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

Abstract

Increased portal pressure during variceal bleeding may have an influence on the treatment failure rate, as well as on short- and long-term survival. However, the usefulness of hepatic hemodynamic measurement during the acute episode has not been prospectively validated, and no information exists about the outcome of hemodynamically defined high-risk patients treated with early portal decompression. Hepatic venous pressure gradient (HVPG) measurement was made within the first 24 hours after admission of 116 consecutive patients with cirrhosis with acute variceal bleeding treated with a single session of sclerotherapy injection during urgent endoscopy. Sixty-four patients had an HVPG less than 20 mm Hg (low-risk [LR] group), and 52 patients had an HVPG greater than or equal to 20 mm Hg (high-risk [HR] group). HR patients were randomly allocated into those receiving transjugular intrahepatic portosystemic shunt (TIPS; HR-TIPS group, n = 26) within the first 24 hours after admission and those not receiving TIPS (HR-non-TIPS group). The HR-non-TIPS group had more treatment failures (50% vs. 12%, P =.0001), transfusional requirements (3.7 +/- 2.7 vs. 2.2 +/- 2.3, P =.002), need for intensive care (16% vs. 3%, P <.05), and worse actuarial probability of survival than the LR group. Early TIPS placement reduced treatment failure (12%, P =.003), in-hospital and 1-year mortality (11% and 31%, respectively; P <.05). In conclusion, increased portal pressure estimated by early HVPG measurement is a main determinant of treatment failure and survival in variceal bleeding, and early TIPS placement reduces treatment failure and mortality in high risk patients defined by hemodynamic criteria.

Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis

“…More recently, a small study has suggested that early TIPS placement (within 24 hours of hemorrhage) is associated with a significant improvement in survival in "high-risk" patients (defined as those with an HVPG Ͼ20 mmHg) with acute variceal hemorrhage. 34 These results will require confirmation in a larger number of patients followed for a longer period before early TIPS can be recommended. The performance of both shunt surgery and TIPS are dependent on local expertise.…”

“…[30][31][32] Patients with an HVPG Ͼ20 mmHg (measured within 24 hours of variceal hemorrhage) have been identified as being at a higher risk for early rebleeding (recurrent bleeding within the first week of admission) or failure to control bleeding (83% vs. 29%) and a higher 1-year mortality (64% vs. 20%) compared to those with lower pressure. 33,34 Late rebleeding occurs in approximately 60% of untreated patients, mostly within 1-2 years of the index hemorrhage. 35,36 Variceal wall tension is probably the main factor that determines variceal rupture.…”

Diagnosis and management of acute variceal bleeding: Asian Pacific Association for Study of the Liver recommendations

“…In the Baveno conference, it was considered that a second attempt at endoscopic therapy was one possibility and one could perform TIPS after failure of the second endoscopic therapy [1]. A small study suggests that early TIPS placement (within 24 h of hemorrhage) is associated with a significant improvement in survival in patients with HVPG greater than 20 mmHg [31]. Therefore, HVPG can provide useful information that allows for risk stratification and more aggressive treatment in high-risk patients.…”

Esophageal Stents for Acute Variceal Bleeding: Expanding the Possibilities

“…This is the rationale for preemptive or early TIPS [8]. Indeed, two RCT [9,10] and two observational studies confirm the efficacy of early TIPS (within the first 72 h after admission) in such high-risk patients. Indeed, experts attending the Baveno VI consensus conference recommended the use of early TIPS in patients with Child-Pugh B cirrhosis and active bleeding despite vasoactive drug therapy and in all patients with Child-Pugh C cirrhosis (< 14 points) [3].…”