Original Contribution | Published:

How much reduction in portal pressure is necessary to prevent variceal rebleeding? a longitudinal study in 225 patients with transjugular intrahepatic portosystemic shunts

American Journal of Gastroenterology volume 96, pages 33793383 (2001) | Download Citation

Subjects

Abstract

OBJECTIVES:

This longitudinal study determines the risk of rebleeding in relation to the reduction of the portosystemic pressure gradient in patients with a transjugular intrahepatic portosystemic shunt (TIPS) for variceal bleeding.

METHODS:

The study included 225 patients in whom a TIPS revision was indicated by the endoscopic finding of varices with a high risk for rebleeding (n = 167) or a recent variceal rebleed (n = 58). The portosystemic pressure gradient was determined before and after TIPS placement and at revision performed after a mean of 10 ± 15 months.

RESULTS:

The portosystemic pressure gradient at revision approached the index pressure gradient before TIPS implantation (23.1 ± 5.5 mm Hg) by 8.4 ± 31%. Rebleeding was inversely correlated with the reduction in index pressure gradient found at revision. Thus, 80% of rebleedings occurred with pressure gradients close to the index pressure gradient (<25% reduction) or with gradients equal to or greater than the index pressure gradient. In contrast, only one patient (0.4%) and three patients (1.3%) rebled with a pressure gradient of <12 mm Hg or a reduction of the index pressure gradient by >50%, respectively. Kaplan-Meier analysis of rebleeding, which included the 225 patients at risk, showed a probability of rebleeding of 18%, 7%, and 1% for a reduction of the index pressure gradient by 0%, 25–50%, and >50%, respectively.

CONCLUSIONS:

Most rebleedings occurred with pressure gradients similar to the index-pressure gradient measured at first bleeding. Accordingly, a graded reduction by 25–50% sufficiently prevents rebleeding. It can be assumed that, in comparison with the widely used threshold value of 12 mm Hg, a reduction by 25–50% may have a favorable benefit-to-risk ratio with respect to shunt-induced hepatic encephalopathy and liver failure. It should therefore be a goal in the decompressive treatment of portal hypertension and maintained during follow-up of patients with variceal bleeding.

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Affiliations

  1. Department of Gastroenterology, University Hospital, Freiburg, Germany

    • Martin Rössle
    • , Volker Siegerstetter
    • , Andreas Ochs
    • , Elisabeth Berger
    •  & Klaus Haag
  2. Institute of Biometry, Freiburg, Germany

    • Manfred Olschewski

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Corresponding author

Correspondence to Martin Rössle.

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DOI

https://doi.org/10.1111/j.1572-0241.2001.05340.x