Multicenter Retrospective Risk Assessment of Esophageal Variceal Bleeding in Patients with Cirrhosis: An Acoustic Radiation Force Impulse Elastography-Based Prediction Model

BACKGROUND/AIMS: Acoustic radiation force impulse (ARFI) elastography predicts the presence of esophageal varices (EVs). We investigated whether an ARFI-based prediction model can assess EV bleeding (EVB) risk in patients with cirrhosis. METHODS: The records of 262 patients with cirrhosis who underwent ARFI elastography and endoscopic surveillance at two institutions in 2008 to 2013 were retrospectively reviewed, and ARFI spleen diameter-to-platelet ratio scores (ASPS) were calculated. RESULTS: The median patient age (165 men, 97 women) was 56 years. The median ARFI velocity, spleen diameter, platelet count, and ASPS were 1.7 m/sec, 10.1 cm, 145×10⁹/L, and 1.16, respectively. During the median 38-month follow-up, 61 patients experienced EVB. Among all patients (179 without EVs and 83 with EVs), the cutoff value that maximized the sum of the sensitivity (73.1%) and specificity (78.4%) (area under receiver operating characteristic curve [AUROC], 0.824) for predicting EVB was 2.60. The cumulative EVB incidence was significantly higher in patients with ASPS ≥2.60 than in those with ASPS <2.60 (p<0.001). Among patients with EVs (n=83), 49 had high-risk EVs (HEVs), and 22 had EVB. The cumulative EVB incidence was significantly higher in HEV patients than in low-risk EV patients (p=0.037). At an ASPS of 4.50 (sensitivity, 66.7%; specificity, 70.6%; AUROC, 0.691), the cumulative EVB incidence was significantly higher in patients with a high ASPS than in those with a low ASPS (p=0.045). A higher ASPS independently predicted EVB (hazard ratio, 4.072; p=0.047). CONCLUSIONS: ASPS can assess EVB risk in patients with cirrhosis. Prophylactic management should be considered for patients with HEVs and ASPS ≥4.50.

Left Gastric Vein Visualization with Hepatopetal Flow Information in Healthy Subjects Using Non-Contrast-Enhanced Magnetic Resonance Angiography with Balanced Steady-State Free-Precession Sequence and Time-Spatial Labeling Inversion Pulse

OBJECTIVE: To selectively visualize the left gastric vein (LGV) with hepatopetal flow information by non-contrast-enhanced magnetic resonance angiography under a hypothesis that change in the LGV flow direction can predict the development of esophageal varices; and to optimize the acquisition protocol in healthy subjects. MATERIALS AND METHODS: Respiratory-gated three-dimensional balanced steady-state free-precession scans were conducted on 31 healthy subjects using two methods (A and B) for visualizing the LGV with hepatopetal flow. In method A, two time-spatial labeling inversion pulses (Time-SLIP) were placed on the whole abdomen and the area from the gastric fornix to the upper body, excluding the LGV area. In method B, nonselective inversion recovery pulse was used and one Time-SLIP was placed on the esophagogastric junction. The detectability and consistency of LGV were evaluated using the two methods and ultrasonography (US). RESULTS: Left gastric veins by method A, B, and US were detected in 30 (97%), 24 (77%), and 23 (74%) subjects, respectively. LGV flow by US was hepatopetal in 22 subjects and stagnant in one subject. All hepatopetal LGVs by US coincided with the visualized vessels in both methods. One subject with non-visualized LGV in method A showed stagnant LGV by US. CONCLUSION: Hepatopetal LGV could be selectively visualized by method A in healthy subjects.

Biliary Cystadenoma Causing Esophageal Varices / 고신대학교의과대학학술지

Biliary cystadenomas are benign but potentially malignant cystic neoplasm. The preferred treatment is radical resection because it is difficult to differentiate a benign from a malignant biliary cystadenoma. A 40 year-old woman presented with moderate abdominal discomfort. Esophageal varix was found up to mid-esophagus on endoscopy. She has no prior history of liver disease or chronic alcohol ingestion. About 15cm sized biliary cystadenoma was diagnosed by ultrasonography, computed tomography and magnetic resonance imaging. Serum level of bilirubin, alanine aminotransferase, alkaline phosphatase, gamma-glutamyl transpeptidase and tumor marker were elevated. The patient underwent US-guided aspiration. Tumor markers from the aspirated fluid are increased. Left hepatectomy was performed to completely remove the cyst. Histology of the resected specimen confirmed a biliary cystadenoma of the liver with ovary-like stroma. Without prior history of liver disease or chronic alcoholic ingestion, incidental finding of esophageal varix could show an important clue for diagnosis of biliary cystadenoma.

A case of portal hypertension by presumed as plexiform neurofibroma at the hepatic hilum

Neurofibromas can occur anywhere in the body, but they usually involve the head, neck, pelvis, and extremities. Abdominal visceral involvement is rare, and intrahepatic involvement is even less common. We describe a patient who suffered from plexiform neurofibromatosis with liver involvement. A 49-year-old man, who had previously been diagnosed with neurofibromatosis, underwent esophagogastroduodenoscopy and abdominal ultrasonography for screening purposes. Esophagogastroduodenoscopy showed grade 2 esophageal varices and abdominal ultrasonography showed conglomerated nodules with echogenic appearances in the perihepatic space. Magnetic resonance imaging showed presumed plexiform neurofibroma involving the lesser sac and hepatic hilum and encasing the common hepatic artery celiac trunk and superior mesenteric artery left portal triad. We report an unusual case of portal hypertension attributed to the compressive narrowing of the portal vein by presumed as plexiform neurofibroma at the lesser sac and hepatic hilum.

