Skip to main content
SpringerLink
Log in

Management of Symptomatic Portal Hypertension: TIPS vs. Medical Management

  • Chapter
  • First Online:
Difficult Decisions in Hepatobiliary and Pancreatic Surgery

Part of the book series: Difficult Decisions in Surgery: An Evidence-Based Approach ((DDSURGERY))

  • 1103 Accesses

Abstract

Portal hypertension is a common manifestation of decompensated cirrhosis and can have a profound impact on patient survival and quality of life. Portal hypertension can be managed with medical therapy through use of diuretics or portal pressure lowering agents, however in some cases more invasive procedures such as transjugular intrahepatic portosystemic shunt (TIPS) may be more effective. In this systematic review of the literature, clinical outcomes following medical management and TIPS are compared across various manifestations of portal hypertension. Overall, we found that data favors use of TIPS to prevent recurrent variceal bleeding and recurrent ascites however risk of hepatic encephalopathy is higher than medical management. In addition, in selected patients, TIPS may also improve mortality in those with variceal hemorrhage and refractory ascites. Compared to esophageal varices and ascites, there is limited data supporting use of TIPS vs medical management for conditions such as hepatic hydrothorax, nonesophageal varices and hepatorenal syndrome.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 119.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 169.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Garcia-Pagan JC, Gracia- Sancho J, Bosch J. Functional aspects on the pathophysiology of portal hypertension in cirrhosis. J Hepatol. 2012;57:458–61.

    Article  PubMed  Google Scholar 

  2. Samonakis DN, Triantos CK, Thalheimer U, Patch DW, Burroughs AK. Management of portal hypertension. Postgrad Med J. 2004;80:634–41.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W, Practice Guidelines Committee of the American Association for the Study of Liver Disease, Practice Parameters Committee of the American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46:922–38.

    Article  CAS  PubMed  Google Scholar 

  4. Loffroy R, Estivalet L, Cherblanc V, Favelier S, Pottecher P, Hamza S, et al. Transjugular intrahepatic portosystemic shunt for the management of acute variceal hemorrhage. World J Gastroenterol. 2013;19:6131–43.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Boyer TD, Haskal ZJ. AASLD practice guidelines: the role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension. J Vasc Interv Radiol. 2005;16:615–29.

    Article  PubMed  Google Scholar 

  6. Russo MW, Sood A, Jacobson IM, Brown RS. Transjugular intrahepatic portosystemic shunt for refractory ascites: an analysis of the literature on efficacy, morbidity, and mortality. Am J Gastroenterol. 2003;98:2521–7.

    Article  PubMed  Google Scholar 

  7. Rossle M, Gerbes AL. TIPS for the treatment of refractory ascites, hepatorenal syndrome, and hepatic hydrothorax: a critical update. Gut. 2010;59:988–1000.

    Article  PubMed  Google Scholar 

  8. Machicao VI, Balakrishnan M, Fallon MB. Pulmonary complications in chronic liver disease. Hepatology. 2014;59:1627–37.

    Article  PubMed  Google Scholar 

  9. Martin P, DiMartini A, Feng S, Brown R, Fallon M. Evaluation of liver transplantation in adults: 2013 practice guidelines of the American Association for the Study of Liver Diseases and the American Society of Transplantation. Hepatology. 2014;59:1144–65.

    Article  PubMed  Google Scholar 

  10. Boyer TD. Transjugular intrahepatic portosystemic shunt in the management of complications of portal hypertension. Curr Gastroenterol Rep. 2008;10:30–5.

    Article  PubMed  Google Scholar 

  11. Nusrat S, Khan MS, Fazili J, Madhoun MF. Cirrhosis and it’s complications: evidence based treatment. World J Gastroenterol. 2014;20:5442–60.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Monescillo A, Martinez-Lagares F, Ruiz-del-Arbol L, Sierra A, Guevara C, Jimenez E, et al. Influence of portal hypertension and it’s early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology. 2004;40:793–801.

