What is the recommended management for portal hypertension?

Management of Portal Hypertension

The management of portal hypertension should follow a stepwise approach based on the clinical presentation, with transjugular intrahepatic portosystemic stent-shunt (TIPSS) recommended for refractory variceal bleeding and selected patients with refractory ascites. 1

First-Line Management

Variceal Bleeding

• Non-selective beta blockers (NSBBs) remain the pharmacotherapy of choice for primary prevention of variceal bleeding and secondary prophylaxis 2
• For acute variceal bleeding, early administration of vasoactive agents followed by endoscopic therapy is recommended 1
• Combination therapy with endoscopic treatment plus vasoactive drugs significantly improves 5-day hemostasis rates (77% vs 58% with endoscopy alone) 1
• Antibiotic prophylaxis in cirrhotic patients with acute upper gastrointestinal bleeding reduces mortality, bacterial infections, and rebleeding 1
• Carvedilol is more potent than traditional NSBBs (propranolol, nadolol) in reducing portal pressure and is better tolerated in many patients 3, 2

Ascites and Other Complications

• Medical management with diuretics is first-line for ascites 1
• For portal hypertensive gastropathy, NSBBs and iron therapy are recommended as initial treatment 1
• Regular monitoring of hemodynamic parameters is essential in patients with portal hypertension 4

Advanced Management: TIPSS Indications

For Variceal Bleeding

• TIPSS is strongly recommended for gastro-oesophageal variceal bleeding refractory to endoscopic and drug therapy (as defined by Baveno 6 criteria) 1
• Early or pre-emptive TIPSS should be considered within 72 hours of a variceal bleed in patients who:
  • Have Child's C disease (C10-13) or MELD ≥19
  • Are bleeding from oesophageal varices or GOV1/GOV2 gastric varices
  • Are hemodynamically stable 1
• Salvage TIPSS is not recommended where Child-Pugh score is >13 1
• In secondary prevention of gastric variceal bleeding, TIPSS ± embolization is recommended when patients rebleed despite endoscopic injection therapy 1

For Ascites

• In selected patients with refractory or recurrent ascites, TIPSS is strongly recommended provided there are no contraindications 1
• TIPSS should only be undertaken after discussion with the regional transplant center for transplant-eligible patients 1
• Contraindications for TIPSS in ascites include:
  • Bilirubin >50 μmol/L
  • Platelets <75×10^9
  • Pre-existing encephalopathy
  • Active infection
  • Severe cardiac failure
  • Severe pulmonary hypertension 1

For Other Complications

• Selected patients with refractory hepatic hydrothorax may be considered for TIPSS insertion 1
• TIPSS is recommended for Budd-Chiari syndrome when patients fail to respond to medical therapy with anticoagulation or hepatic vein interventions 1
• TIPSS for hepatorenal syndrome remains experimental 1
• For bleeding from ectopic varices refractory to local and pharmacological therapies, TIPSS with embolization is suggested 1

TIPSS Procedure and Follow-up

• Covered stents are preferred over bare metal stents due to superior patency rates 1
• A Doppler ultrasound is recommended one week after TIPSS implantation in patients with prothrombotic conditions 1
• Regular Doppler ultrasound follow-up at 6-12 month intervals is recommended 1
• The main complications of TIPSS include hepatic encephalopathy (affecting approximately one-third of patients), bleeding, infection, heart failure, liver failure, and kidney failure 1

Special Considerations

• Portal vein thrombosis is not an absolute contraindication to TIPSS placement, although cavernoma presence is associated with higher failure rates 1
• In patients with esophageal varices or history of variceal bleeding, appropriate prophylaxis should be maintained with NSBBs or endoscopic band ligation 4
• The role of TIPSS in idiopathic non-cirrhotic portal hypertension should follow similar indications as in cirrhosis 1

By following this structured approach to portal hypertension management, clinicians can optimize outcomes while minimizing complications in this complex patient population.