Background Patients with cirrhosis in Child–Pugh class C or those in class B who have persistent bleeding at endoscopy are at high risk for treatment failure and a poor prognosis, even if they have undergone rescue treatment with a transjugular intrahepatic portosystemic shunt (TIPS). This study evaluated the earlier use of TIPS in such patients. Methods We randomly assigned, within 24 hours after admission, a total of 63 patients with cirrhosis and acute variceal bleeding who had been treated with vasoactive drugs plus endoscopic therapy to treatment with a polytetrafluoroethylene-covered stent within 72 hours after randomization (early-TIPS group, 32 patients) or continuation of vasoactive-drug therapy, followed after 3 to 5 days by treatment with propranolol or nadolol and long-term endoscopic band ligation (EBL), with insertion of a TIPS if needed as rescue therapy (pharmacotherapy–EBL group, 31 patients). Results During a median follow-up of 16 months, rebleeding or failure to control bleeding occurr...

/pdf/early-use-of-tips-in-patients-with-cirrhosis-and-variceal-15tvh0zimy.pdf

Early Use of TIPS in Patients with Cirrhosis and Variceal Bleeding

https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.1840400408

Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding

http://www.annalsgastro.gr/files/journals/1/earlyview/2013/ev-02-2013-10-1672.pdf

Use of early-TIPS for high-risk variceal bleeding: Results of a post-RCT surveillance study

To the Editor: We disagree with several points in the commentary of our study on early use of transjugular intrahepatic portosystemic shunts (TIPS) in patients with cirrhosis and variceal bleeding (1), which was abstracted in ACP Journal Club (2). TIPS should be offered as a first treatment option only to a small proportion of patients with acute variceal hemorrhage—that is, those at high risk for treatment failure. Our study clearly shows that in this high-risk cirrhotic population, mortality is reduced with early use of TIPS. Therefore, to exclude 82% of patients is not a limitation of the study, as suggested by Dr. Korula. The use of vasoactive drugs followed by endoscopic therapy, nonselective β-blockers, and nitrates also cannot be considered a limitation of the study: This is recommended by current guidelines (3).

/pdf/early-use-of-tips-in-patients-with-cirrhosis-and-variceal-gn3c6gbuyj.pdf

Early use of TIPS in patients with cirrhosis and variceal bleeding

https://www.journal-of-hepatology.eu/article/S0168-8278(01)00185-4/pdf

Salvage transjugular intrahepatic portosystemic shunt for uncontrolled variceal bleeding in patients with decompensated cirrhosis

Thirty-five patients for whom emergency sclerotherapy or conservative treatment, or both, failed to arrest variceal bleeding, or who had early rebleeding and required emergency portosystemic shunts (EPSS) were studied. EPSS permanently controlled the variceal bleeding in all but one patient. In this patient, the shunt was patent as demonstrated by angiography. Esophageal varices disappeared in 18 patients and were reduced in 14. Three patients died before the endoscopic examination could be performed. The causes of death were hepatic failure in two and bleeding ulcerations of the gastric fundus in the other patient. One patient was classified in Child's category B and two in Child's category C. Thirty-two patients submitted to EPSS and were discharged alive. Twelve of these patients subsequently died, at an average of 11.2 months after undergoing the shunt procedure. Four of 12 patients died of hepatic failure; two patients died of hepatomas; two, other neoplasia; three, hemorrhaging duodenal ulcers, and one patient, renal failure. Analysis of actuarial survival rates showed that the five year survival rate was 43 per cent. The long term survival rates were fewer for patients with Child's category C than for those with combined Child's categories A and B (five year survival rates were 21 versus 55 per cent; p less than 0.05). During the follow-up period, none of the patients had variceal bleeding. Chronic encephalopathy developed in six, which was mild in three, moderate in one instance and severe in two. It developed soon after EPSS, with onset in the first month after discharge in three. Thus, when conservative treatment fails to arrest variceal bleeding, EPSS should be performed to guarantee definitive control of hemorrhage and prolong the survival period.

Emergency portosystemic shunt in patients with variceal bleeding

This randomized double-blind controlled study analyzed the hemodynamic effects of penbutolol, a new levorotatory beta-blocker, using radionuclide angiography. Twenty cirrhotics with esophageal varices were randomized to two groups: 10 received 40 mg/day of penbutolol orally and the others placebo. Angioscintigraphy was performed before and after an 8-day treatment period. Three cases in the penbutolol group were lost due to software damage, hence the data of 17 patients were analyzed. The two groups were matched for age, sex, etiology of cirrhosis and hepatic function. The index of portal perfusion decreased significantly (-29%; p = 0.018) and the hepatic artery index increased significantly (+23%; p = 0.018), while no changes were observed after placebo. The heart rate decreased significantly after penbutolol (-9%; p = 0.028), while neither penbutolol nor placebo modified the ejection fraction. In conclusion, penbutolol decreased portal perfusion index (the compensatory increase in the hepatic artery index confirmed this change) without major modification of total hepatic blood flow or systemic hemodynamics. Angioscintigraphy is reasonably accurate, reproducible, safe and can be considered suitable for routine use in the assessment of liver hemodynamics.

Angioscintigraphic assessment of hemodynamic effects of penbutolol in cirrhotics with portal hypertension. A double-blind, randomized, controlled study.

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Emergency portosystemic shunt in patients with variceal bleeding

Angioscintigraphic assessment of hemodynamic effects of penbutolol in cirrhotics with portal hypertension. A double-blind, randomized, controlled study.