Upper GI bleed: varices: TIPS prevented rebleeds more effectively than sclerotherapy

Clinical bottom line (level 1b)

  1. Patients with a recent variceal bleed who had a transjugular intrahepatic portosystemic shunt (TIPS) inserted rather than having sclerotherapy were less likely to rebleed at 6 weeks (NNT = 3 at 6 weeks) or 2 years (NNT = 2 at 2 years) .
  2. There was no clear effect on mortality or occurrence of hepatic encephalopathy.
Garcia-Villareal et al: Hepatology 1999; 29: 27-32
Expires October 2002

The study

Double-blinded ?concealed randomised trial with intention-to-treat
Setting: university hospital, Spain

46 patients (aged mean 57, 80% male) with cirrhosis and an endoscopically proven oesophageal variceal bleed

Excluded if
  • aged <18, >75
  • history of chronic encephalopathy
  • portal vein thrombosis
  • hepatocellular carcinoma
  • end-stage liver disease: any of prothrombin time index <35%, bilirubin >5 mg/dl, plasma creatinine > 3mg/dl
  • follow-up not possible


    • Note:
  • All patients were resuscitated and treated with endoscopic sclerotherapy with vasoactive drugs and balloon tamponade when necessary. Patients were randomised after 24 hours of stability.

Control Group: (n = 24, 24 analysed): endoscopic sclerotherapy
Experimental Group: (n = 22, 22 analysed): transjugular intrahepatic portosystemic shunt (TIPS)

100% followed for 2 years range 6 days to 4 years

The evidence

Outcome Time to outcome CEREERRRR
(95% CI)		ARR
(95% CI)		NNT
(95% CI)
variceal bleed 6 weeks 8
(33.3%)		 1
(4.55%)		 86%
(0% to 98%)		 28.79%
(8.02% to 49.56%)		 3
(2 to 12)
variceal bleed 2 years 12
(50.0%)		 2
(9.09%)		 82%
(28% to 95%)		 40.91%
(17.58% to 64.24%)		 2
(2 to 6)
death weeks 8
(33.3%)		 3
(13.64%)		 59%
(-35% to 88%)		 19.7%
(-4.0% to 43.39%)		 5
(NNT = 2 to infinity;
NNH = 25 to infinity)
hepatic encephalopathy weeks 6
(25.0%)		 5
(22.7%)		 9%
(-156% to 68%)		 2.27%
(-22.4% to 26.9%)		 44
(NNT = 4 to infinity;
NNH = 4 to infinity)

Comments

  1. The study is too small to show any effect of TIPS on mortality or hepatic encephalopathy.
  2. Band ligation is now considered the endoscopic treatment of choice to prevent recurrent variceal haemorrhage , with TIPS used primarily as a salvage therapy.

Citation

  1. Garcia-Villareal L, Martinez-Lagares F, Sierra A, et al: Transjugular intrahepatic portosystemic shunt versus endoscopic sclerotherapy for the prevention of variceal rebleeding after recent variceal hemorrhage. Hepatology 1999; 29: 27-32
Contributor: Chris Ball and Musab Hayatli, October 1999
Reviewer: Horand Meier

Clinical Question.
Patient variceal bleed
Intervention or Exposure sclerotherapy
Comparison TIPS
Outcome death, rebleed, encephalopathy