P433 IS TIPS INDICATED IN CIRRHOTIC PATIENTS WITH CHILD–PUGH B SCORE AND ACTIVE VARICEAL BLEEDING?

Abstract

Background: The indication of early transjugular intrahepatic portosystemic sunt (TIPS) in case of variceal bleeding is currently debated. In particular, Child-Pugh C patients and Child-Pugh B patients with active bleeding are considered by the Baveno V consensus as high risk of treatment failure in case of variceal bleeding. However, there are no strong data confirming that active bleeding at endoscopy is predictive of bad survival pronostic in ChildPugh B patients. Aims: We aimed to determine which subgroup of patients could beneficiate from an early TIPS. Methods: We reviewed all consecutive cirrhotic patients admitted to our University Hospital for variceal bleeding between January 2007 and December 2011. The primary endpoint was the mortality at six weeks. Results: One hundred and forty-three patients were included: 114 men, mean age 58.4 years (31-89). Alcohol was the main cirrhosis etiology (73.9%). Patients were classified in Child-Pugh A (18.2%), Child-Pugh B (39.2%) and Child-Pugh C (42.6%). The varices were esophageal in 97.9% of the cases, gastric in 11.2% (GOV 10.5%, IGV 0.7%), ectopic in 6.3%. Twenty-six patients (18.2%) had an hepatocellular carcinoma, 22 patients (15.4%) a portal thrombosis. Active bleeding during initial endoscopy was observed in 30 patients (24.1%). During the acute phase, a pharmacological treatment associating vasoactive drugs (octreotide 94.2%) and antibiotic prophylaxis (third-generation cephalosporins, quinolones) were used respectively in 92.5% and 75% of the cases. In 118 patients (88.5%), an endoscopic therapy was performed (band ligation in 94%). A balloon tamponade was used in 7 patients because of failure of pharmacological and endoscopic treatment. Six patients underwent a TIPS placement including three in an early stage (within 72 hours). A bleeding recurrence was observed in 27% (8.3% between day 3 and day 5, 5.5% between day 6 and 42, and 13.2% between day 6 and six month). The six-week mortality rate was 18.9% (27 patients): Child A=0 (0%), Child B=1 (1.8%) and Child C=26 (42.6%). Child-Pugh C and early bleeding recurrence (day 3 to 5) were associated with an increased mortality at six weeks (respectively p<0.001 and p=0.05). Active bleeding during initial endoscopy was also a risk factor of six-week mortality (p=0.001). Therefore, in the subgroup of Child-Pugh B patients, active bleeding was not a risk factor of six-week mortality (p=1). Conclusions: The six-week mortality was 18.9%, which is in accordance with Baveno V consensus (10-20%). This mortality rate could probably be decreased by amore frequent use of early TIPS, which should be considered in patients at high-risk of mortality (Child-Pugh C). In our study, like in the study of Thabut et al, active bleeding at endoscopy was not associated with a poor survival in Child B patients.