Category: Critical Care
Keywords: Cirrhosis, Varices, GI Bleeding, TIPS, Interventional Radiology (PubMed Search)
There are few conditions that can be as dramatic or difficult to control as variceal GI bleeding in a cirrhotic patient. It is important to be familiar with all options in these cases, from Blakemore/Minnesota tube placement to massive transfusion to when and which consultants to get involved. In cases that are refractory or not amenable to endoscopic intervention, emergent interventional radiology consultation for Transjugular Intrahepatic Portosystemic Shunt (TIPS) may be a consideration. In high risk cases, think about getting IR on the phone at the same time as you engage GI, in case endoscopic management fails. Variceal bleed patients can decompensate rapidly, get your consultants involved early!
Generally accepted indications for emergent TIPS (both of the following should be true):
-GI bleeding not amenable or not controllable by endoscopy
-Cause is felt to be variceal. May also consider in portal hypertensive gastropathy
-Right heart failure or pulmonary hypertension
-Severe liver failure (MELD > 22, T Bili > 3 or Child-Pugh C. In these cases TIPS may not confer a significant survival benefit)
-Hepatic encephalopathy (relative contradindication. HE may be worsened by TIPS).
-Polycystic liver disease (makes TIPS technically challenging)
-Chronic portal vein thrombus (makes TIPS technically challenging. Acute PV thrombus is NOT considered a contraindication)
Bottom Line: In cases of variceal GI bleeding from portal hypertension, consider getting IR on the phone early to discuss emergent TIPS.
Loffroy R, Favelier S, Pottecher P, et al. Transjugular intrahepatic portosystemic shunt for acute variceal gastrointestinal bleeding: Indications, techniques and outcomes. Diagn Interv Imaging. 2015;96(7-8):745-55. (https://www.sciencedirect.com/science/article/pii/S2211568415001989?via%3Dihub)
EMRAP Blakemore Tube Placement: https://www.emrap.org/episode/placemenofa/placemenofa
EMRAP Minnesota Tube Placement: https://www.emrap.org/episode/placementofa1/placementofa