    Article  PubMed  Google Scholar 

  13. Garcia-Pagan JC, Caca K, Bureau C, Laleman W, Appenrodt B, Luca A, et al. Early use of TIPS in patient with cirrhosis and variceal bleeding. N Engl J Med. 2010;362:2370–9.

    Article  CAS  PubMed  Google Scholar 

  14. Bureau C, Garcia-Pagan JC, Otal P, Pomier-Layrargues G, Chabbert V, Cortez C, et al. Improved clinical outcome using polytetrafluoroethlene-coated stents for TIPS. Results of a randomized study. Gastroenterology. 2004;126:469–75.

    Article  PubMed  Google Scholar 

  15. Corbett C, Mangat K, Olliff S, Tripathi D. The role of transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the management of variceal hemorrhage. Liver Int. 2012;32:1493–504.

    Article  PubMed  Google Scholar 

  16. Escorsell A, Banares R, Carcia-Pagan JC, Gilabert R, Moitinho E, Piqueras B, et al. TIPS versus drug therapy in preventing variceal rebleeding in advanced cirrhosis: a randomized controlled trial. Hepatology. 2002;35:385–92.

    Article  PubMed  Google Scholar 

  17. Cabrera J, Maynar M, Granados R, Gorriz E, Reyes R, Pulido-Duque JM, et al. Transjugular intrahepatic portosystemic shunt versus sclerotherapy in the elective treatment of variceal hemorrhage. Gastroenterology. 1996;110:832–9.

    Article  CAS  PubMed  Google Scholar 

  18. Cello JP, Ring EJ, Olcott EW, Koch J, Gordon R, Sandhu J, et al. Endoscopic sclerotherapy compared with percutaneous transjugular intrahepatic portosystemic shunt after initial sclerotherapy in patients with acute variceal hemorrhage. A randomized, controlled trial. Ann Intern Med. 1997;26:1115–22.

    Google Scholar 

  19. Jalan R, Forrest EH, Stanley AJ, Redhead DN, Forbes J, Dillon JF, et al. A randomized trial comparing transjugular intrahepatic portosystemic shunt-shunt with variceal band ligation in the prevention of rebleeding from esophageal varices. Hepatology. 1997;26:1115–22.

    CAS  PubMed  Google Scholar 

  20. Rossle M, Deibert P, Haag K, Ochs A, Olschewski M, Siegerstetter V, et al. Randomised trial of tranjugular-intrahepatic-portosystemic shunt versus endoscopy plus propranolol for prevention of variceal bleeding. Lancet. 1997;349:1043–9.

    Article  CAS  PubMed  Google Scholar 

  21. Sanyal AJ, Freedman AM, Luketic VA, Purdum PP, Shiffman ML, Cole PE, et al. Transjugular intrahepatic portosystemic shunts compared with endoscopic sclerotherapy for the prevention of recurrent variceal hemorrhage. A randomized controlled trial. Ann Intern Med. 1997;126:849–57.

    Article  CAS  PubMed  Google Scholar 

  22. Sauer P, Theilmann L, Stremmel W, Benz C, Richter GM, Stiehl A. Transjugular intrahepatic portosystemic shunt versus sclerotherapy plus propranolol for variceal rebleeding. Gastroenterology. 1997;113:1623–31.

    Article  CAS  PubMed  Google Scholar 

  23. Merli M, Salaerno F, Riggio O, de Franchis R, Fiaccadori F, Meddi P, et al. Transjugular intrahepatic portosystemic shunt versus endoscopic sclerotherapy for the prevention of variceal bleeding in cirrhosis: a randomized multicenter trial. Gruppo Italiano Studio TIPS (G.I.S.T). Hepatology. 1998;27:48–53.

    Article  CAS  PubMed  Google Scholar 

  24. Garcia-Villarreal L, Martinez-Lagares F, Sierra A, Guevara C, Marrero JM, Jimenez E, et al. Transjugular intrahepatic portosystemic shunt versus endoscopic sclerotherapy for the prevention of variceal rebleeding after recent variceal hemorrhage. Hepatology. 1999;29:27–32.

