SALVAGE THERAPIES FOR REFRACTORY VARICEAL HEMORRHAGE

Many of the recent advances in managing patients with portal hypertension and variceal bleeding have been in the pharmacologic and endoscopic therapy for variceal bleeding, but 25% to 30% of patients still rebleed despite these treatments. These are the patients who need salvage therapy.5, 6, 8 A commonly asked question is what defines failure of pharmacologic and endoscopic therapy. Although rigid definitions (e.g., a 2-unit transfusion requirement, a hematocrit fall of 6 points or more, multiple repeated portal hypertensive rebleeds, or persistence of large size varices with endoscopic risk factors) have been used in clinical trials,6, 8, 27 such definitions are not always applicable in day-to-day practice. What is happening to the patient as a whole is as important as what is happening to the varices themselves in declaring variceal bleeding refractory. Thus, the definition of failure of primary therapy for a patient with Child's class C cirrhosis awaiting liver transplantation may be quite different than for a noncirrhotic or Child's class A cirrhotic patient with recurrent variceal bleeding.

This article considers the management of a patient with variceal bleeding to fall into two phases¹³: (1) first-line treatment, which may be mono- or combination therapy with pharmacologic agents or endoscopic therapy, and (2) second-line treatment, that is, salvage therapy when first-line treatment has failed. For patients with advanced disease, the salvage therapy may be liver transplantation. The indications for transplantation, decompressive therapy with surgical shunt or transjugular intrahepatic portosystemic shunt (TIPS) for patients who do not need transplantation or who are not candidates for transplantation or surgical devascularization procedures are presented. This article thus focuses on the radiologic and surgical options for variceal bleeding refractory to first-line treatment.