Role of early transjugular intrahepatic portosystemic stent-shunt in acute variceal bleeding:An update of the evidence and future directions

Variceal bleeding is a serious complication of cirrhosis and portal hypertension.Despite the improvement in management of acute variceal bleed(AVB),it still carries significant mortality.Portal pressure is the main driver of variceal bleeding and also a main predictor of decompensation.Reduction in portal pressure has been the mainstay of management of variceal bleeding.Transjugular intrahepatic porto-systemic stent shunt(TIPSS)is a very effective modality in reducing the portal hypertension and thereby,controlling portal hypertensive bleeding.However,its use in refractory bleeding(rescue/salvage TIPSS)is still associated with high mortality.“Early”use of TIPSS as a“pre-emptive strategy”in patients with AVB at high risk of failure of treatment has shown to be superior to standard treatment in several studies.While patients with Child C cirrhosis(up to 13 points)clearly benefit from early-TIPSS strategy,it’s role in less severe liver disease(Child B)and more severe disease(Child C>13 points)remains less clear.Moreover,standard of care has improved in the last decade leading to improved 1-year survival in high-risk patients with AVB as compared to earlier“early”TIPSS studies.Lastly in the real world,only a minority of patients with AVB fulfil the stringent criteria for early TIPSS.Therefore,there is unmet need to explore role of early TIPSS in management of AVB in well-designed prospective studies. In this review, we have appraised the role of early TIPSS, patient selection anddiscussed future directions in the management of patients with AVB.

Systematic review and meta-analysis of trans-jugular intrahepatic portosystemic shunt for cirrhotic patients with portal vein thrombosis

BACKGROUND Portal vein thrombosis(PVT)was previously a contraindication for trans-jugular intrahepatic portosystemic shunt(TIPS).AIM To perform a systematic review and meta-analysis of the current available studies investigating outcomes of TIPS for cirrhotic patient with PVT.METHODS Multiple databases were systematically searched to identify studies investigating the outcomes of TIPS for cirrhotic patients with PVT.The quality of studies was assessed by Cochrane Collaboration method and Methodological Index for Non-Randomized Studies.The demographic data,outcomes,combined treatment,and anticoagulation strategy were extracted.RESULTS Twelve studies were identified with 460 patients enrolled in the analysis.The technical success rate was 98.9%in patients without portal vein cavernous transformation and 92.3%in patients with portal vein cavernous transformation.One-year portal vein recanalization rate was 77.7%,and TIPS patency rate was 84.2%.The cumulative encephalopathy rate was 16.4%.One-year overall survival was 87.4%.CONCLUSION TIPS is indicated for portal hypertension related complications and the restoration of pre-transplantation portal vein patency in cirrhotic patients with PVT.Cavernous transfor-mation is an indicator for technical failure.Post-TIPS anticoagulation seems not mandatory.Simultaneous TIPS and percutaneous mechanical thrombectomy device could achieve accelerated portal vein recanalization and decreased thrombolysis-associated complications,but further investigation is still needed.

Antibiotic prophylaxis in patients with cirrhosis: Current evidence for clinical practice

Patients with cirrhosis show an increased susceptibility to infection due to disease-related immune-dysfunction.Bacterial infection therefore represents a common,often detrimental event in patients with advanced liver disease,since it can worsen portal hypertension and impair the function of hepatic and extrahepatic organs.Among pharmacological strategies to prevent infection,antibiotic prophylaxis remains the first-choice,especially in high-risk groups,such as patients with acute variceal bleeding,low ascitic fluid proteins,and prior episodes of spontaneous bacterial peritonitis.Nevertheless,antibiotic prophylaxis has to deal with the changing bacterial epidemiology in cirrhosis,with increased rates of gram-positive bacteria and multidrug resistant rods,warnings about quinolonesrelated side effects,and low prescription adherence.Short-term antibiotic prophylaxis is applied in many other settings during hospitalization,such as before interventional or surgical procedures,but often without knowledge of local bacterial epidemiology and without strict adherence to antimicrobial stewardship.This paper offers a detailed overview on the application of antibiotic prophylaxis in cirrhosis,according to the current evidence.