Efficacy and Safety of Transjugular Intrahepatic Portosystemic Shunt in the Treatment of Nongastric Extraesophageal Variceal Bleeding (original) (raw)

2004, Journal of Clinical Gastroenterology

Background: Pleural effusions(PE) complicate cirrhosis in ~5% of patients. Identification of cause and related complications is imperative. Unlike refractory ascites, large-scale studies on interventions for refractory PE are limited. Methods: Consecutive hospitalized cirrhotics having PE were retrospectively analyzed. None had liver transplantation (LT) within 6-month follow-up. We determined safety, efficacy and mortality predictors for PE managed with standard medical treatment(SMT), thoracentesis, catheter drainage and TIPS. Results: Of 1149 cirrhotics with PE(mean Child-Pugh 10.6 ±1.8 and MELD 21.2 ±7.4), 82.6% had hepatic hydrothorax(HH) and 12.3% were suspected tubercular PE(TBPE). Despite comparable HVPG and MELD scores, patients with HH developed more AKI, encephalopathy and septic shock (all P<0.01) on follow up. Among HH, 73.5% were symptomatic, 53.2% isolated right-sided PE and 21.3% had SBE. Presence of SBP[Odd's ratio,OR:4.5] and catheter drainage[OR:2.1] were independent predictors for SBE. In 70.3% of admissions, HH responded to SMT alone, 12.9% required thoracentesis and 11.5% underwent catheter drainage. 51 patients were selected for TIPS [lower mean CTP 9.9±1.6 and MELD score 18.7±5.4]. Despite reduction in pressure gradient from 23.1±3.8 mm Hg to 7.2±2.5 mm Hg, 25 patients had partial response, 10 had complete HH resolution. Major post-TIPS complications were portosystemic encephalopathy(8 patients, 6 resolved) and ischemic hepatitis(4 patients, 2 resolved). Overall, 35.9% patients with HH had 6-month mortality and independent predictors were MELD >25, SBP and septic shock. Conclusion: Refractory PE in cirrhosis requiring interventions including TIPS has poor outcome. Role of hemodynamics in predicting post-TIPS response and complications is limited. Early referral for LT is imperative.