S5278 Peribiliary Variceal Bleeding: Is TIPS the Answer?

Introduction: Peribiliary varices are an uncommon manifestation of chronic portal hypertension and can result in extrinsic compression and narrowing of the common bile duct. Their rarity and anatomical complexity make management particularly challenging, especially when they hinder standard endoscopic interventions. Case Description: A 63-year-old man with cirrhosis secondary to metabolic-associated steatotic liver disease (MASLD) and chronic portal venous occlusion presented with new-onset jaundice. Magnetic resonance cholangiopancreatography (MRCP) revealed intrahepatic biliary ductal dilation. He was initially scheduled for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). EUS demonstrated large peribiliary varices compressing the common bile duct and a distal choledocholithiasis. Duodenal bulb stenosis from extrinsic variceal compression was also noted. Due to the high risk of hemorrhage and technical difficulty, ERCP was aborted. The patient underwent transjugular intrahepatic portosystemic shunt (TIPS) placement and splenic artery embolization to decompress the portal circulation. TIPS was deemed safe in this case, with a Model for End-Stage Liver Disease score of 18 and no prior hepatic encephalopathy. Post-TIPS, repeat ERCP showed significant reduction in esophageal, gastric, and peribiliary varices. The biliary stone was successfully extracted, and a plastic stent was placed. Discussion: This case underscores the critical role of TIPS in the management of peribiliary varices that cause biliary obstruction. By reducing portal pressure, TIPS can facilitate safe and effective biliary intervention in patients where traditional endoscopic access is impeded. Early recognition and multidisciplinary management are essential in such complex presentations.