From the Guidelines
Refractory esophageal varices treatment options are limited, but Transjugular Intrahepatic Portosystemic Shunt (TIPS) is the most effective treatment.
Treatment Options
- TIPS: is recommended as a rescue therapy for patients who fail first-line treatment with non-selective beta blockers (NSBBs) and endoscopic variceal ligation (EVL) 1.
- NSBBs and EVL: are the primary treatment for preventing esophageal variceal rebleeding, with the combination of both being more effective than either alone 1.
- Liver transplantation: may be considered in patients with recurrent variceal rebleeding 1.
TIPS Procedure
- Covered stents: are recommended for TIPS procedure, as they have been shown to be more effective than uncovered stents in reducing rebleeding rates 1.
- TIPS patency: should be assessed by Doppler ultrasound every 6 months to ensure the stent remains patent 1.
Patient Selection
- Child-Pugh score: is used to assess the severity of liver disease, with higher scores indicating more severe disease 1.
- MELD score: may also be used to select patients for early TIPS, with a score of ≥19 indicating a potential benefit from the procedure 1.
Complications
- Hepatic encephalopathy: is a potential complication of TIPS, and patients should be monitored closely for signs of encephalopathy 1.
- Rebleeding: is a risk after TIPS, and patients should be followed closely for signs of rebleeding 1.
From the Research
Treatment Options for Refractory Esophageal Varices
The treatment options for refractory esophageal varices include:
- Endoscopic strategies such as sclerotherapy or variceal ligation 2, 3, 4, 5
- Pharmacological therapy, including vasopressin, somatostatin, or beta-blockade 2, 3, 5
- Radiologic embolization or shunting, including transjugular intrahepatic portosystemic shunt (TIPS) 2, 3, 4, 6
- Balloon-occluded retrograde transvenous obliteration (BRTO) for hemorrhage related to gastric varices 6
- Surgical options, including esophageal transection, distal splenorenal shunt, or liver transplantation 2, 3, 4, 5
- Combined approaches, such as TIPS + BRTO 6
Management of Acute Variceal Hemorrhage
The management of acute variceal hemorrhage involves:
- Fluid resuscitation 2
- Pharmacological therapy to control the bleeding 2, 3, 5
- Endoscopic treatment, such as sclerotherapy or variceal ligation, to obliterate the varices 2, 3, 4, 5
- Consideration of TIPS or other shunting procedures if bleeding continues 2, 3, 4, 6
Prevention of Recurrent Bleeding
To prevent recurrent bleeding, options include: