Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1209_Библиотеки_им_академика_М_И_Перельмана.pdf
372
balloon should be defl ated every 12 h to prevent necrosis. Twenty to thirty percent
of patients undergoing balloon tamponade have complications related to tube placement and include aspiration pneumonia, esophageal tears or rupture [ 11 ]. One series
reported effective control of bleeding with tube placement in 79 % of patients [ 12 ],
making tamponade an effective means for temporary control of severe hemorrhage
while awaiting defi nitive treatment with TIPS or surgery .
TIPS
Transjugular intrahepatic portosystemic shunt ( TIPS ) was developed as a minimally
invasive shunt, designed to create portosystemic bypass with the primary advantage
of avoiding major surgery , while maintaining blood fl ow to the liver. TIPS is widely
considered salvage therapy for the 10–20 % of patients that fail fi rst-line therapy.
The fi rst two large series reporting outcomes for TIPS for the management of recurrent variceal bleeding (only 10 % were emergent cases), yielded 92 % success in
achieving hemostasis, with overall 1-year survival rates of 75–100 %, 68–86 %, and
49–73 % percent for Child-Pugh A, B, and C, respectively [ 13 , 14 ].
For patients with acute bleeding refractory to endoscopic therapy, emergent or
“salvage” TIPS is also very effective, controlling bleeding in 94 % of patients with
low rebleeding rates. However, the 30-day mortality is 30 %, with only half of all
patients surviving to 1 year [ 15 ]. The high mortality among those requiring rescue
therapies likely refl ects the severity of liver disease and the underlying degree of
portal hypertension in this population. Furthermore, the delay between initial bleed
and TIPS placement, number of endoscopic attempts, and need for balloon tamponade correlates with increased mortality when using TIPS as a salvage therapy [ 11 ].
In order to decrease the mortality of TIPS, attempts have been made to identify
patients most likely to fail endoscopic therapy, and potentially undergo earlier TIPS
placement, in order to improve survival . The strongest predictor of negative outcome is a HVPG greater than 20 mmHg, in which patients are 4–5 times more likely
to fail medical and endoscopic therapy [ 16 , 17 ]. HVPG measurement is not routine
practice in the setting of acute bleeding in the United States. Risk factors for a
HVPG >20 include Child-Pugh C cirrhosis , non-alcohol related cause of cirrhosis,
systolic blood pressure at the time of bleeding of less than 100 mmHg, or active
bleeding at the time of endoscopy [ 17 , 18 ].
Early TIPS
Two randomized trials have shown that early TIPS (within 24–72 h of admission) is
associated with signifi cant improvement in survival among high-risk patients
(Child-Pugh class B and C patients and/or those with hepatic vein-portal gradient
(HVPG) >20 mmHg) [ 12 , 19 ]. The fi rst of these two randomized studies, utilized
measurement of hepatic venous pressure gradient within 24 h of admission of acute
variceal bleed. All patients received endoscopic sclerotherapy and those with HVPG
J.N. Gaetano and K.G. Reddy
373
>20 were randomized to TIPS or continued medical therapy. Those receiving TIPS
had less rebleeding (12 % vs. 50 %), in-hospital mortality (11 % vs. 38 %) and
1-year mortality (31 % vs. 65 %) [ 19 ]. Of note, neither control nor treatment group
received continuous vasoactive therapy. Furthermore, the decision to place TIPS
was determined by HVPG measurement, a tool that is not widely available.
A subsequent randomized trial evaluated early TIPS versus EBL in Child-Pugh
B and C patients with acute variceal bleeding. Medical therapy plus EBL had signifi cantly more rebleeding or failure to control bleeding when compared to TIPS
(TIPS, 1/32 patients; EBL, 14/31 patients) [ 12 ]. ICU stay was shortened in the early
TIPS group. The rate of survival at 6 weeks was 97 % in the TIPS group compared
with 67 % in the EBL group. No signifi cant differences were reported in serious
adverse events, including number or severity of hepatic encephalopathy (TIPS,
25 %; EBL, 39 %). Although not statistically signifi cant, the rate of acute liver failure was 9 % in the TIPS group compared to 3 % in the EBL group [ 12 ]. This study
was underpowered to show a signifi cant difference in rate of acute liver failure and
excluded patients greater than 75 years of age and Child-Pugh score greater than 13
points [ 12 ].
