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Ren J, Liu T, Yang Z, Yuan X, Yang M. Comparative efficacy of pre-emptive TIPS and elective TIPS in EGVB patients with cirrhosis: A single-center retrospective study. Saudi J Gastroenterol 2025; 31:168-175. [PMID: 39918030 DOI: 10.4103/sjg.sjg_389_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2024] [Accepted: 12/30/2024] [Indexed: 05/20/2025] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is the main method to prevent the rebleeding of esophagogastric varices. Many studies have demonstrated that pre-emptive TIPS (p-TIPS) is superior to medicine combined with endoscopic standard therapy in the efficacy of high-risk patients, but very few relevant studies reported whether p-TIPS is more effective than elective TIPS. This study aims to compare the efficacy and prognosis of p-TIPS and elective TIPS for the treatment of esophagogastric variceal bleeding (EGVB) patients with cirrhosis. METHODS In this retrospective study, clinical data of 92 patients with cirrhosis who accepted TIPS treatment after EGVB of cirrhosis were collected. According to the different times of TIPS, the patients were divided into the p-TIPS group and the elective TIPS group. The following information is documented: clinical manifestations and laboratory examination at 1, 3, and 6 months after the operation, survival state, the rates of rebleeding at 6 weeks and 6 months, and postoperative complications and serious adverse events during follow-up. RESULTS The Child-Pugh score ( P = 0.002) and MELD score ( P = 0.006) in the p-TIPS group were significantly lower than those in the elective TIPS group in the 6 th month after treatment. The rate of no gastric coronary vein embolization in the p-TIPS group was higher than in the elective TIPS group ( P = 0.034). The hospitalized days ( P < 0.001) and hospitalized costs ( P < 0.001) were significantly lower in the p-TIPS group than in the elective TIPS group. No significant differences were observed between the two groups concerning rebleeding, overt hepatic encephalopathy, ascites, complications, and serious adverse events, occurrence. CONCLUSION The p-TIPS contributes to liver function recovery and enhances patient survival benefits at 6-months postoperation in the treatment of EGVB compared with elective TIPS, without increasing the incidence of complications and adverse events.
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Affiliation(s)
- Jinfeng Ren
- School of Medical and Life Sciences, Chengdu University of Traditional Chinese Medicine, Sichuan, China
| | - Tianyu Liu
- School of Medical and Life Sciences, Chengdu University of Traditional Chinese Medicine, Sichuan, China
- Department of Digestive Endoscopy Center, Suining Central Hospital, Sichuan, China
| | - Zhengying Yang
- School of Medical and Life Sciences, Chengdu University of Traditional Chinese Medicine, Sichuan, China
| | - Xihui Yuan
- School of Medical and Life Sciences, Chengdu University of Traditional Chinese Medicine, Sichuan, China
| | - Minyuan Yang
- School of Medical and Life Sciences, Chengdu University of Traditional Chinese Medicine, Sichuan, China
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Biswas S, Lo GH, Mehta S, Elhence A, Wong YJ, Vaishnav M, Arora U, Dwarakanathan V, Swaroop S, Aggarwal A, Agarwal A, Singh P, Chavan A, Tripathi S, Dhibar DP, Ali SM, Sharma V, Kumar A, Agarwal S, Shalimar. Abbreviated Duration of Vasoactive Agents Has Similar Outcomes as Standard Duration of Therapy in Patients with Liver Cirrhosis and Variceal Bleeding: An Individual Patient Data Meta-Analysis. Dig Dis Sci 2025; 70:1201-1214. [PMID: 39869165 DOI: 10.1007/s10620-025-08851-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2024] [Accepted: 01/04/2025] [Indexed: 01/28/2025]
Abstract
BACKGROUND This two-stage individual patient data meta-analysis (IPD-MA) compared the efficacy of a shorter duration (≤ 2 days) of vasoactive (VA) drug therapy to standard duration (3-5 days) after acute variceal bleeding (AVB) in patients with liver cirrhosis. PATIENTS AND METHODS Randomized clinical trials on patients with cirrhosis and AVB undergoing endoscopic band ligation which compared a short duration versus the standard duration of VA therapy were included. The primary outcome was 5-day rebleeding rate. Secondary outcomes included 5-day and 42-day mortality, 42-day rebleeding rate, and length of hospital stay in patients receiving short duration of therapy as compared to those receiving standard duration. Aggregate data meta-analysis and IPD-MA of trials were performed for these outcomes and comparisons in patients with different severities of liver disease. RESULTS Out of 11 eligible trials, 542 IPD data sets were available from 6 trials. Two hundred and seventy-nine patients received short duration and 263 received standard duration VA therapy. Two-stage IPD-MA revealed no significant differences in the 5-day rebleeding rate (HR = 0.59, 95%CI: 0.19-1.81, p = 0.66), 5-day mortality (HR = 1.12, 95%CI: 0.18-6.63, p = 0.44), 42-day rebleeding rate (HR = 0.95, 95%CI: 0.47-1.90, p = 0.90) and 42-day mortality (HR = 1.05, 95% CI: 0.43-2.56, p = 0.34) between the two groups. One-stage IPD-MA revealed no significant differences in the outcomes across Child-Pugh classes, with shorter hospital stay in short duration group. CONCLUSIONS Short duration VA therapy has similar outcomes to standard duration in patients with liver cirrhosis presenting with AVB, irrespective of severity of liver disease.
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Affiliation(s)
- Sagnik Biswas
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Gin-Ho Lo
- Division of Gastroenterology, Department of Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Shubham Mehta
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Anshuman Elhence
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Manas Vaishnav
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Umang Arora
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | | | - Shekhar Swaroop
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Arnav Aggarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Ayush Agarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Pranjal Singh
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Amitkumar Chavan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Shashank Tripathi
- Department of Community Medicine, University College of Medical Sciences, New Delhi, India
| | - Deba Prasad Dhibar
- Department of Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sheik Manwar Ali
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Vishal Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Kumar
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Samagra Agarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India.
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de Mattos AA, de Mattos AZ, Manica M, Tovo CV. Which patients benefit the most? An update on transjugular intrahepatic portosystemic shunt. World J Hepatol 2025; 17:99809. [PMID: 40027554 PMCID: PMC11866145 DOI: 10.4254/wjh.v17.i2.99809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 12/23/2024] [Accepted: 01/09/2025] [Indexed: 02/20/2025] Open
Abstract
This is a narrative review in which the advances in technical aspects, the main indications, limitations and clinical results of the transjugular intrahepatic portosystemic shunt (TIPS) in portal hypertension (PH) are addressed. With the emergence of the coated prosthesis, a better shunt patency, a lower incidence of hepatic encephalopathy (HE) and better survival when compared to TIPS with the conventional prosthesis are demonstrated. The main indications for TIPS are refractory ascites, acute variceal bleeding unresponsive to pharmacological/endoscopic therapy and, lastly, patients considered at high risk for rebleeding preemptive TIPS (pTIPS). Absolute contraindications to the use of TIPS are severe uncontrolled HE, systemic infection or sepsis, congestive heart failure, severe pulmonary arterial hypertension, and biliary obstruction. The control of hemorrhage due to variceal rupture can reach up to 90%-100% of cases, and 55% in refractory ascites. Despite evidences regarding pTIPS in patients at high risk for rebleeding, less than 20% of eligible patients are treated. TIPS may also decrease the incidence of future decompensation in cirrhosis and increase survival in selected patients. In conclusion, TIPS is an essential treatment for patients with PH, but is often neglected. It is important for the hepatologist to form a multidisciplinary team, in which the role of the radiologist with experience in interventional procedures is prominent.
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Affiliation(s)
- Angelo Alves de Mattos
- Postgraduation Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90050-170, Rio Grande do Sul, Brazil
| | - Angelo Zambam de Mattos
- Postgraduation Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90050-170, Rio Grande do Sul, Brazil
| | - Muriel Manica
- Postgraduation Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90050-170, Rio Grande do Sul, Brazil
| | - Cristiane Valle Tovo
- Postgraduation Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90050-170, Rio Grande do Sul, Brazil.
