A 52-year-old man from Delhi presents with a 3-day history of haematemesis and melaena. He has a 10-year history of alcohol-related cirrhosis with portal hypertension. On examination, he is tachycardic (HR 110/min), hypotensive (BP 88/56 mmHg), and has clinical signs of hepatic encephalopathy. Upper endoscopy confirms actively bleeding oesophageal varices refractory to two sessions of endoscopic variceal ligation. Urgent CT angiography of the abdomen shows patent portal vein and splenic vein. The interventional radiologist is called for emergency intervention. Which of the following is the most appropriate next step in management?

Explanation

## Clinical Context This patient has variceal haemorrhage refractory to endoscopic therapy — a life-threatening emergency requiring urgent decompression of the portal venous system. **Key Point:** TIPS is the definitive interventional radiological procedure for refractory variceal bleeding in portal hypertension. It creates a low-resistance shunt between the portal vein and hepatic vein, reducing portal pressure below the variceal bleeding threshold (target: reduction of hepatic venous pressure gradient [HVPG] to <12 mmHg or by ≥20% from baseline). ## Why TIPS Is Correct 1. **Mechanism of action:** TIPS decompresses the portal system directly, reducing the driving pressure for variceal bleeding. 2. **Timing:** Indicated when endoscopic therapy (variceal ligation/sclerotherapy) fails — typically after 2 failed attempts. 3. **Patency requirement:** The portal vein must be patent (confirmed on CT angiography in this case), which is essential for successful TIPS creation. 4. **Survival benefit:** TIPS reduces rebleeding from 60% to ~20% and improves survival in refractory variceal bleeding. **High-Yield:** TIPS is contraindicated in: - Thrombosed portal vein - Uncontrolled sepsis - Severe hepatic encephalopathy (relative) - Severe cardiopulmonary disease ## Comparison of Other Interventions | Intervention | Indication | Mechanism | Limitation | |---|---|---|---| | **TIPS** | Refractory variceal bleeding | Portosystemic decompression | Encephalopathy risk, TIPS stenosis | | **Splenic artery embolisation** | Splenic infarction, splenic rupture, hypersplenism | Reduces splenic blood flow | Does NOT reduce portal pressure; ineffective for variceal bleeding | | **Portal vein embolisation** | Hepatic resection planning, portal vein thrombosis management | Redirects flow; promotes contralateral hypertrophy | Contraindicated in active bleeding; used for surgical planning only | | **Hepatic artery embolisation** | HCC, hepatic aneurysm, arterial bleeding | Reduces arterial supply | Does NOT address portal hypertension; not indicated for variceal bleeding | **Clinical Pearl:** The decision to place TIPS should be made within 12 hours of failed endoscopic therapy. Delaying TIPS in refractory bleeding increases mortality. Post-TIPS monitoring includes surveillance for stenosis (Doppler ultrasound at 1, 3, 6 months) and encephalopathy management. **Mnemonic — TIPS Indications:** **REFRACTORY BLEED** - **R**efractory variceal haemorrhage (after ≥2 endoscopic attempts) - **E**sophageal or gastric varices - **F**ailed medical therapy (octreotide, antibiotics) - **R**epeated bleeding despite endoscopy - **A**cute variceal bleeding with high-risk features (Child-Pugh C, HVPG >20 mmHg) - **C**irrhosis with portal hypertension - **T**reatment bridge to liver transplantation - **O**ther: secondary prophylaxis in high-risk patients - **R**efractory ascites (alternative indication) - **Y**ankauer or balloon tamponade failure (temporary bridge) [cite:Robbins 10e Ch 20; Harrison 21e Ch 295]