Complications of TIPS
Early complications of TIPS are most commonly related to the direct shunting of
portal fl ow into the venous system and include: heart failure (increase venous return/
preload), liver failure (ischemia) and hepatic encephalopathy (less toxin clearance).
The reported incidence of new onset or worsening hepatic encephalopathy ranges
from 13 to 35 % of those undergoing TIPS [ 20 ]. In addition, the nature of the pro-
cedure itself has risks independent of the effect of shunting. These procedural risks
include liver capsular perforation, puncture of the gall bladder or a bile duct , and
hepatic artery injury requiring coil embolization or surgery .
Systematic risk stratifi cation for who should undergo TIPS was fl awed when the
Child-Pugh system was applied as this system was originally designed to determine
risk for undergoing surgical portosystemic shunt, and has limitations when applied
to TIPS. Most patients requiring emergent TIPS for bleeding are class C, and the
system only divides patients into low, intermediate and high risk. Furthermore, the
model uses subjective measures such as encephalopathy and ascites , which can be
altered by therapy. The creation of the Model for End-stage Liver Disease ( MELD )
score, which is now universally used for liver transplant listing, was initially
designed to predict 3-month mortality in patients undergoing elective TIPS. The
MELD score utilizes objective measures of total serum bilirubin, serum creatinine,
and prothrombin time to risk stratify patients [ 21 ]. The score was later validated to
predict 1-month mortality, concluding that patients with a MELD score of >24
undergoing elective TIPS are at higher risk of early death [ 22 ].
In the early era of TIPS , bare metal expandable stents were found to be particular
vulnerable to stenosis from pseudointimal hyperplasia within the stent, occurring in
30–70 % of patients within 1 year [
23 ], and by 2 years virtually all patient develop
33 When Should Patients with Bleeding Esophageal Varices Undergo TIPS Versus…
374
some degree of stenosis [ 24 ]. The advent of polytetrafl uoroethylene (PTFE) covered
stents led to a dramatic improvement in stent patency, without an impact of rebleeding, encephalopathy, or survival . The frequency of stenosis declined to 18 % at 1
year, while patency improved from 36 to 76 % at 2 years [ 25 ].
There are important contraindications and relative contraindications to TIPS that
require consideration (Table 33.2 ). Absolute contraindications to TIPS are primary
prevention of variceal bleeding, congestive heart failure, severe pulmonary hypertension, multiple hepatic cysts, uncontrolled systemic infection or sepsis, and unrelieved biliary obstruction . Relative contraindications include hepatoma if centrally
located, obstruction of hepatic veins, portal vein thrombosis, severe coagulopathy
(INR >5), platelets <20,000/cm 3 , and moderate pulmonary hypertension [ 26 ].
Surgical Shunt
For more than half a century, the creation of a surgical portosystemic shunt has been
used to bypass the site of increased resistance (cirrhotic liver), thereby decreasing
portal venous pressure, and control (and prevent) variceal bleeding. The direct portocaval shunt was prominent in the 1960s–1970s, and while very effective in controlling
bleeding, there was signifi cant operative morbidity , induction of liver failure , and
worsening of acute and chronic hepatic encephalopathy related to complete redirection of portal blood fl ow. The distal splenorenal shunt (DSRS) took root in the
1970s–1980s followed by the interposition “C” or “H” graft portocaval shunts in the
1990s and 2000s. These small-diameter portocaval shunts are partial portosystemic
shunts that effectively reduce portal pressure while preserving nutrient blood fl ow to
the liver, minimizing postoperative encephalopathy and liver failure. Surgical shunting
effectively reduces portal pressure [ 27 ] and controls acute bleeding in 99–100 % of
patients undergoing surgery [ 28 ], however given the poor short term survival among
Child-Pugh C patients [ 27 ] and considerable morbidity from surgery, the Child-Pugh
A patient with minimal comorbidities is the best candidate for this therapy.
In Child-Pugh A and B patients with refractory bleeding, DSRS has been compared to TIPS , which revealed no statistically signifi cant difference in rate of
rebleeding (DSRS, 5.5 % and TIPS, 10.5 %,) or survival at 2 years (DSRS, 81 %
and TIPS 88 %) or survival at 5 years (DSRS, 62 % and TIPS, 61 %). Half the
patients in each group developed hepatic encephalopathy [ 29 ].
Table 33.2 Absolute and relative contraindication to transjugular intrahepatic portosystemic
shunt ( TIPS ) placement
Absolute Relative
Congestive heart failure Hepatoma, if centrally located
Severe pulmonary hypertension Moderate pulmonary hypertension
Multiple hepatic cysts Portal vein thrombosis
Uncontrolled systemic infection or sepsis Obstruction of hepatic veins
Unrelieved biliary obstruction Severe coagulopathy (INR >5, platelets <20,000)
J.N. Gaetano and K.G. Reddy
375
Recommendations
It should be reinforced that the backbone of initial therapy for acute bleeding from
varices relies upon hemodynamic resuscitation (while avoiding over transfusion),
having a low threshold for endotracheal intubation to ensure the patient’s airway is
protected, and addressing coagulopathies. Prophylactic antibiotics (fl uoroquinolone
or third generation cephalosporin) as well as vasoactive therapy (octreotide, somatostatin, or terlipressin) must be initiated and maintained for 3–5 days.
After initial resuscitation, airway management , correction of coagulopathy, an
EGD should be performed as soon as possible after admission (within 12 h) with
appropriate endoscopic therapy if an esophageal variceal bleed is confi rmed [ 9 , 26 ].
In general, those patients who fail endoscopic therapy for variceal bleeding
should undergo defi nitive therapy with either TIPS or a surgical shunt. As noted
above, the two procedures are equal in effi cacy and appear to have no difference in
mortality adverse outcomes , including worsening or new hepatic encephalopathy.
The choice of surgical shunt versus percutaneous TIPS should be made based on
available expertise and patient preference.
Early TIPS (within 72 h of acute variceal bleeding) appears to be a safe and
effective modality to treat acute variceal bleeding in a select patient population in
conjunction with medical therapy. The mortality of rescue TIPS (after failure of
endoscopic therapy) is associated with a high mortality, which has been attributed,
in part, to the delay from the time of initial bleed until TIPS. For this reason, recognition of a patient likely to fail endoscopic and medical therapy should be considered for early TIPS (Fig. 33.1 ). This recommendation pertains to Child-Pugh class
B with active bleeding at the time of initial endoscopy or class C patients, and
patients with an HVPG >20. Early-TIPS cannot be recommended in patients with
Child-Pugh class A cirrhosis because failure of endoscopic and medical therapy, as
well as mortality are low in this patient population. Early TIPS also cannot be recommended in patients with a MELD score >24 given evidence of early mortality
after TIPS in these patients [ 22 ], as well as patients over the age of 75 or Child-Pugh
score over 13 because these patients were excluded from the early-TIPS trial [ 12 ].
A Personal View of the Data
Acute variceal bleeding is a serious sequela of cirrhosis and portal hypertension,
which still carries signifi cant morbidity and mortality . Advances in therapeutics
allowed for endoscopic management to emerge as fi rst line therapy two decades
ago. There is ample data demonstrating effi cacy of EBL, TIPS , as well as surgical
shunting. Given the need for initial endoscopy to prove variceal hemorrhage as the
source of GI bleeding, accessibility of endoscopy, as well as limited access to HVPG
measurement; TIPS is unlikely to replace EBL as initial therapy in The United
States. TIPS remains a crucial rescue therapy for those with refractory bleeding, or
33 When Should Patients with Bleeding Esophageal Varices Undergo TIPS Versus…
376
early rebleeding who are considered to have failed an endoscopic approach. Areas
of interest for further research within this topic include the role of new pharmacologic therapies with greater effect on HVPG and the role of capsule endoscopy to
diagnose acute variceal hemorrhage.
Recommendations
– For patients with suspected acute esophageal variceal hemorrhage, we recom-
mend early (within 12 h) endoscopy as both initial diagnostic and therapeutic
procedure. (evidence quality high; strong recommendation)
– In patients with suspected variceal hemorrhage, prompt attention to airway man-
agement , volume resuscitation, antimicrobial prophylaxis, and pharmacologic
therapy are crucial. (evidence quality high; strong recommendation)
– TIPS is indicated in patients with refractory bleeding, or early rebleeding who
are considered to have failed an endoscopic and medical therapy. (Evidence
quality moderate, strong recommendation)
– In patients with refractory bleeding, Child A status, with a non-cardiopulmonary
contraindication to TIPS (e.g. centrally located hepatoma), distal splenorenal
Suspected variceal
hemorrhage
Vasoactive Therapy
Antibiotics
Airway management
EGD confirms EV as
source
No
Source-specific
management
Yes
Endoscopic band
ligation
Any of the following?
