The role of the transjugular intrahepatic portosystemic stent shunt (TIPSS) in the management of bleeding gastric varices: clinical and haemodynamic correlations.
BACKGROUND
The transjugular intrahepatic portosystemic stent shunt (TIPSS) is effective in the management of both oesophageal and gastric variceal bleeding. Although it has been reported that gastric varices can bleed at pressures of < or = 12 mm Hg, this phenomenon has been little studied in the clinical setting.


OBJECTIVE
To assess the efficacy of TIPSS on rebleeding and mortality following gastric and oesophageal variceal bleeding, and the importance of portal pressure in both groups.


METHODS
Forty eligible patients who had bled from gastric varices and 232 from oesophageal varices were studied. Patients were also subdivided into those whose portal pressure gradients (PPG) prior to TIPSS were < or = 12 mm Hg (group 1) and >12 mm Hg (group 2).


RESULTS
There was no difference in Child-Pugh score, age, sex, or alcohol related disease between patients bleeding from gastric or oesophageal varices. Patients who bled from gastric varices had a lower PPG pre-TIPSS (15.8 (0.8) v 21.44 (0.4) mm Hg; p<0.001). There was no difference in the rebleeding rate (20.0% v 14.7%; NS). There was a significant difference (p<0.05) in favour of the gastric varices group in the one year mortality (30.7% v 38.7%) and five year mortality (49.5% v 74.9%), particularly in those patients in group 2. Gastric variceal bleeding accounted for significantly more cases in group 1 than in group 2 (36.8% v 10.2%; p<0.001). Most patients in group 2 who rebled had a PPG post-TIPSS of >7 mm Hg.


CONCLUSIONS
TIPSS is equally effective in the prevention of rebleeding following gastric and oesophageal variceal bleeding. A significant proportion of gastric varices bleed at a PPG < or = 12 mm Hg. The improved mortality in patients with gastric variceal bleeding is seen only in those that bleed at a PPG >12 mm Hg, and warrants further study.
Centre for Liver and Digestive Disorders and Department of Medicine, Royal Infirmary of Edinburgh, UK. dtripathi@ed.ac.uk
D
D
Tripathi
G
G
Therapondos
E
E
Jackson
D N
DN
Redhead
P C
PC
Hayes
D016009:Chi-Square Distribution; D004932:Esophageal and Gastric Varices / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D019168:Portasystemic Shunt, Transjugular Intrahepatic; D015996:Survival Rate; D016896:Treatment Outcome