on this topic, I will consider early TIPS for patients presenting with AVB who have a high risk of bleeding and mortality.
Source
Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010 Jun 24;362(25):2370-9. doi: 10.1056/NEJMoa0910102. PMID: 20573925
