Cirrhotic patients who survive an episode of acute variceal haemorrhage are at high risk of recurrent
bleeding. Many treatments have been found to be effective at preventing rebleeding, including
drug therapy, endoscopic treatments and transjugular intrahepatic portosystemic stunt (
TIPS). In this issue of European Journal of Gastroenterology & Hepatology,
Jalan et al. compared three historical cohorts of patients with
cirrhosis after index variceal bleed and found a lower rebleeding rate in patients receiving
TIPS (16.2%) compared to either band
ligation (39.3%) or endoscopic variceal
sclerotherapy (74.6%). Despite the efficacy of
TIPS in preventing variceal rebleeding, there was no significant difference in survival between the three cohorts. However, sub-group analysis found a lower mortality in patients with Child-Pugh class C
cirrhosis receiving
TIPS. Unfortunately, this promising observation in patients with advanced
cirrhosis is not supported by the results of meta-analysis of randomized studies. Therefore, we do not recommend
TIPS as first-line
therapy to prevent variceal rebleeding in patients with
cirrhosis.