    Article  CAS  PubMed  Google Scholar 

  25. Narahara Y, Kanazawa H, Kawamata H, Tada N, Saitoh H, Matsuzaka S, et al. A randomized clinical trial comparing transjugular intrahepatic portosystemic shunt with endoscopic sclerotherapy in the long-term management of patients with cirrhosis after recent variceal hemorrhage. Hepatol Res. 2001;21:189–98.

    Article  PubMed  Google Scholar 

  26. Pomier-Layrargues G, Villeneuve JP, Deschenes M, Bui B, Perreault P, Fenyves D, et al. Transjugular intrahepatic portosystemic shunt (TIPS) versus endoscopic variceal ligation in the prevention of variceal rebleeding in patients with cirrhosis: a randomized trial. Gut. 2001;48:390–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Gulberg V, Schepke M, Geigenberger G, Holl J, Brensing KA, Waggershauser T, et al. Transjugular intrahepatic portosystemic shunting is not superior to endoscopic variceal band ligation for prevention of variceal rebleeding in cirrhotic patients: a randomized, controlled trial. Scand J Gastroenterol. 2002;37:338–43.

    Article  CAS  PubMed  Google Scholar 

  28. Sauer P, Hansmann J, Richter GM, Stremmel W, Stiehl A. Endoscopic variceal ligation plus propranolol vs. transjugular intrahepatic portosystemic stent shunt: a long-term randomized trial. Endoscopy. 2002;34:690–7.

    Article  CAS  PubMed  Google Scholar 

  29. Luca A, D’Amico G, La Galla R, Midiri M, Morabito A, Pagliaro L. TIPS for prevention of recurrent bleeding in patients with cirrhosis: meta-analysis of randomized clinical trials. Radiology. 1999;212:411–21.

    Article  CAS  PubMed  Google Scholar 

  30. Papatheodoridis GV, Goulis J, Leandro G, Patch D, Burroughs AK. Transjugular intrahepatic portosystemic shunt compared with endoscopic treatment for prevention of variceal rebleeding: a meta-analysis. Hepatology. 1999;30:612–22.

    Article  CAS  PubMed  Google Scholar 

  31. Burroughs AK, Vangeli M. Transjugular intrahepatic portosystemic shunt versus endoscopic therapy: randomized trials for secondary prophylaxis of variceal bleeding: an updated meta-analysis. Scan J Gastroenterol. 2002;37:249–52.

    Article  CAS  Google Scholar 

  32. Khan S, Tudur SC, Williamson P, Sutton R. Portosystemic shunts versus endoscopic therapy for variceal rebleeding in patients with cirrhosis. Cochrane Database Syst Rev. 2006;18:CD000553.

    Google Scholar 

  33. Zheng M, Chen Y, Bai J, Zeng Q, You J, Jin R, et al. Transjugular intrahepatic portosystemic shunt versus endoscopic therapy in the secondary prophylaxis of variceal rebleeding in cirrhotic patients. J Clin Gastroenterol. 2008;42:507–16.

    Article  PubMed  Google Scholar 

  34. Russo MW, Zacks SL, Sandler RS, Brown RS. Cost-effectiveness analysis of transjugular intrahepatic portosystemic shunt (TIPS) versus endoscopic therapy for the prevention of recurrent esophageal variceal bleeding. Hepatology. 2000;31:358–63.

    Article  CAS  PubMed  Google Scholar 

  35. Rubenstein JH, Eisen GM, Inadomi JM. A cost-utility analysis of secondary prophylaxis for variceal hemorrhage. Am J Gastroenterol. 2004;99:1274–88.

    Article  PubMed  Google Scholar 

  36. Harman DJ, McCorry RB, Jacob RP, Lim TR, O’Neill R, Ryder SD, et al. Economic modeling of early transjugular intrahepatic portosystemic shunt insertion for acute variceal hemorrhage. Eur J Gastroenterol Hepatol. 2013;25:201–7.

    Article  PubMed  Google Scholar 

  37. Lebrec D, Giuily N, Hadengue A, Vilgrain V, Moreau R, Poynard T, et al. Transjugular intrahepatic portosystemic shunts: comparison with paracentesis in patients with cirrhosis and refractory ascites: a randomized control trial. J Hepatol. 1996;25:135–44.

