When Should Patients with Bleeding Esophageal Varices Undergo TIPS Versus Endoscopic Therapy?

Abstract

Acute variceal bleeding is a serious sequela of cirrhosis and portal hypertension, which carries significant morbidity and mortality. Advances in therapeutic techniques as well as accessibility and overall safety of esophagogastroduodenoscopy (EGD) allowed for endoscopic management to emerge as first line therapy two decades ago, and remain first-line therapy today. Transjugular intrahepatic portosystemic shunt (TIPS) is a critical rescue therapy for those that fail endoscopic management, while rescue TIPS carries significant morbidity and mortality, efforts to identify patients that are likely to fail endoscopy and benefit from early TIPS are ongoing. Surgical portosystemic shunts, particularly distal splenorenal shunt, can be considered for refractory bleeding in ideal patients with minimal comorbidities, where surgeon experience is adequate and TIPS cannot be performed.