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Dunne PDJ, Manship T, Sinha R, Stanley AJ, Lachlan N, Shams A, Forrest EH, Hayes P. Long-term follow-up of a randomised clinical trial: standard of care versus pre-emptive transjugular intrahepatic portosystemic shunt (TIPSS) in patients with cirrhosis and oesophageal variceal bleeding. Frontline Gastroenterol 2025:flgastro-2024-102858. [DOI: 10.1136/flgastro-2024-102858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2025] Open
Abstract
Background and aimsPre-emptive transjugular intrahepatic portosystemic shunt (pTIPSS) within 72 hours following acute oesophageal variceal bleeding has potential survival benefit. However, there is uncertainty whether pTIPSS is advantageous over standard of care (SOC) and long-term outcomes remain unstudied.ApproachPatients recruited to a Scottish randomised control trial were allocated to SOC or pTIPSS and had follow-up extended to 3 years. The primary outcome was 3-year transplant-free survival on intention to treat and per-protocol analysis.Results58 patients were initially recruited, 29 patients per group. Of the 29 in the pTIPSS group, only 23 received TIPSS placement due to logistical reasons. On intention to treat analysis, 3-year transplant-free survival rate in the SOC group was significantly higher than that of the pTIPSS group (55.2% vs 20.1%, p=0.006, HR 2.5, 95% CI 1.3 to 4.87). On per-protocol analysis, 3-year transplant-free survival rate in the SOC group was significantly higher than that of the pTIPSS group (55.2% vs 15.4%, p=0.03, HR 2.93, 95% CI 1.27 to 7.94). There were significantly higher rates of sepsis-related death or sepsis-induced liver failure-related death in the pTIPSS group compared with the SOC group (48.2% vs 3.6%, p<0.001, reciprocal of RR 13.0, 95% CI 2.46 to 75.45). There were no differences in other outcomes associated with portal hypertension on intention to treat analysis.ConclusionpTIPSS was associated with significantly reduced rates of transplant-free survival at 3 years compared with SOC. This may be due to higher rates of sepsis. Further large studies are required to validate these findings.
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Albillos A, Bañares R, Hernández-Gea V. Portal hypertension: recommendations for diagnosis and treatment. Consensus document sponsored by the Spanish Association for the Study of the Liver (AEEH) and the Biomedical Research Network Centre for Liver and Digestive Diseases (CIBERehd). GASTROENTEROLOGIA Y HEPATOLOGIA 2025; 48:502208. [PMID: 39756832 DOI: 10.1016/j.gastrohep.2024.502208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/07/2024] [Accepted: 04/09/2024] [Indexed: 01/07/2025]
Abstract
Portal hypertension is a hemodynamic abnormality that complicates the course of cirrhosis, as well as other diseases that affect the portal venous circulation. The development of portal hypertension compromises prognosis, especially when it rises above a certain threshold known as clinically significant portal hypertension (CSPH). In the consensus conference on Portal Hypertension promoted by the Spanish Association for the Study of the Liver and the Hepatic and Digestive diseases area of the Biomedical Research Networking Center (CIBERehd), different aspects of the diagnosis and treatment of portal hypertension caused by cirrhosis or other diseases were discussed. The outcome of this discussion was a set of recommendations that achieved varying degrees of consensus among panelists and are reflected in this consensus document. The six areas under discussion were: the relevance of CSPH and the non-invasive methods used for its diagnosis and that of cirrhosis, the prevention of the first episode of decompensation and its recurrence, the treatment of acute variceal bleeding and other complications of portal hypertension, the indications for the use of TIPS, and finally, the diagnosis and treatment of liver vascular diseases.
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Affiliation(s)
- Agustín Albillos
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España.
| | - Rafael Bañares
- Servicio de Medicina de Aparato Digestivo, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Universidad Complutense, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España.
| | - Virginia Hernández-Gea
- Servicio de Hepatología, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, España.