    Article  CAS  PubMed  Google Scholar 

  38. Rossle M, Ochs A, Gulberg V, Siegerstetter V, Holl J, Deibert P, et al. A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites. N Engl J Med. 2000;342:1701–7.

    Article  CAS  PubMed  Google Scholar 

  39. Gines P, Uriz J, Calahorra B, Garcia-Tsao G, Kamath PS, Del Arbol LR, et al. Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis. Gastroenterology. 2002;123:1839–47.

    Article  PubMed  Google Scholar 

  40. Sanyal AJ, Genning C, Reddy KR, Wong F, Kowdley KV, Benner K, et al. The North American study for the treatment of refractory ascites. Gastroenterology. 2003;124:634–41.

    Article  PubMed  Google Scholar 

  41. Salerno F, Merli M, Riggio O, Cazzaniga M, Valeriano V, Pozzi M, et al. Randomized controlled study of TIPS versus paracentesis plus albumin in cirrhosis with severe ascites. Hepatology. 2004;40:629–35.

    Article  CAS  PubMed  Google Scholar 

  42. Narahara Y, Kanazawa H, Fukuda T, Matsushita Y, Harimoto H, Kidokoro H, et al. Transjugular intrahepatic portosystemic shunt versus paracentesis plus albumin in patients with refractory ascites who have good hepatic and renal function: a prospective randomized trial. J Gastroenterol. 2011;46:78–85.

    Article  CAS  PubMed  Google Scholar 

  43. Deltenre P, Mathurin P, Dharancy S, Moreau R, Bulois P, Henrion J, et al. Transjugular intrahepatic portosystemic shun in refractory ascites: a meta-analysis. Liver Int. 2005;25:349–56.

    Article  CAS  PubMed  Google Scholar 

  44. Albillos A, Banares R, Gonzalez M, Catalina MV, Molinero LM. A meta-analysis of 9. transjugular intrahepatic portosystemic shunt versus paracentesis for refractory ascites. J Hepatol. 2005;43:990–6.

    Article  PubMed  Google Scholar 

  45. D’Amico G, Luca A, Morabito A, Miraglia R, D’Amico M. Uncovered transjugular intrahepatic portosystemic shunt for refractory ascites: a meta- analysis. Gastroenterology. 2005;129:1282–93.

    Article  PubMed  Google Scholar 

  46. Saab S, Nieto JM, Lewis SK, Runyon BA. TIPS versus paracentesis for cirrhotic patients with refractory ascites. Cochrane Database Syst Rev. 2006; (4):CD004889.

    Google Scholar 

  47. Salerno F, Camma C, Enea M, Rossle M, Wong F. Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data. Gastroenterology. 2007;133:825–34.

    Article  CAS  PubMed  Google Scholar 

  48. Campbell MS, Brensinger CM, Sanyal AJ, Gennings C, Wong F, Kowdley KV, et al. Quality of life in refractory ascites: transjugular intrahepatic poral-systemic shunting versus medical therapy. Hepatology. 2005;42:635–40.

    Article  PubMed  Google Scholar 

  49. Lo GH, Lian HL, Chen WC, Chen MH, Lai KH, Hsu PI, et al. A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal bleeding. Endoscopy. 2007;39:679–85.

    Article  PubMed  Google Scholar 

  50. Spahr L, Villeneuve JP, Dufresne MP, Tasse D, Bui B, Willems B, et al. Gastric antral vascular ectasia in cirrhotic patients: absence of relation with portal hypertension. Gut. 1999;44:739–42.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  51. Kamath PS, Lacerda M, Ahlquist DA, McKusick MA, Andrews JC, Nagorney DA. Gastric mucosal responses to intrahepatic portosystemic shunting in patients with cirrhosis. Gastroenterology. 2000;118:905–11.

    Article  CAS  PubMed  Google Scholar 

  52. Vangeli M, Patch D, Terreni N, Tibballs J, Watkinson A, Davies N, Burroughs AK. Bleeding ectopic varices – treatment with transjugular intrahepatic porto-systemic shunt (TIPS) and embolisation. J Hepatol. 2004;41:560–6.

