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Transjugular Intrahepatic Portosystemic Stent-Shunt In Guidelines Transjugular intrahepatic portosystemic stent-shunt in Gut: first published as 10.1136/gutjnl-2019-320221 on 29 February 2020. Downloaded from the management of portal hypertension Dhiraj Tripathi ,1,2,3 Adrian J Stanley ,4 Peter C Hayes ,5 Simon Travis,6 Matthew J Armstrong ,1,2,3 Emmanuel A Tsochatzis ,7 Ian A Rowe ,8 Nicholas Roslund,9 Hamish Ireland ,10 Mandy Lomax,11 Joanne A Leithead,12 Homoyon Mehrzad,13 Richard J Aspinall ,14 Joanne McDonagh,1 David Patch7 For numbered affiliations see ABSTRact ► In secondary prevention of oesophageal end of article. These guidelines on transjugular intrahepatic variceal bleeding, TIPSS can be considered portosystemic stent- shunt (TIPSS) in the management where patients rebleed despite combination of Correspondence to of portal hypertension have been commissioned by the VBL +NSBB taking into account the severity Dr Dhiraj Tripathi, Liver Unit, University Hospitals Birmingham Clinical Services and Standards Committee (CSSC) of of rebleeding and other complications of portal NHS Foundation Trust, the British Society of Gastroenterology (BSG) under the hypertension, with careful patient selection Birmingham B15 2TH, UK; auspices of the Liver Section of the BSG. The guidelines to minimise hepatic encephalopathy (weak d. tripathi@ bham. ac. uk are new and have been produced in collaboration with recommendation, moderate- quality evidence). Received 2 November 2019 the British Society of Interventional Radiology (BSIR) Further large controlled trials are required to Revised 20 January 2020 and British Association of the Study of the Liver (BASL). investigate the role of TIPSS as first- line therapy Accepted 22 January 2020 The guidelines development group comprises elected in secondary prevention (strong recommenda- members of the BSG Liver Section, representation tion, low quality of evidence). from BASL, a nursing representative and two patient ► In secondary prevention of gastric variceal representatives. The quality of evidence and grading bleeding, TIPSS ±embolisation is recommended of recommendations was appraised using the GRADE where patients rebleed despite endoscopic system. These guidelines are aimed at healthcare injection therapy (strong recommendation, professionals considering referring a patient for a TIPSS. moderate- quality evidence). TIPSS ±embolisa- They comprise the following subheadings: indications; tion can also be considered in selected patients patient selection; procedural details; complications; and with large or multiple gastric varices as first-line research agenda. They are not designed to address: the therapy in secondary prevention (weak recom- management of the underlying liver disease; the role of mendation, moderate- quality evidence). http://gut.bmj.com/ TIPSS in children; or complex technical and procedural ► In patients with bleeding from ectopic varices aspects of TIPSS. refractory to local and pharmacological ther- apies, TIPSS usually with embolisation is suggested (weak recommendation, low-quality evidence). EXECUTIVE SUMMARY OF RECOMMENDATIONS ► In patients with bleeding from portal hyperten- Recommendations: TIPSS for variceal bleeding sive gastropathy (PHG) refractory to NSBB and on September 24, 2021 by guest. Protected copyright. ► In patients who have gastro- oesophageal iron therapy, TIPSS may be considered (weak variceal bleeding refractory to endoscopic and recommendation, low-quality evidence). drug therapy as defined by Baveno 6 critera,32 transjugular intrahepatic portosystemic stent- Recommendations: TIPSS for ascites shunt (TIPSS) is recommended (strong recom- ► In patients who are eligible for liver trans- mendation, moderate- quality evidence). plantation, TIPSS for ascites should only be Salvage TIPSS is not recommended where the undertaken after discussion with the regional Child- Pugh score is >13 (strong recommenda- transplant centre (strong recommendation, tion, low quality of evidence). very low quality evidence). ► In patients who have Child’s C disease (C10- ► In selected patients with refractory or recur- 13) or MELD ≥19, and bleeding from oesoph- rent ascites, we recommend insertion of TIPSS © Author(s) (or their ageal varices or GOV1 and GOV2 gastric provided there are no contraindications to employer(s)) 2020. Re- use varices and are haemodynamically stable, the procedure (strong recommendation, high permitted under CC BY- NC. No early or pre- emptive TIPSS should be consid- quality evidence). commercial re- use. See rights ered within 72 hours of a variceal bleed where ► In addition to the standard TIPSS contrain- and permissions. Published by BMJ. local resources allow (weak recommenda- dications, patients who may not benefit from tion, moderate quality of