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Albillos A, Bañares R, Hernández-Gea V. Portal hypertension: recommendations for diagnosis and treatment. Consensus document sponsored by the Spanish Association for the Study of the Liver (AEEH) and the Biomedical Research Network Center for Liver and Digestive Diseases (CIBERehd). REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2025; 117:14-57. [PMID: 39350672 DOI: 10.17235/reed.2024.10805/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2025]
Abstract
Portal hypertension is a hemodynamic abnormality that complicates the course of cirrhosis, as well as other diseases that affect the portal venous circulation. The development of portal hypertension compromises prognosis, especially when it rises above a certain threshold known as clinically significant portal hypertension (CSPH). In the consensus conference on Portal Hypertension promoted by the Spanish Association for the Study of the Liver and the Hepatic and Digestive diseases area of the Biomedical Research Networking Center (CIBERehd), different aspects of the diagnosis and treatment of portal hypertension caused by cirrhosis or other diseases were discussed. The outcome of this discussion was a set of recommendations that achieved varying degrees of consensus among panelists and are reflected in this consensus document. The six areas under discussion were: the relevance of clinically significant portal hypertension and the non-invasive methods used for its diagnosis and that of cirrhosis, the prevention of the first episode of decompensation and its recurrence, the treatment of acute variceal bleeding and other complications of portal hypertension, the indications for the use of TIPS, and finally, the diagnosis and treatment of liver vascular diseases.
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Affiliation(s)
- Agustín Albillos
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, España
| | - Rafael Bañares
- Servicio de Medicina de Aparato Digestivo, Hospital General Universitario Gregorio Marañón
| | - Virginia Hernández-Gea
- Servicio de Hepatología, Hospital Clínic. Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)
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Celaj S, Estevez J, Novelli P, Orons P, Al-Khafaji A, Jonassaint NL, Cruz RJ, Malik SM. Challenges and Opportunities in the Adoption of p-TIPS for Acute Variceal Bleeding: Insights from a US Tertiary Center. Dig Dis Sci 2025; 70:399-405. [PMID: 39586926 DOI: 10.1007/s10620-024-08745-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2024] [Accepted: 11/06/2024] [Indexed: 11/27/2024]
Abstract
BACKGROUND AND AIMS Since the overwhelmingly positive results of the 'early use of TIPS' published in 2010, studies in Europe and Asia have confirmed early/pre-emptive transjugular intrahepatic portosystemic shunt (p-TIPS) in high-risk patients with acute variceal bleed (AVB) reduces treatment failure and mortality compared to standard of care (SOC). There are no studies evaluating p-TIPS in a US cohort. METHODS A review of patients with cirrhosis from June 2010 to June 2020 with AVB was conducted from a single large US center. RESULTS Of 745 cirrhotic patients with AVB, 18% met criteria for p-TIPS. Alcohol and HCV accounted for 75% of etiology; 13% MASLD. The mean MELD-Na score in our cohort was 24, which is ten points higher than reported in the literature for over 600 p-TIPS cases. Only 9 patients underwent p-TIPS. Patients undergoing p-TIPS were less likely to have MASLD, more likely to be female and less likely to have PSE at baseline. One-year mortality in the SOC group (including patients undergoing 'rescue TIPS') was 53% versus 0% for p-TIPS (p = 0.01). CONCLUSION Our observation suggests hesitancy among providers to recommend p-TIPS, likely due to concerns regarding a 'sicker' patient population. The current SOC in high-risk patients remain suboptimal. Limited data, including our own, suggest that p-TIPS may confer a survival benefit even in patients with high MELD. However, the recommendation of p-TIPS in such patients necessitates validation of its safety and efficacy. Consequently, we advocate for a RCT in the US to conclusively assess the utility of p-TIPS in this context. Until such evidence is established, it is likely that underutilization of this life-saving intervention will persist.
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Affiliation(s)
- Stela Celaj
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, 200 Lothrop Street, Kaufmann Building, Suite 201, Pittsburgh, PA, 15213, USA
| | - J Estevez
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, 200 Lothrop Street, Kaufmann Building, Suite 201, Pittsburgh, PA, 15213, USA
| | - Paula Novelli
- Department of Interventional Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Philip Orons
- Department of Interventional Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ali Al-Khafaji
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Naudia L Jonassaint
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, 200 Lothrop Street, Kaufmann Building, Suite 201, Pittsburgh, PA, 15213, USA
| | - Ruy J Cruz
- Department of Transplant Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Shahid M Malik
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, 200 Lothrop Street, Kaufmann Building, Suite 201, Pittsburgh, PA, 15213, USA.
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Nadjiri J. [Optimized imaging for suspected acute organ bleeding]. RADIOLOGIE (HEIDELBERG, GERMANY) 2025; 65:22-27. [PMID: 39604517 DOI: 10.1007/s00117-024-01391-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/24/2024] [Indexed: 11/29/2024]
Abstract
CLINICAL/METHODOLOGICAL PROBLEM Contrast-enhanced computed tomography (CT) is the standard procedure for diagnosing acute organ bleeding. It provides rapid, precise and comprehensive visualization of the bleeding situation, which is crucial in emergency situations. RADIOLOGICAL STANDARD PROCEDURES The examination is usually conducted in three phases: native, arterial and venous. These phases enable the precise identification and localization of the source of bleeding. The CT imaging is not only used to confirm the diagnosis but also aids in planning further treatment, facilitating targeted preparation for interventional radiologists, surgeons and endoscopists. METHODOLOGICAL INNOVATIONS The possibilities for use of the technique in CT have significantly advanced in recent years. High-resolution CT scanners provide detailed images, which are particularly useful for detecting small bleedings and traumatic injuries. Multi-energy CT provides additional advantages by enabling virtual native examinations and mono-energetic image reconstructions, which enhance the visibility of iodine-based contrast agents. These technologies improve the sensitivity for detecting bleeding and enable a better characterization of the source of bleeding. RECOMMENDATION FOR THE PRACTICE To optimize the CT diagnostics for bleeding, the use of a highly concentrated iodine contrast agent with a fast injection rate is recommended. Additionally, imaging data should be reconstructed with a slice thickness of 1-3 mm to achieve optimal diagnostic results. Multiplanar reconstructions are essential in all cases to ensure comprehensive imaging information. The combination of these advanced techniques and settings leads to improved diagnostics and treatment of acute organ bleeding.
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Affiliation(s)
- Jonathan Nadjiri
- Interventionelle Radiologie, School of Medicine, Klinikum rechts der Isar, TUM Universitätsklinikum, Technische Universität München, München, Deutschland.
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Singh S, Chandan S, Vinayek R, Aswath G, Facciorusso A, Maida M. Comprehensive approach to esophageal variceal bleeding: From prevention to treatment. World J Gastroenterol 2024; 30:4602-4608. [PMID: 39575399 PMCID: PMC11572636 DOI: 10.3748/wjg.v30.i43.4602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2024] [Revised: 10/02/2024] [Accepted: 10/18/2024] [Indexed: 10/31/2024] Open
Abstract
Esophageal variceal bleeding is a severe complication often associated with portal hypertension, commonly due to liver cirrhosis. Prevention and treatment of this condition are critical for patient outcomes. Preventive strategies focus on reducing portal hypertension to prevent varices from developing or enlarging. Primary prophylaxis involves the use of non-selective beta-blockers, such as propranolol or nadolol, which lower portal pressure by decreasing cardiac output and thereby reducing blood flow to the varices. Endoscopic variceal ligation (EVL) may also be employed as primary prophylaxis to prevent initial bleeding episodes. Once bleeding occurs, immediate treatment is essential. Initial management includes hemodynamic stabilization followed by pharmacological therapy with vasoactive drugs such as octreotide or terlipressin to control bleeding. Endoscopic intervention is the cornerstone of treatment, with techniques such as EVL or sclerotherapy applied to directly manage the bleeding varices. In cases where bleeding is refractory to endoscopic treatment, transjugular intrahepatic portosystemic shunt may be considered to effectively reduce portal pressure. Long-term management after an acute bleeding episode involves secondary prophylaxis using beta-blockers and repeated EVL sessions to prevent rebleeding, complemented by monitoring and managing liver function to address the underlying disease. In light of new scientific evidence, including the findings of the study by Peng et al, this editorial aims to review available strategies for the prevention and treatment of esophageal varices.
