ADWE-05 Pre-emptive tipss improves clinical outcomes in patients with variceal haemorrhage: a retrospective cohort study. (8th June 2018)

• Record Type: Journal Article
• Authors: Haq, Ihteshamul; Lau, Meagan; Jongman, Emma; Crichton, Robert; Chinnappan, Lalitha; Ollif, Simon; Mehrzad, Homoyon; Karkhanis, Salil Karkhanis; Snelson, Catherine; Murphy, Nick; Tripathi, Dhiraj
• Is Part Of: Gut. Volume 67(2018)Supplement 1
• Page Start: A108
• Page End: A108
• Publication Date: 2018-06-08
• Subjects: Gastroenterology -- Periodicals; 616.33
• DOI: 10.1136/gutjnl-2018-BSGAbstracts.214
• Languages: English
• ISSNs: 0017-5749

Abstract

Abstract : Variceal haemorrhage is a medical emergency associated with a 30 day mortality of 15% and a re-bleeding rate of 26%. If there is failure to control bleeding endoscopically salvage TIPSS is reported to control bleeding in 90%–100% of cases, with re-bleeding rates of 6%–16%. However mortality remains high. Approximately 20% of patients are 'high risk'; here early or pre-emptive TIPSS, before treatment failure (up to 5 days post bleed), can significantly reduce morbidity/mortality. A recent multicentre study has shown that pre-emptive covered TIPSS was associated with good outcomes but poses significant challenges in the 'real world' situation. We evaluated the clinical outcomes of patients undergoing a covered TIPSS following an acute variceal bleed and subsequent admission to the Intensive Care Unit with focus on pre-emptive TIPSS strategies. Method: We used the CRIS Radiology Information System to construct a database of all patients undergoing a TIPSS for variceal haemorrhage at between 2013 and 2016. For each patient we collected a wide range of data, which were analysed using SPSS (SPSS Inc. Chicago IL, USA) and expressed as means±SD. Mortality data were analysed using the Kaplan-Meier Method. Results: We studied 96 patients with a mean age 51.0±12.1 years, M:F ratio (67:29), alcohol related liver disease (59.4%), MELD score 15.8±6.8, and follow up 25.4±18.3 months. All TIPSS procedures were successful, and indication was as salvage (42%), pre-emptive (44%), and secondary prevention (14%). Initial management involved band ligation in combination with vasoconstrictors and/or Sengstaken- Blakemore Tube in all cases. Patient mortality at 6 weeks, 6 months, 12 months and 24 months was 19%, 24%, 30% and 34% respectively. MELD score >15 was significantly associated with mortality following multivariate analysis. Six week mortality was significantly higher with salvage TIPSS compared to pre-emptive strategy (33% versus 9%, p<0.05), even after controlling for MELD. There was no difference in mortality between pre-emptive and secondary prevention strategies. The overall re-bleeding rate was 2%. Conclusion: The outcomes of patients admitted to ICU following a variceal bleed are good and comparable to published literature. This is probably a reflection of high-standard ICU care. Pre-emptive TIPSS up to five days following the index variceal bleed Results in significantly better outcomes than salvage TIPSS, with mortality comparable to TIPSS for secondary prevention. However, the currently hub and spoke model of TIPSS services in the UK is unable to accommodate a pre-emptive strategy in all region