• Child-Pugh A
• Child C, score > 13
• MELD > 24
• Age > 75
• HVPG < 20mmHg
NoYes
Continued medical
therapy and long term
endoscopic therapy
Contraindication to
TIPS?
Hemostasis achieved
No
Consider
Early T IPS
Rescue Therapy:
Balloon tamponade
TIPS
Surgery
No
Yes
Yes
Rebleeding
Yes
No
Fig. 33.1 Risk stratifi ed approach to the management of acute variceal bleeding. Abbreviations:
EGD esophagogastroduodenoscopy, EV esophageal varices , TIPS transjugular intrahepatic porto-
systemic shunt, MELD Model for End-Stage Liver Disease, HVPG hepatic venous pressure
gradient
J.N. Gaetano and K.G. Reddy
377
shunt should be considered if the surgical expertise is available. (Evidence qual-
ity moderate, strong recommendation)
– Early TIPS should be considered for bleeding esophageal varices in patients with
the following characteristics: Child-Pugh class B with active variceal bleeding at
the time of initial endoscopy or class C patients with a Child-Pugh score <14,
MELD score <24, and age <75, and with HVPG >20 mmHg in centers where
portal gradient measurement is available. (Evidence quality moderate, moderate
recommendation)
References
1. Jamal MM, Samarasena JB, Hashemzadeh M, Vega KJ. Declining hospitalization rate of
esophageal variceal bleeding in the United States. Clin Gastroenterol Hepatol.
2008;6(6):689–95.
2. Carbonell N, Pauwels A, Serfaty L, Fourdan O, Lévy VG, Poupon R. Improved survival after
variceal bleeding in patients with cirrhosis over the past two decades. Hepatology.
2004;40(3):652–9.
3. de Franchis R. Evolving consensus in portal hypertension report of the Baveno IV consensus
workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol.
2005;43(1):167–76.
4. Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esopha-
geal variceal bleeding. A meta-analysis. Ann Intern Med. 1995;123(4):280–7.
5. Stiegmann GV, Goff JS, Michaletz-Onody PA, Korula J, Lieberman D, Saeed ZA, Reveille
RM, Sun JH, Lowenstein SR. Endoscopic sclerotherapy as compared with endoscopic ligation
for bleeding esophageal varices. N Engl J Med. 1992;326(23):1527–32.
6. Lo GH, Lai KH, Cheng JS, Hwu JH, Chang CF, Chen SM, Chiang HT. A prospective, random-
ized trial of sclerotherapy versus ligation in the management of bleeding esophageal varices.
Hepatology. 1995;22(2):466–71.
7. Laine L, el-Newihi M, Migikovsky B, Sloane R, Garcia F. Endoscopic ligation compared with
sclerotherapy for the treatment of bleeding esophageal varices. Ann Intern Med.
1993;119(1):1–7.
8. D’amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: a meta-analytic review.
Hepatology. 1995;22(1):332–54.
9. de Franchis R, Baveno V Faculty. Revising consensus in portal hypertension: report of the
Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2010;53(4):762–8.
10. Habib A, Sanyal AJ. Acute variceal hemorrhage. Gastrointest Endosc Clin N Am.
2007;17(2):223–52.
11. Herrera JL. Management of acute variceal bleeding. Clin Liver Dis. 2014;18(2):347–57.
12. García-Pagán JC, Caca K, Bureau C, Laleman W, Appenrodt B, Luca A, Abraldes JG, Nevens
F, Vinel JP, Mössner J, Bosch J. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010;362(25):2370–9.
13. Rossle M, Haag K, Ochs A, Sellinger M, Noldge G, Perarnau J-M, Berger E, Blum U,
Gabelmann A, Hauenstein K, Langer M, Gerok W. The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding. N Engl J Med. 1994;330(3):165–71.
14. Laberge JM, Somberg KA, Lake JR, Gordon RL, Kerlan Jr RK, Ascher NL, Roberts JP, Simor
MM, Doherty CA, Hahn J, BachettiI P, Ring EJ. Two-year outcome following transjugular
intrahepatic portosystemic shunt for variceal bleeding: results in 90 patients. Gastroenterology.
