Is TIPS (Transjugular Intrahepatic Portosystemic Shunt) more efficacious than EGD (Esophagogastroduodenoscopy) with gluing for treating gastric varices?

TIPS vs EGD with Gluing for Gastric Varices

For cardiofundal varices (GOV2 or IGV1), TIPS is more efficacious than EGD with gluing in preventing rebleeding, though it carries a higher risk of hepatic encephalopathy without survival benefit. 1

Treatment Approach Based on Variceal Type

GOV1 Varices (Esophageal Varices Extending to Lesser Curvature)

• First-line treatment: Either endoscopic band ligation (if technically feasible) or cyanoacrylate glue injection
• TIPS is not recommended as first-line therapy for GOV1 varices due to lack of survival benefit and increased risk of hepatic encephalopathy 1
• For secondary prophylaxis: Combination of non-selective beta blockers (NSBBs) and endoscopic therapy 1

Cardiofundal Varices (GOV2 or IGV1)

• Acute bleeding management:

  • Initial approach: Volume resuscitation, vasoactive drugs, antibiotics before endoscopy 1
  • First endoscopic attempt: Cyanoacrylate glue injection 1
  • TIPS is the treatment of choice when endoscopic management fails 1

• For prevention of rebleeding:

  • TIPS is superior to repeated glue injections in preventing rebleeding (11% vs 38% rebleeding rate) 1
  • Recent evidence from a randomized trial suggests pre-emptive TIPS (within 72 hours) provides significantly better rebleeding-free survival compared to standard therapy, particularly in Child-Pugh B or C patients 2

Efficacy Comparison

Advantages of TIPS

• More effective in preventing rebleeding from cardiofundal varices 1
• Addresses the underlying portal hypertension 1
• Particularly beneficial for patients with Child-Pugh B or C scores 2
• Provides better long-term control of bleeding 1

Disadvantages of TIPS

• Higher rate of hepatic encephalopathy (26% vs 3%) 1
• Risk of hepatic decompensation, especially with higher MELD scores 1
• No demonstrated survival benefit over endoscopic therapy 1

Advantages of EGD with Gluing

• Good initial hemostasis rates (94% for cyanoacrylate vs 80% for band ligation) 1
• Lower risk of hepatic encephalopathy 1
• Can be performed immediately during diagnostic endoscopy 1
• Suitable for patients with contraindications to TIPS 1

Disadvantages of EGD with Gluing

• Higher rebleeding rates compared to TIPS 1
• Technical expertise required; not approved for GV treatment in the US 1
• May require multiple sessions 1

Clinical Decision Algorithm

1. Identify the type of gastric varices:

   • GOV1: Treat like esophageal varices with band ligation or gluing
   • GOV2/IGV1: Consider location, size, and bleeding status

2. For acute bleeding from GOV2/IGV1:

   • First attempt: Cyanoacrylate glue injection
   • If bleeding persists or high risk of rebleeding: Consider early TIPS (within 72 hours)

3. For prevention of rebleeding from GOV2/IGV1:

   • TIPS is first-line treatment
   • Consider patient's liver function (Child-Pugh score) and risk of encephalopathy
   • For patients with contraindications to TIPS: Repeated cyanoacrylate injections

Important Caveats

• The evidence supporting TIPS over gluing comes primarily from a single randomized trial with bare metal stents; newer covered stents may provide better outcomes 1
• Cyanoacrylate glue injection requires expertise and is not FDA-approved for gastric varices in the US 1
• The risk of hepatic encephalopathy after TIPS must be carefully considered, especially in patients with marginal liver function 1
• For patients with fundal varices who have a higher early rebleeding rate, TIPS should be considered earlier than for other types of varices 1
• Recent evidence suggests pre-emptive TIPS may be particularly beneficial for Child-Pugh B or C patients with gastric fundal varices 2

In summary, while both treatments are effective for initial hemostasis, TIPS provides superior prevention of rebleeding from cardiofundal varices but at the cost of increased hepatic encephalopathy risk.