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Affiliation(s)
- Sahib Singh
- Department of Internal Medicine, Sinai Hospital, Baltimore, MD 21215, United States
| | - Saurabh Chandan
- Center for Interventional Endoscopy, Advent Health, Orlando, FL 32803, United States
| | - Rakesh Vinayek
- Department of Gastroenterology, Sinai Hospital of Baltimore, Baltimore, MD 21215, United States
| | - Ganesh Aswath
- Division of Gastroenterology and Hepatology, State University of New York Upstate Medical University, Syracuse, NY 13210, United States
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia 71122, Italy
| | - Marcello Maida
- Department of Medicine and Surgery, University of Enna ‘Kore’, Enna 94100, Sicilia, Italy
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Shalaby S, Nicoară-Farcău O, Perez-Campuzano V, Olivas P, Torres S, García-Pagán JC, Hernández-Gea V. Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Treatment of Bleeding from Cardiofundal and Ectopic Varices in Cirrhosis. J Clin Med 2024; 13:5681. [PMID: 39407741 PMCID: PMC11476950 DOI: 10.3390/jcm13195681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 07/26/2024] [Accepted: 09/21/2024] [Indexed: 10/20/2024] Open
Abstract
Acute variceal bleeding in cirrhosis represents a critical clinical event that significantly impacts patient prognosis, with mortality rates increasing further after a second episode. This underscores the need for immediate intervention and optimal prophylaxis. The creation of a transjugular intrahepatic portosystemic shunt (TIPS) has been proven to be highly effective for managing esophageal variceal bleeding. However, the use of TIPS for managing cardiofundal gastric varices and ectopic varices remains debated due to their unique vascular anatomy and the limited data available. These varices, although less prevalent than esophageal varices, are complex and heterogeneous vascular shunts between the splanchnic venous system and the systemic veins. Indeed, while endoscopic therapy with tissue adhesives is widely endorsed for achieving hemostasis in active hemorrhage, there is no consensus regarding the optimal approach for secondary prophylaxis. Recent research emphasizes the efficacy of endovascular techniques over endoscopic treatments, such as TIPS and endovascular variceal embolization techniques. This review examines the use of TIPS in managing acute variceal bleeding in patients with cirrhosis, focusing specifically on cardiofundal gastric varices and ectopic varices, discussing optimal patient care based on the latest evidence, aiming to improve outcomes for this challenging subset of patients.
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Affiliation(s)
- Sarah Shalaby
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Oana Nicoară-Farcău
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Hepatology Department, Regional Institute of Gastroenterology and Hepatology “Octavian Fodor”, “Iuliu Hatieganu” University of Medicine and Pharmacy, 3rd Medical Clinic, 400394 Cluj-Napoca, Romania
| | - Valeria Perez-Campuzano
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Pol Olivas
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Sonia Torres
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
- Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, 08036 Barcelona, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
- Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, 08036 Barcelona, Spain
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11
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Kalo E, Read S, George J, Roberts SK, Majumdar A, Ahlenstiel G. Attitudes towards transjugular intrahepatic portosystemic shunt (TIPS) in Australia: a national survey of TIPS centres. BMJ Open Gastroenterol 2024; 11:e001308. [PMID: 38519047 DOI: 10.1136/bmjgast-2023-001308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/20/2024] [Indexed: 03/24/2024] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive therapeutic option to treat the sequelae of portal hypertension. It is unclear whether current international recommendations are reflected in current clinical practice across Australia and the extent of variations in care. This study aimed to address this gap in knowledge and benchmark the current landscape of TIPS services in Australia against international guidelines. METHODS We designed a 42-item questionnaire according to practice-based recommendations and standards of international guidelines to investigate current landscape of TIPS service across four key domains: (1) service provision, (2) patient selection and indications, (3) best procedure practice, and (4) postoperative care. RESULTS Gastroenterologist/hepatologists from 23 major liver centres (67.6%) across Australia currently performing TIPS completed the questionnaire. Between 2017 and 2020, there were 456 elective TIPS insertions. Units offering TIPS service had a low median number of TIPS insertions (n=7 per annum). More than half of respondents (56.5%) did not have institutional clinical practice protocols. There was marked variation in practices across institutions in terms of TIPS indications and patient selection. Despite variations, the success rate of elective TIPS was high at 91.7% (79-100%), with 86.6% (29-100%) for rescue TIPS. There was significant variation in postoperative follow-up and care. CONCLUSION Current TIPS practice in Australia varies significantly across institutions. There is a need for a national consensus clinical practice guidelines to improve access and minimise unwarranted variation. A national registry for TIPS could measure, monitor, and report on quality of clinical care and patient outcomes.