1995;108(4):1143–51.
33 When Should Patients with Bleeding Esophageal Varices Undergo TIPS Versus…
378
15. Azoulay D, Castaing D, Majno P, Saliba F, Ichaı P, Smail A, Delvart V, Danaoui M, Samuel D,
Bismuth H. Salvage transjugular intrahepatic portosystemic shunt for uncontrolled variceal
bleeding in patients with decompensated cirrhosis. J Hepatol. 2001;35(5):590–7.
16. Moitinho E, Escorsell A, Bandi JC, Salmerón JM, García-Pagán JC, Rodés J, Bosch
J. Prognostic value of early measurements of portal pressure in acute variceal bleeding.
Gastroenterology. 1999;117(3):626–31.
17. Villanueva C, Piqueras M, Aracil C, Gómez C, López-Balaguer JM, Gonzalez B, Gallego A,
Torras X, Soriano G, Sáinz S, Benito S, Balanzó J. A randomized controlled trial comparing
ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute
variceal bleeding. J Hepatol. 2006;45(4):560–7.
18. Vangeli M, Patch D, Burroughs AK. Salvage tips for uncontrolled variceal bleeding. J Hepatol.
2002;37(5):703–4.
19. Monescillo A, Martínez-Lagares F, Ruiz-del-Arbol L, Sierra A, Guevara C, Jiménez E,
Marrero JM, Buceta E, Sánchez J, Castellot A, Peñate M, Cruz A, Peña E. Infl uence of portal
hypertension and its early decompression by TIPS placement on the outcome of variceal
bleeding. Hepatology. 2004;40(4):793–801.
20. Riggio O, Nardelli S, Moscucci F, Pasquale C, Ridola L, Merli M. Hepatic encephalopathy
after transjugular intrahepatic portosystemic shunt. Clin Liver Dis. 2012;16(1):133–46.
21. Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PCJ. A model to predict
poor survival in patients undergoing transjugular intrahepatic portosystemic shunts.
Hepatology. 2000;31(4):864–71.
22. Montgomery A, Ferral H, Vasan R, Postoak DW. MELD score as a predictor of early death in
patients undergoing elective transjugular intrahepatic portosystemic shunt (TIPS) procedures.
Cardiovasc Intervent Radiol. 2005;28(3):307–12.
23. Riggio O, Ridola L, Angeloni S, Cerini F, Pasquale C, Attili AF, Fanelli F, Merli M, Salvatori
FM. Clinical effi cacy of transjugular intrahepatic portosystemic shunt created with covered
stents with different diameters: results of a randomized controlled trial. J Hepatol.
2010;53(2):267–72.
24. Sanyal AJ, Freedman AM, Luketic VA, Purdum PP, Shiffman ML, DeMeo J, Cole PE, Tisnado
J. The natural history of portal hypertension after transjugular intrahepatic portosystemic
shunts. Gastroenterology. 1997;112(3):889–98.
25. Bureau C, Pagan JCG, Layrargues GP, Metivier S, Bellot P, Perreault P, Otal P, Abraldes J-G,
Peron JM, Rousseau H, Bosch J, Vinel JP. Patency of stents covered with polytetrafl uoroethylene in patients treated by transjugular intrahepatic portosystemic shunts: long-term results of
a randomized multicentre study. Liver Int. 2007;27(6):742–7.
26. Prevention and management of gastroesophageal varices and variceal hemorrhage in
cirrhosis – Prevention and Management of Gastro Varices and Hemorrhage.pdf. [Online].
Available:
http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Practice%20
Guidelines/Prevention%20and%20Management%20of%20Gastro%20Varices%20and%20
Hemorrhage.pdf
. Accessed: 27 July 2014.
27. Hillebrand DJ, Kojouri K, Cao S, Runyon BA, Ojogho O, Concepcion W. Small-diameter
portacaval H-graft shunt: a paradigm shift back to surgical shunting in the management of variceal bleeding in patients with preserved liver function. Liver Transpl. 2000;6(4):459–65.
28. Orloff MJ, Orloff MS, Orloff SL, Rambotti M, Girard B. Three decades of experience with
emergency portacaval shunt for acutely bleeding esophageal varices in 400 unselected patients
with cirrhosis of the liver. J Am Coll Surg. 1995;180(3):257–72.
29. Henderson JM, Boyer TD, Kutner MH, Galloway JR, Rikkers LF, Jeffers LJ, Abu-Elmagd K,
Connor J, DIVERT Study Group. Distal splenorenal shunt versus transjugular intrahepatic
portal systematic shunt for variceal bleeding: a randomized trial. Gastroenterology.
2006;130(6):1643–51.
J.N. Gaetano and K.G. Reddy
379© Springer International Publishing Switzerland 2016
J.M. Millis, J.B. Matthews (eds.), Diffi cult Decisions in Hepatobiliary
and Pancreatic Surgery, Diffi cult Decisions in Surgery: An Evidence-Based
Approach, DOI 10.1007/978-3-319-27365-5_34
Chapter 34
Management of Symptomatic Portal
Hypertension: TIPS vs. Medical Management
Anouar Teriaky and Andrew Aronsohn
Abstract Portal hypertension is a common manifestation of decompensated
cirrhosis and can have a profound impact on patient survival and quality of life.
Portal hypertension can be managed with medical therapy through use of diuretics
or portal pressure lowering agents, however in some cases more invasive procedures
such as transjugular intrahepatic portosystemic shunt (TIPS) may be more effective.
In this systematic review of the literature, clinical outcomes following medical management and TIPS are compared across various manifestations of portal hypertension. Overall, we found that data favors use of TIPS to prevent recurrent variceal
bleeding and recurrent ascites however risk of hepatic encephalopathy is higher
than medical management. In addition, in selected patients, TIPS may also improve
mortality in those with variceal hemorrhage and refractory ascites. Compared to
esophageal varices and ascites, there is limited data supporting use of TIPS vs medical management for conditions such as hepatic hydrothorax, nonesophageal varices
and hepatorenal syndrome.
Keywords Portal hypertension • TIPS • Varices • Ascites • Diuretics • Paracentesis
• Quality of life
Introduction
Portal hypertension (PH) is a common complication of chronic liver disease [ 1 ]. PH
can manifest in a variety of forms including gastrointestinal hemorrhage, ascites ,
hepatic hydrothorax, portopulmonary hypertension, hepatopulmonary syndrome,
and hepatorenal syndrome (HRS). It leads to great morbidity and mortality as liver
disease further progresses [ 2 ]. Most complications of PH are initially managed
medically with more invasive measures added when necessary.
A. Teriaky (*) • A. Aronsohn
Center for Liver Diseases , University of Chicago Medical Center ,
5841 S. Maryland Ave , Chicago , IL 60637 , USA
e-mail:
ateriaky@mail.bsd.uchicago.edu
380
Medical management of esophageal varices may involve non-selective betablockers or endoscopic variceal ligation (EVL) for primary prophylaxis and variceal
hemorrhage is managed with hemodynamic resuscitation, vasoactive agents, antibiotics, and EVL [ 3 ]. Rebleeding esophageal varices carry a high mortality [ 4 ].
Ascites is initially managed with sodium restriction and diuretics . Refractory ascites can occur in cirrhotic patients that are unresponsive to salt restriction and aggressive diuretic therapy or that develop intolerances to diuretic use [ 5 ]. These patients
represent 10 % of cirrhotics with ascites [ 6 ]. This occurrence predicts poor out-
comes with greater than 50 % dying within 1 year without liver transplant ation .
Hepatic hydrothorax is managed in a similar fashion to ascites . HRS develops as
an end-stage complication of refractory ascites. There are two types with type 1
occurring more rapidly and possessing a higher mortality . Vasoactive agents with
albumin have been shown to improve renal function [ 7 ]. Portopulmonary hyperten-
sion has been managed with vasodilators and hepatopulmonary syndrome with oxygen therapy [ 8 ]. Ultimately when PH and its manifestations become severe or
refractory, referral to liver transplant centers might provide the greatest survival [ 9 ].
Transjugular intrahepatic portosystemic shunt ( TIPS ) has largely replaced surgical portacaval shunts in decompressing the portal circulation. It has been used for
the treatment of severe or refractory complications of PH [ 5 ]. TIPS is not without
complications and should only be performed when necessary. Complications
include transcapsular puncture, intraperitoneal hemorrhage, hepatic infarction, fi stulization, hemobilia, hemolysis, encephalopathy, stent infection, stent thrombosis
or stenosis, and stent migration [ 10 ]. This chapter reviews the evidence for medical
management versus TIPS to treat the various manifestations of severe or refractory
symptomatic PH.
Search
A literature search on medical management versus TIPS for symptomatic PH
(Table 34.1 ) was conducted on the following databases: Pubmed, Embase, and
Cochrane Evidence Based Medicine . English language publications between 1994
and 2014 were reviewed. Terms used in the search query included various combinations of the following terms: transjugular intrahepatic portosystemic shunt, medical
management, diuretics , paracentesis , portal hypertension, varices , variceal hemorrhage, ascites , hepatic hydrothorax, portopulmonary hypertension, hepatorenal syndrome, hepatopulmonary syndrome, portal hypertensive gastropathy, control,
mortality , morbidity , quality of life , and cost. After reviewing the literature, the
Table 34.1 PICO table for symptomatic portal hypertension management with TIPS
P atients I ntervention C omparison O utcomes
Symptomatic patients
with portal hypertension
TIPS Medical
management
Control of portal hypertension,
morbidity, mortality, and cost
A. Teriaky and A. Aronsohn
381
most relevant articles with the highest level of evidence were included. The GRADE
system was used to classify data.
Results
Esophageal Varices
Esophageal variceal hemorrhage represents one of the most fatal complications of
PH. Patients are generally screened at the time of diagnosis of cirrhosis and regularly thereafter. Primary prophylaxis for esophageal varices is the prevention of fi rst
variceal bleed medically with a non-selective beta-blocker or EVL until obliteration. EVL may be considered for large varices , high risk stigmata, and Child Pugh
B and C cirrhosis [ 11 ]. TIPS is contraindicated for primary prophylaxis of esopha-
geal varices [ 3 ].
Acute variceal hemorrhage is a medical emergency and is initially managed with
hemodynamic resuscitation, vasoactive drugs, antibiotics, and EVL. Most patients
respond to this treatment, but TIPS has been used as rescue therapy when necessary.
Controlled studies support the use of early TIPS in esophageal variceal hemorrhage
(Table 34.2 ). Monescillo et al. showed that in patients presenting with a variceal
bleed with a hepatic venous pressure gradient greater than 20 mmHg, TIPS within
24 h was superior to endoscopic therapy in reducing treatment failure (12 % vs.
50 % p = 0.0001) and 1-year mortality (31 % vs. 65 % p = 0.01) without increasing
encephalopathy (p = 31 % vs. 35 % p = n.s) [ 12 ]. A limitation of this study was the
use of sclerotherapy instead of EVL, which is the standard of care [ 3 ].
Garcia-Pagan et al. showed that in Child-Pugh B and C cirrhotics, early closed
stent TIPS combined with medical therapy was superior to medical therapy alone.
Medical therapy consisted of vasoactive drugs and endoscopic therapy. The 1-year
probability of remaining free of rebleeding was 50 % with the control group and
97 % in the TIPS group (p < 0.001). The 1-year survival was 61 % in the endoscopic
therapy group and 86 % in the combined endoscopic therapy and TIPS group
(p = 0.001). There were no signifi cant differences in adverse events between the two
groups [ 13 ]. Closed stents have better patency requiring less revisions when com-
pared to open stents and do not increase the risk of encephalopathy [ 14 ].
Recurrent variceal hemorrhage is associated with high mortality [ 4 , 15 ].
Secondary prophylaxis of esophageal varices in patients that have survived an acute
variceal bleed can be managed medically with a non-selective beta-blocker and
EVL until obliteration [ 3 ]. TIPS has also been used in this patient population. When
comparing propranolol and isosorbide-5-mononitrate to TIPS, patients who underwent TIPS had lower rebleeding rates and equivalent mortality rates although rates
of encephalopathy were higher [ 16 ]. However, this is not the standard of care in
secondary prophylaxis. Multiple trials including several meta-analyses have compared open stent TIPS to EVL or sclerotherapy with or without beta blockers
(Table
34.2 ) [ 17 – 33 ]. In a recent meta-analysis, Zheng et al., showed that TIPS
34 Management of Symptomatic Portal Hypertension: TIPS vs. Medical Management