These guidelines on transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the management of portal hypertension have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the Liver Section of the BSG. The guidelines are new and have been produced in collaboration with the British Society of Interventional Radiology (BSIR) and British Association of the Study of the Liver (BASL). The guidelines development group comprises elected members of the BSG Liver Section, representation from BASL, a nursing representative and two patient representatives. The quality of evidence and grading of recommendations was appraised using the GRADE system. These guidelines are aimed at healthcare professionals considering referring a patient for a TIPSS. They comprise the following subheadings: indications; patient selection; procedural details; complications; and research agenda. They are not designed to address: the management of the underlying liver disease; the role of TIPSS in children; or complex technical and procedural aspects of TIPSS.

Summary Background Early‐transjugular intrahepatic porto‐systemic shunt (TIPSS) has been recommended in international guidelines for high‐risk patients with oesophageal variceal bleeding. Aim To validate the results of a previous randomised control trial which supports use of early‐TIPSS. Methods In a two‐centre open‐label parallel‐group randomised control trial, patients with cirrhosis and acute variceal bleeding were recruited following haemostasis with vaso‐active drugs and endoscopic band ligation. Participants were randomised to standard of care or early‐TIPSS. The primary outcome was 1‐year survival, secondary outcomes included early and late rebleeding, and complications of portal hypertension. Results Fifty‐eight patients (58 ± 11.12 years; 32.7% female) were randomised. After one year, seven patients died in the standard of care group and six in the early‐TIPSS group, a 1‐year survival of 75.9% vs 79.3% respectively (P = 0.79). Variceal rebleeding occurred in eight patients in the standard of care group compared with three patients in the early‐TIPSS group (P = 0.09). Not all participants randomised to early‐TIPSS received the intervention in time. For those receiving TIPSS per‐protocol, variceal rebleeding rates were reduced (0% vs 27.6%, P = 0.04) but this had no effect on survival (76.9% vs 75.9%, P = 0.91). Serious adverse events were similar in both treatment groups, except that rates of hepatic encephalopathy were higher in patients receiving TIPSS (46.1% vs 20.7%, P < 0.05). Conclusions Early‐TIPSS reduced variceal rebleeding, increased encephalopathy but had no effect on survival in high‐risk patients with oesophageal variceal bleeding. Early‐TIPSS may not be feasible in many centres however, larger studies are needed. ClinicalTrials.gov reference: NCT02377141.

SUMMARY BackgroundBleeding from ectopic varices is uncommon but can be difficult to manage.

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