Transjugular intrahepatic portosystemic shunt in the treatment of refractory bleeding from ruptured gastric varices

Abstract

The optimal management of ruptured gastric varices in patients with cirrhosis has not been codified yet. The present study reports the use of transjugular intrahepatic portosystemic shunt (TIPS) in patients with refractory gastric variceal bleeding. Thirty-two consecutive patients were included. All had been unresponsive to vasoactive agents infusion, sclerotherapy, and/or tamponade and were considered poor surgical candidates. They were followed-up until death, transplantation, or at least 1 year (median: 509 days; range 4 to 2,230). Hemostasis was achieved in 18 out of 20 patients actively bleeding at the time of the procedure. In the whole sample of 32 patients, rebleeding rates were 14%, 26%, and 31%, respectively at 1 month, 6 months, and 1 year. De novo encephalopathy was observed in 5 (16%) patients. Seven patients experienced complications and consequently 4 of these patients died. TIPS primary patency rates were 84%, 74%, and 51%, respectively, at 1 month, 6 months, and 1 year. For the same periods of time, survival rates were 75%, 62%, and 59%. These results suggest that TIPS can be used in cirrhotic patients with refractory gastric variceal bleeding and are effective in achieving hemostasis as well as in preventing rebleeding. (HEPATOLOGY 1999;30:1139-1143.)In the absence of any specific controlled trial the management of bleeding gastric varices in patients with cirrhosis is still a difficult problem. These bleedings are generally considered more severe than those originating from ruptured esophageal varices and more prone to relapse. 1 Transjugular intrahepatic portosystemic shunt (TIPS) has been extensively used within the last 10 years. It allows decompression of the portal system through a percutaneous approach and has consequently been used to treat both ascites 2 and variceal bleeding. [3][4][5][6][7][8][9][10]

The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension†

“…[81][82][83] In these small series, TIPS was equally effective at controlling bleeding from gastric as well as esophageal varices. [81][82][83][84] Controlled trials comparing surgical shunts or glue in the treatment of these patients would help to better define the role of TIPS in the management of patients with bleeding from gastric varices. In the authors' opinion, TIPS is an important tool in the control of gastric variceal bleeding, though the final portosystemic gradient required to achieve variceal decompression may be lower than what is required for esophageal variceal bleeding, and embolization of the varices also may be required.…”

Variceal bleeding: consensus meeting report from the Brazilian Society of Hepatology

“…Due to the safety profile and cost of TIPS, cyanoacrylate endoscopic injection is preferred for treatment of the acute bleeding episode. TIPS has been shown to control bleeding in 90% of the cases with recurrence rates of 10%-30% at 1 year (10,34) . However, some studies (122,142) failed to demonstrate efficacy of TIPS in patients with gastric varices.…”

Transjugular intrahepatic portosystemic shunts: An update

“…Moreover, TIPS has been used successfully both in the treatment of refractory acute gastric variceal bleeding as well as in the prevention of rebleeding from gastric varices. 1,2 A smaller study has shown the efficacy of TIPS in the prevention of bleeding from severe portal hypertensive gastropathy, but not in the prevention of bleeding from gastric vascular ectasia. 3 Similarly, TIPS may be used in the treatment of ectopic variceal bleeding.…”