DIET & NUTRITION 
PATIENT EDUCATION 
OBESITY/WEIGHT MANAGEMENT 
EXERCISE/TRAINING 
LEGAL MATTERS 
GUIDELINES/RECOMMENDATIONS 
This review article examines the role of TIPS in managing acute variceal hemorrhage in cirrhosis patients. The article provides evidence-based recommendations for TIPS placement with focus on patient selection, timing, and outcomes based on recent guidelines including Baveno VII.
Key Clinical Considerations
- Preemptive TIPS within 72 hours should be considered for high-risk patients (Child-Pugh class C ≥10 points or class B with active bleeding), showing a 97% vs 50% rate of remaining bleeding-free at 1 year compared to standard care.
- Salvage TIPS is indicated for uncontrolled bleeding or recurrence within 5 days but has poorer outcomes with MELD >30, Child-Pugh score ≥14, or lactate >12 mmol/L.
- TIPS is recommended as first-line secondary prophylaxis for gastric fundal variceal hemorrhage, which bleeds more severely than esophageal varices.
- Absolute contraindications include heart failure (AHA stage C/D), EF <50%, severe pulmonary hypertension, severe tricuspid regurgitation, and uncontrolled hepatic encephalopathy.
- Pre-procedure evaluation requires contrast imaging, echocardiography, and multidisciplinary assessment; prophylactic rifaximin reduces post-TIPS encephalopathy by 19%.
Clinical Practice Impact
- Patient Communication: Explain that TIPS is a minimally invasive procedure creating a shunt to reduce portal pressure, with 97% success in preventing rebleeding in high-risk patients but carrying risks of encephalopathy (10-50%) and potential cardiac complications.
- Practice Integration: Implement a protocol for rapid identification of high-risk patients (Child-Pugh C or B with active bleeding) who would benefit from preemptive TIPS within 72 hours of variceal hemorrhage.
- Risk Management: Establish a systematic pre-TIPS assessment including cardiac function, coagulation status, and hepatic encephalopathy risk; consider prophylactic rifaximin to reduce post-procedure encephalopathy.
- Action Items: Develop a multidisciplinary approach involving hepatology, interventional radiology, and critical care for rapid evaluation and decision-making for TIPS candidates with acute variceal hemorrhage.
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