Role of transjugular intrahepatic portosystemic shunts in the treatment of variceal bleeding
- Jasmohan S Bajaj, MD
Jasmohan S Bajaj, MD
- Associate Professor of Medicine
- Virginia Commonwealth University and McGuire VA Medical Center
- Arun J Sanyal, MD
Arun J Sanyal, MD
- Charles Caravati Professor of Medicine
- Virginia Commonwealth University School of Medicine
- Section Editor
- Sanjiv Chopra, MD, MACP
Sanjiv Chopra, MD, MACP
- Editor-in-Chief — Gastroenterology/Hepatology
- Section Editor — General Hepatology
- Section Editor — Gallbladder and Biliary Tract Disease
- Professor of Medicine
- Harvard Medical School
- Senior Consultant in Hepatology
- James Tullis Firm Chief
- Beth Israel Deaconess Medical Center
Transjugular intrahepatic portosystemic shunts (TIPS) involve creation of a low-resistance channel between the hepatic vein and the intrahepatic portion of the portal vein (usually the right branch) using angiographic techniques (figure 1 and image 1). The tract is kept patent by deployment of an expandable metal stent across it, thereby allowing blood to return to the systemic circulation. The ability of TIPS to function like a surgical side-to-side portacaval shunt without requiring general anesthesia and major surgery led to its rapid acceptance into clinical practice . However, the expanding use of TIPS has also led to its misuse in some instances.
This topic review will discuss the role of TIPS in the management of acute esophageal, gastric, or ectopic variceal hemorrhage, and in the prevention of recurrent variceal bleeding. Other indications for the use of TIPS (eg, ascites and hydrothorax), contraindications, and complications associated with this procedure are discussed separately (see "Transjugular intrahepatic portosystemic shunts: Indications and contraindications" and "Transjugular intrahepatic portosystemic shunts: Complications"). A guideline (updated in 2009) issued by the American Association for the Study of Liver Diseases (AASLD) is also available . The AASLD guideline can be accessed through the AASLD website.
ACUTE VARICEAL HEMORRHAGE
Several treatments are available for the management of acute variceal hemorrhage. These can be broadly grouped into treatments that address the local bleeding site and those that reduce portal pressure directly. Examples of the former are esophageal sclerotherapy, band ligation, and balloon tamponade. Treatments to reduce portal pressure include pharmacologic agents (such as somatostatin, vasopressin, and their analogues), surgically created shunts, and transjugular intrahepatic portosystemic shunts (TIPS). In clinical practice, these modalities are sometimes used together. Patients who have recurrent bleeding or bleeding refractory to a specific therapy may benefit from one of these alternatives. (See "Methods to achieve hemostasis in patients with acute variceal hemorrhage".)
None of the treatments available for variceal hemorrhage is optimal. This is due both to the failure of any treatment to uniformly achieve hemostasis and to the inability to arrest progression of cirrhosis or prevent liver failure. In addition, each modality has its unique spectrum of complications, which also contribute to morbidity and mortality. The choice of a specific therapeutic modality depends upon its relative efficacy and safety in a given clinical setting.
Active hemorrhage from esophageal varices — The goal of treatment of active variceal hemorrhage is to quickly arrest initial bleeding and bleeding-related complications, prevent recurrent bleeding, and minimize treatment-associated morbidity and mortality. Endoscopic and pharmacologic treatment is first-line therapy for active esophageal variceal hemorrhage. Endoscopic sclerotherapy or band ligation can be performed at the bedside by practically all trained gastroenterologists and achieves hemostasis in 80 to 90 percent of subjects. Both methods decrease early rebleeding and improve short-term survival. Pharmacologic therapy is also effective, widely available, and can be used in combination with endoscopic therapy. (See "Methods to achieve hemostasis in patients with acute variceal hemorrhage".)
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- ACUTE VARICEAL HEMORRHAGE
- Active hemorrhage from esophageal varices
- Salvage therapy for patients who are poor surgical candidates
- Salvage therapy for patients who are good surgical candidates
- Bleeding gastric varices
- Bleeding ectopic varices
- PREVENTION OF RECURRENT VARICEAL HEMORRHAGE
- TIPS versus endoscopic therapy
- Recurrence of portal hypertension and stent stenosis
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS