When endoscopic therapy or pharmacotherapy fails to control variceal bleeding: what should be done?

Rössle, Martin

doi:10.1007/s00423-003-0372-8

Cited by 13 publications

(6 citation statements)

References 58 publications

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“…In the era of bare metal TIPS, embolization of collateral varices would exclude a competing shunt that may decrease TIPS patency, limit variceal filling, and thus limit recurrent VH due to shunt dysfunction. 66,71 Pre-TIPS embolization has the technical benefit of increased GEV visualization due to variceal filling and decreased risk of nontarget systemic coil embolization, as no large-caliber shunt is present to allow systemic coil migration. Comparatively, post-TIPS embolotherapy provides the technical benefit of having a patent shunt to access and assessment of TIPS efficacy for variceal nonfilling.…”

Section: Embolotherapy and Tipsmentioning

confidence: 99%

Endovascular Treatment for Variceal Hemorrhage: TIPS, BRTO, and Combined Approaches

Lipnik

Pandhi

Khabbaz

et al. 2018

Semin intervent Radiol

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Variceal hemorrhage is a feared complication of portal hypertension, with high rates of morbidity and mortality. Optimal management requires a thoughtful, multidisciplinary approach. In cases of refractory or recurrent esophageal hemorrhage, endovascular approaches such as transjugular intrahepatic portosystemic shunt (TIPS) have a well-defined role. For hemorrhage related to gastric varices, the optimal treatment remains to be established; however, there is increasing adoption of balloon-occluded retrograde transvenous obliteration (BRTO). This article will review the concept, history, patient selection, basic technique, and outcomes for TIPS, BRTO, and combined TIPS + BRTO procedures for variceal hemorrhage.

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Section: Embolotherapy and Tipsmentioning

confidence: 99%

Endovascular Treatment for Variceal Hemorrhage: TIPS, BRTO, and Combined Approaches

Lipnik

Pandhi

Khabbaz

et al. 2018

Semin intervent Radiol

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“…However, if the second endoscopic treatment fails, salvage modalities should be employed at once [4, 9, 11, 18, 26]. Some clinicians suggest rescue therapy be taken immediately after the initial failure [3, 11, 16, 19, 35, 36]. Rescue modalities include balloon tamponade, TIPS, PTVE and shunt surgery.…”

Section: Emergency Treatment Of Variceal Hemorrhagementioning

confidence: 99%

Management of Variceal Hemorrhage

Zhang

2009

Gastroen Res

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Variceal hemorrhage is a frequent and lethal complication of portal hypertension. Bleeding occurs in 30%-40% of patients with cirrhosis and varices. The first episode of variceal bleeding is associated with a high mortality as well as a high incidence of rebleeding. Thus, management of variceal hemorrhage should be categorized into 3 phases: primary prophylaxis (prevention of the first episode of bleeding), emergency treatment (management of acute bleeding), and secondary prophylaxis (prevention of re-bleeding). Modalities involved include pharmacological, endoscopic, surgical, interventional radiological therapy and balloon tamponade. This review summarizes the current choices of management during each phase, and concentrates on the following questions, what can we do to prevent the formation and development of varices; how can we predicate the risk of bleeding; what should we do in case of bleeding; what is the first-line therapy; what should we do when current therapy fails; when should we give up and what is the optimal strategy for secondary prophylaxis.

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“…13,17 TIPS FOR ACUTE VARICEAL BLEEDING At the present time the recommended standard treatment for acute variceal bleeding consists of immediate pharmacological treatment with early endoscopic band ligation and/or sclerotherapy. 18,19 TIPS is recommended as ''rescue'' treatment if primary hemostasis cannot be obtained with endoscopic and pharmacological therapy, or if uncontrollable early rebleeding occurs within 48 hours. Reasons for failed endoscopy therapy include massive bleeding rendering visualization of the bleeding vessels impossible, unsuccessful hemostasis of an actively bleeding vessel, or recurrent bleeding after two attempts at endoscopic hemostasis.…”

Section: Treatment Optionsmentioning

confidence: 99%

“…A generous indication to early TIPS implantation before multiorgan failure occurs may decrease the high mortality of acute variceal bleeding. 18,19 Bizollon and coworkers reported a series of 28 patients with refractory variceal bleeding in whom TIPS was performed early, within 48 hours following failed endoscopic and medical treatment. The 40-day mortality was 25%; 17 (61%) of the patients were Child C cirrhosis.…”

Section: Timing Of Emergency Tipsmentioning

confidence: 99%

“…20,36 Currently, it is not clear whether the combination of TIPS and variceal embolization is more effective than TIPS alone. Some authors recommend transjugular embolization of the varices to increase the effect of the shunt with respect to acute hemostasis, 18,59 and other authors don't perform any embolization during the TIPS procedure. 13 In our clinical PT, prothrombin time.…”

Section: Other Management Alternatives In Patients With Acute Variceamentioning

confidence: 99%

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Role of Emergency Transjugular Intrahepatic Portosystemic Shunts

Lopera

2005

Semin intervent Radiol

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Transjugular intrahepatic portosystemic shunts (TIPS) is a highly effective treatment for bleeding esophageal varices, with control of the bleeding in over 90% of the patients. TIPS is recommended as ''rescue'' treatment if primary hemostasis cannot be obtained with endoscopic and pharmacological therapy, or if uncontrollable early rebleeding occurs within 48 hours. TIPS is also a very effective technique for patients presenting with severe refractory bleeding gastric and ectopic varices, cases where endoscopic techniques are less effective. Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and sclerotherapy fail, before the clinical condition worsens. Every effort should be made to stabilize the patient before TIPS, including the use of tamponade tubes and aggressive correction of coagulopathy. Patients with acute variceal bleeding with a Child-Pugh score > 12, Apache score II > 18 points, hemodynamically unstable, receiving vasopressors and coagulopathy, and/or bilirrubin > 6 mg/dL have a high risk of early death after TIPS. Expedite liver transplantation after emergency TIPS should be considered for high-risk patients.KEYWORDS: Hypertension-portal, liver-interventional procedures, shunts-portosystemic, varicesObjectives: Upon completion of this article, the reader should be able to (1) review the current treatment alternatives for patients with bleeding esophageal varices, (2) review the role of TIPS in the setting of acute refractory esophageal varices bleeding, (3) discuss the prognostic factors that might influence patient selection for emergency TIPS, and (4) review the role of TIPS in the treatment of gastric and ectopic varices. Accreditation: Tufts University School of Medicine (TUSM) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Credit: TUSM designates this educational activity for a maximum of 1 Category 1 credit toward the AMA Physicians Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.The role of transjugular intrahepatic portosystemic shunts (TIPS) for the prevention of rebleeding of esophageal varices and control of refractory ascites has become more precisely defined in the past 10 years with several comparative studies showing better control of these complications of portal hypertension with TIPS than with standard forms of therapy.1 However, the role of the TIPS as an emergency, lifesaving procedure is less well defined and remains highly controversial.The purpose of this article is to describe the different treatment options for patients with refractory esophageal and gastric varices bleeding and the role of

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When endoscopic therapy or pharmacotherapy fails to control variceal bleeding: what should be done?

Abstract: Only strict adherence to the definition of failure of standard treatment and a generous indication to the TIPS implantation before multiorgan failure occurs may decrease the high mortality of acute variceal bleeding.

Cited by 13 publications

References 58 publications

Endovascular Treatment for Variceal Hemorrhage: TIPS, BRTO, and Combined Approaches

Endovascular Treatment for Variceal Hemorrhage: TIPS, BRTO, and Combined Approaches

Management of Variceal Hemorrhage

Role of Emergency Transjugular Intrahepatic Portosystemic Shunts

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