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Affiliation(s)
- Eric Kalo
- Blacktown Mt Druitt Clinical School and Research Centre, Western Sydney University, Blacktown, New South Wales, Australia
- Blacktown Hospital, Blacktown, New South Wales, Australia
| | - Scott Read
- Blacktown Mt Druitt Clinical School and Research Centre, Western Sydney University, Blacktown, New South Wales, Australia
- Westmead Institute for Medical Research Storr Liver Centre, Westmead, New South Wales, Australia
| | - Jacob George
- Faculty of Medicine, Westmead Institute for Medical Research Storr Liver Centre, Westmead, New South Wales, Australia
- Gastroenterology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Stuart K Roberts
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Avik Majumdar
- Victorian Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Golo Ahlenstiel
- Blacktown Mt Druitt Clinical School and Research Centre, Western Sydney University, Blacktown, New South Wales, Australia
- Blacktown Hospital, Blacktown, New South Wales, Australia
- Westmead Institute for Medical Research Storr Liver Centre, Westmead, New South Wales, Australia
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12
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Wilechansky RM. Fellows' Corner. Hepatology 2024; 79:527-528. [PMID: 38363853 DOI: 10.1097/hep.0000000000000751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 12/22/2023] [Indexed: 02/18/2024]
Affiliation(s)
- Robert M Wilechansky
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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13
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Villanueva C. The hidden face of preemptive TIPS. Hepatology 2024; 79:535-537. [PMID: 38085849 DOI: 10.1097/hep.0000000000000714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 01/25/2024]
Affiliation(s)
- Càndid Villanueva
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
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14
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Friis KH, Thomsen KL, Laleman W, Montagnese S, Vilstrup H, Lauridsen MM. Post-Transjugular Intrahepatic Portosystemic Shunt (TIPS) Hepatic Encephalopathy-A Review of the Past Decade's Literature Focusing on Incidence, Risk Factors, and Prophylaxis. J Clin Med 2023; 13:14. [PMID: 38202028 PMCID: PMC10779844 DOI: 10.3390/jcm13010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 01/12/2024] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for portal hypertension and its' complications in liver cirrhosis, yet the development of hepatic encephalopathy (HE) remains a significant concern. This review covers the reported incidence, risk factors, and management strategies for post-TIPS HE over the past decade. Incidence varies widely (7-61%), with factors like age, liver function, hyponatremia, and spontaneous portosystemic shunts influencing risk. Procedural aspects, including TIPS timing, indication, and stent characteristics, also contribute. Pharmacological prophylaxis with lactulose and rifaximin shows promise, but current evidence is inconclusive. Procedural preventive measures, such as shunt embolization and monitoring portal pressure gradients, are explored. Treatment involves pharmacological options like lactulose and rifaximin, and procedural interventions like stent diameter reduction. Ongoing studies on novel predictive markers and emerging treatments, such as faecal microbiota transplant, reflect the evolving landscape in post-TIPS HE management. This concise review provides clinicians with insights into the multifaceted nature of post-TIPS HE, aiding in improved risk assessment, prophylaxis, and management for patients undergoing TIPS procedures.
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Affiliation(s)
- Karina Holm Friis
- Department of Gastroenterology and Hepatology, University Hospital of Southern Denmark, Finsensgade 35, 6700 Esbjerg, Denmark
| | - Karen Louise Thomsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, 3000 Leuven, Belgium
| | - Sara Montagnese
- Department of Medicine, University of Padova, 35122 Padova, Italy
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Mette Munk Lauridsen
- Department of Gastroenterology and Hepatology, University Hospital of Southern Denmark, Finsensgade 35, 6700 Esbjerg, Denmark
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