evidence). However, TIPSS for ascites include those with bilirubin To cite: Tripathi D, large multi- centre randomised controlled trials >50 µm/L and platelets<75×109, pre- existing Stanley AJ, Hayes PC, et al. Gut Epub ahead of print: (RCTs) are necessary to determine whether encephalopathy, active infection, severe cardiac [please include Day Month patients with Child’s B disease and active failure or severe pulmonary hypertension Year]. doi:10.1136/ bleeding or with MELD 12–18 benefit from (strong recommendation, moderate quality gutjnl-2019-320221 early pre- emptive TIPSS. evidence). Tripathi D, et al. Gut 2020;0:1–20. doi:10.1136/gutjnl-2019-320221 1 Guidelines Recommendation: TIPSS for hydrothorax ► Screening should ideally be at least two of the following: ► Selected patients with refractory hepatic hydrothorax may psychometric hepatic encephalopathy score (PHES) testing, Gut: first published as 10.1136/gutjnl-2019-320221 on 29 February 2020. Downloaded from be considered for TIPSS insertion. (strong recommendation, Stroop testing, Critical Flicker Frequency and Spectral moderate- quality evidence). Enhanced or quantative EEG (strong recommendation, moderate- quality evidence). Recommendation: TIPSS for hepatorenal syndrome (HRS). ► The presence of covert hepatic encephalopathy is a relative ► Although, renal function has been observed to improve contraindication to elective TIPSS (weak recommendation, following TIPSS, TIPSS for HRS (type 1 and type 2) remains low- quality evidence). experimental (weak recommendation, very low level of ► Although age >65 is not an absolute contraindication, it evidence). might increase the risk of encephalopathy and should be taken into account when deciding the eligibility for elective Recommendations: TIPSS for Budd–Chiari syndrome TIPSS (weak recommendation, low-quality evidence). ► It is recommended that all patients with Budd–Chiari ► Patients who develop encephalopathy following a TIPSS syndrome (BCS) are managed in centres of high expertise should be managed according to standard guidelines, but which are either transplant centres or have formal links with if encephalopathy continues, consideration should be given a liver transplant centre (strong recommendation, very low- to shunt reduction, embolisation or occlusion (weak recom- quality evidence). mendation, low level of evidence). ► TIPSS is recommended where patients fail to respond to medical therapy with anticoagulation or hepatic vein Recommendations: cardiac assessments interventions (strong recommendation, moderate- quality ► A cardiac history, examination, 12-lead ECG and N- Ter- evidence). TIPSS can be considered where hepatic vein inter- minal pro- B- type natriuretic peptide (NT-proBNP) should be ventions is not technically feasible (weak recommendation, undertaken in all patients undergoing elective TIPSS inser- low- quality evidence). tion (strong recommendation, moderate- quality evidence). ► Patients with poor prognostic scores (see text), or those Further cardiac evaluation (echocardiogram +/-cardiology who do not respond to anticoagulation and radiological consultation) should be undertaken before elective TIPSS therapies, have a poor prognosis and should be considered if any of these are abnormal (strong recommendation, for liver transplant assessment (strong recommendation, moderate- quality evidence). moderate- quality evidence). ► Elective TIPSS is not recommended in patients with severe left ventricular dysfunction or severe pulmonary Recommendation: prophylactic TIPSS hypertension (strong recommendation, moderate- quality ► There is insufficient data to recommend TIPSS prior to non- evidence). hepatic surgery, although in compensated cirrhotic patients ► Echocardiogram in acute variceal haemorrhage may be inac- undergoing curative surgery for cancer there may be a role curate and should not delay an emergency, potential life- (weak recommendation, low- quality evidence). Further saving TIPSS insertion (strong recommendation, low- quality research is recommended, with the focus on careful patient evidence). http://gut.bmj.com/ selection. Recommendation: nutritional assessment Recommendation: TIPSS for idiopathic non-cirrhotic portal ► Patients referred for elective TIPSS insertion should undergo hypertension a detailed nutritional and functional assessment (weak ► The indications for TIPSS in idiopathic non- cirrhotic portal recommendation, low- level evidence). hypertension (INCPH) should be similar to cirrhosis, and on September 24, 2021 by guest. Protected copyright. covered stents are preferred. The selection criteria should Recommendations: renal function also be similar to cirrhosis with particular attention to risk ► In patients with significant intrinsic renal disease (stage 4/5), factors for hepatic encephalopathy (weak
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