Management of Refractory Variceal Bleeding

Inspite modern management of Acute Variceal Bleeding, immediate mortality of acute variceal bleeding remains upto 10-20%. The most effective therapy for acute bleeding is combination therapy with Octereotides, Terlipressin and band ligation. This control almost 90% of the variceal bleeding. About 10% of patients which suffer from esophageal variceal bleeding experience massive, continuous or recurrent bleeding, which is refractory to optimal medical and endoscopic management. Generally one attempt to perform EVL before declaring that a recurrant bleeding event is refractory. Other reason for labeling that variceal bleed is refractory include bleeding from gastric varices and two or more recurrent bleeds over the course of weeks to months in spite of aggressive endoscopic and B-blocker treatments. Patients with resistant bleed often require urgent therapy. In emergency theses patients are usually manage with balloon temponade. In order to stabilize them prior to performing shunt surgery or TIPS.

Balloon temponade control variceal bleed in 40-90% of the cases (1) with a fatal complications, rate of 6-20% (1). Portocaval shunts provide rapid, effective portal decompression and are highly successful at halting variceal bleeding. Concerns over procedural mortality and postoperative complications limit their utility in the primary treatment of acute variceal bleeding. However, 50 years after its introduction, shunt surgery, as well as its modern counterpart, TIPS, remain the mainstays of therapy for refractory variceal bleeding.

Portocaval shunt surgery is highly effective in the initial treatment of bleeding. Only 9–22% of patients experience late episodes of rebleeding (1). This figure should be appreciated in the context of a 23–55% rebleeding rate for patients treated with sclerotherapy (2). Nonemergent portocaval shunt surgery carries with it a 7–13% operative mortality rate (3). However, operative mortality jumps to more than 50% when portocaval shunt surgery is performed emergently, especially in the patient with Child class C status (2).

Distal splenorenal shunt surgery (4) attempts to selectively decompress gastroesophageal varices by diverting splenic venous outflow into the renal vein. Splanchnic venous return to the liver is maintained. Its theoretic advantage over portocaval shunts is a decreased incidence of postoperative hepatic encephalopathy and liver failure. The surgery requires considerable technical expertise and is not appropriate in either obese patients or in the emergent setting. However, when performed in an appropriately selected patient, it is highly effective. On average, 17% of patients will suffer rebleeding, with as low as a 3% rebleeding rate described by Henderson et al. (5). There is a 9–13% operative mortality rate (3, 5). Work by Rosch (6), Colapinto (7), Palmaz (8) and colleagues in the 1970s and 1980s laid the groundwork for the first successful creation of TIPS in humans in 1989 (9). TIPS is physiologically equivalent to a side-to-side portocaval shunt.

Although TIPS has not been compared to portocaval shunt surgery in a clinical trial, its procedural complication rate of about 10%, mortality rate of 1–2%, the new onset or worsening of hepatic encephalopathy in 10–30% of patients (10), and a long-term rebleeding rate of 13– 22% (11-13) compare favorably with portocaval shunts. However, the low risk of surgical shunt failure and the well-known propensity of TIPS stents to stenose or occlude lead me to favor portocaval shunt surgery in the well compensated cirrhotic patient with refractory bleeding.

Distal splenorenal shunt surgery is the operation of choice in patients with Child class A status. Side-to-side portocaval or mesocaval shunt surgery may be performed instead in the emergent setting or if technical factors are likely to interfere with the creation of a distal splenorenal shunt. However, a majority of patients with refractory variceal bleeding have Child class B and C status. TIPS is the treatment of choice for these patients, recognizing that patients will require life-long ultrasonographic and angiographic surveillance.