Grade IV varices with high-risk features found on screening: considering a more radical approach

In addition to established uses in refractory variceal bleeding, early trans-jugular intrahepatic portosystemic shunt (TIPS) is recommended in certain high-risk patients who have already experienced variceal bleeding. Notably, this is not currently recommended in patients that are high risk to bleed for the first time as primary prophylaxis, a point that may be worth reconsidering in certain very high-risk patients. A 71-year-old male presented for variceal screening after having been diagnosed with cirrhosis 11 years prior. He had no history of variceal bleeding but was found to have grade IV varices with “red wale sign.” The patient was already on a beta-blocker at that time. Although prophylactic TIPS was considered, the patient died due to severe refractory variceal bleeding shortly thereafter. While literature suggests the potential risk of prophylactic TIPS in such cases outweighs the benefit, a combination of improvements in the procedure itself and the uniquely high-risk status of certain patients make these prior studies less generalizable. In patients with high-risk varices, the risk of bleeding may outweigh the risk of hepatic encephalopathy. We propose that that TIPS should be strongly considered as primary prophylaxis in this high-risk cohort and be compared with the standard of care. Furthermore, we also propose that it may be reasonable to measure portal pressure before and after the initiation of beta-blockers.