    Article  PubMed  Google Scholar 

  53. Vidal V, Joly L, Perreault P, Bouchard L, Lafortune M, Pomier-Layrargues G. Usefulness of transjugular intrahepatic portosystemic shunt in the management of bleeding ectopic varices in cirrhotic patients. Cardiovasc Intervent Radiol. 2006;29:216–9.

    Article  CAS  PubMed  Google Scholar 

  54. Singh A, Bajwa A, Shujaat A. Evidence-based review of the management of hepatic hydrothorax. Respiration. 2013;86:155–73.

    Article  PubMed  Google Scholar 

  55. Guevara M, Gines P, Bandi JC, Gilabert R, Sort P, Jimenez W, et al. Transjugular intrahepatic portosystemic shunt in hepatorenal syndrome: effects on renal function and vasoactive systems. Hepatology. 1998;28:416–22.

    Article  CAS  PubMed  Google Scholar 

  56. Brensing KA, Textor J, Peerz J, Scheidermaier P, Raab P, Strunk H, et al. Long term outcome after transjugular intrahepatic portosystemic stent-shunt in non-transplant cirrhotics with hepatorenal syndrome: a phase 2 study. Gut. 2000;47:288–95.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  57. Testino G, Ferro C, Sumberaz A, Messa P, Morelli N, Gaudagni B, et al. Type-2 hepatorenal syndrome and refractory ascites: role of transjugular intrahepatic portosystemic stent-shunt in eighteen patients with advanced cirrhosis awaiting orthotopic liver transplantation. Hepatogastroenterology. 2003;50:1753–5.

    PubMed  Google Scholar 

  58. Wong F, Pantea L, Sniderman K. Midodrine, octreotide, albumin, and TIPS in selected patients with cirrhosis and type 1 hepatorenal syndrome. Hepatology. 2004;40:55–64.

    Article  CAS  PubMed  Google Scholar 

  59. Garcia-Pagan JC, Heydtmann M, Raffa S, Plessier A, Murad S, Fabris F, Vizzini G, Gonzales Abraldes J, Olliff S, Nicolini A. TIPS for Budd-Chiari syndrome: long-term results and prognostics factors in 124 patients. Gastroenterology. 2008;135:808–15.

    Article  PubMed  Google Scholar 

  60. Azoulay D, Castaing D, Lemoine A, Hargreaves GM, Bismuth H. Transjugular intrahepatic portosystemic shunt (TIPS) for severe veno-occlusive disease of the liver following bone marrow transplantation. Bone Marrow Transplant. 2000;25:987–92.

    Article  CAS  PubMed  Google Scholar 

  61. Paramesh AS, Husain SZ, Shneider B, Guller J, Tokat I, Gondolesi GE, et al. Improvement in hepatopulmonary syndrome after transjugular intrahepatic portosystemic shunt: case report and review of the literature. Pediatr Transplant. 2003;7:157–62.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Center for Liver Diseases, University of Chicago Medical Center, 5841 S. Maryland Ave, Chicago, IL, 60637, USA

    Anouar Teriaky & Andrew Aronsohn

Authors
  1. Anouar Teriaky
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Andrew Aronsohn
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Anouar Teriaky .

Editor information

Editors and Affiliations

  1. The University of Chicago, CHICAGO, Illinois, USA

    J. Michael Millis

  2. The University of Chicago, CHICAGO, Illinois, USA

    Jeffrey B. Matthews

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Teriaky, A., Aronsohn, A. (2016). Management of Symptomatic Portal Hypertension: TIPS vs. Medical Management. In: Millis, J., Matthews, J. (eds) Difficult Decisions in Hepatobiliary and Pancreatic Surgery. Difficult Decisions in Surgery: An Evidence-Based Approach. Springer, Cham. https://doi.org/10.1007/978-3-319-27365-5_34

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-27365-5_34

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-27363-1

  • Online ISBN: 978-3-319-27365-5

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation