Published online Oct 7, 2013. doi: 10.3748/wjg.v19.i37.6131
Revised: August 13, 2013
Accepted: August 20, 2013
Published online: October 7, 2013
Acute variceal hemorrhage, a life-threatening condition that requires a multidisciplinary approach for effective therapy, is defined as visible bleeding from an esophageal or gastric varix at the time of endoscopy, the presence of large esophageal varices with recent stigmata of bleeding, or fresh blood visible in the stomach with no other source of bleeding identified. Transfusion of blood products, pharmacological treatments and early endoscopic therapy are often effective; however, if primary hemostasis cannot be obtained or if uncontrollable early rebleeding occurs, transjugular intrahepatic portosystemic shunt (TIPS) is recommended as rescue treatment. The TIPS represents a major advance in the treatment of complications of portal hypertension. Acute variceal hemorrhage that is poorly controlled with endoscopic therapy is generally well controlled with TIPS, which has a 90% to 100% success rate. However, TIPS is associated with a mortality of 30% to 50% in such a setting. Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and endoscopic sclerotherapy failure, before the clinical condition worsens. Furthermore, admission to specialized centers is mandatory in such a setting and regional protocols are essential to be organized effectively. This review article discusses initial management and then focuses on the specific role of TIPS as a primary therapy to control acute variceal hemorrhage, particularly as a rescue therapy following failure of endoscopic approaches.
Core tip: The transjugular intrahepatic portosystemic shunts (TIPS) is a highly effective treatment for bleeding esophageal and gastric varices with control of the bleeding in over 90% of the patients. Many papers have been published in the last decade that led to technical improvements and definition of the best indications for this promising treatment of complications of portal hypertension. 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 TIPS as a rescue therapy. Technical aspects of this procedure and the current indications are also discussed.