Prevention of Variceal Rebleeding According to the Dose of Propranolol / 대한내과학회지

Esophageal variceal bleeding is a common complication of liver cirrhosis. Non-selective beta blockers (NSBB) have been established in numerous studies as one of the medical treatment for cirrhosis, especially in the primary and secondary prevention of variceal bleeding. The dose of NSBB is adjusted for a reduction in the resting heart rate by 25%, to 55 beat/min, or until the occurrence of adverse effect. The mean adjusted dose of propranolol in Korean study is 160 mg/day. Nevertheless, low dose propranolol is frequently used in real clinical field. A study by Kwon et al. showed that effect of propranolol in the prevention for esophageal rebleeding was superior in maximally-tolerable dose group of propranolol than low dose group. In this editorial, we have reviewed the studies of prevention for variceal rebleeding focusing on the dose of propranolol.

Stroke after percutaneous transhepatic variceal obliteration of esophageal varix in Caroli syndrome / 소아과

Here we present the case of an 11-year-old female patient diagnosed with Caroli syndrome, who had refractory esophageal varices. The patient had a history of recurrent bleeding from esophageal varices, which was treated with endoscopic variceal ligation thrice over a period of 2 years. However, the bleeding was not controlled. When the patient finally visited the Emergency Department, the hemoglobin level was 4.4 g/dL. Transhepatic intrajugular portosystemic shunt was unsuccessful. Subsequently, the patient underwent percutaneous transhepatic variceal obliteration. Twenty hours after this procedure, the patient complained of aphasia, dizziness, headache, and general weakness. Six hours later, the patient became drowsy and unresponsive to painful stimuli. Lipiodol particles used to embolize the coronary and posterior gastric veins might have passed into the systemic arterial circulation, and they were found to be lodged in the brain, kidney, lung, and stomach. There was no abnormality of the portal vein on portal venography, and blood flow to the azygos vein through the paravertebral and hemiazygos systems was found to drain to the systemic circulation on coronary venography. Contrast echocardiography showed no pulmonary arteriovenous fistula. Symptoms improved with conservative management, and the esophageal varices were found to have improved on esophagogastroduodenoscopy.

Major Hepatectomy in the HCC Patient with an Indocyanine Green Retention Rate at 15 Minutes of 10% or Higher: Predictive Values of Postoperative Hepatic Failure

PURPOSE: Major hepatic resection is sometimes inevitable in patients with impaired liver function. We evaluated risk factors that cause postoperative liver failure after major hepatic resection in patients with over a 10% Indocyanine Green Retention rate at 15 minutes (ICGR15). METHODS: From Apr. 2002 to Aug. 2009, 32 patients who had over a 10% rate of ICGR15 underwent major hepatic resection (> or =4 Couinaud segments). Among the 32, 9 patients showed postoperative liver failure (less than 50% prothrombine time and/or 5 mg/dl or higher of total bilirubin). This high-risk group was compared to the rest who constituted a low-risk group. RESULTS: Patients with esophageal varix were more common in the high risk group (4 versus 2, p=0.043). Other clinicopathologic features showed no difference between the two groups. We had 2 in-hospital deaths in the high risk group. CONCLUSION: Great care is needed in patients with esophageal varix and limited liver function during major hepatic resection.

A Case of Essential Thrombocythemia Presenting as Esophageal Varix Bleeding and Multiple Thrombosis / 영남의대학술지

Essential thrombocythemia (ET), a subcategory of chronic myeloproliferative disorder, is characterized by absolute thrombocytosis due to excessive clonal proliferation of platelets, hyperaggregability of platelets, and increased incidence of thrombosis and hemorrhage. We consider a diagnosis of ET when an unexplained and persistent thrombocytosis is observed. It is difficult to consider ET first when we meet a patient with esophageal varix bleeding or unusual multiple thromboses like mesenteric vein, splenic vein, and portal vein. This article reports a patient who presented initially with esophageal varix bleeding and unusual multiple thromboses, thereafter, she was diagnosed with ET after testing positive for the Janus Tyrosine Kinase 2 (JAK2) V617F mutation. In conclusion, in patients with varix bleeding and unusual multiple thromboses, myeloproliferative disorders like essential thrombocythemia should be considered as a potential cause and testing for the JAK2 mutation is warranted.

A Case of Portal Hypertension after the Treatment of Oxaliplatin Based Adjuvant-Chemotherapy for Rectal Cancer / 대한소화기학회지

We report herein a case of 35-years-old woman in whom portal hypertension (esophageal varix and splenomegaly) developed after 12 cycles of oxaliplatin based adjuvant chemotherapy for rectal cancer. She was transferred for the evaluation of etiology of new-onset portal hypertension. The esophageal varix and splenomegaly were absent before the oxaliplatin based adjuvant chemotherapy. Thorough history taking and serological exam revealed no evidence of chronic liver disease. Liver biopsy was done and there was no cirrhotic nodule formation. Instead, perivenular fibrosis was noted. Considering new development of esophageal varices and splenomegaly after 12 cycles of oxaliplatin-based adjuvant chemotherapy, we could conclude that portal hypertension in this patient were due to sinusoidal injury by oxaliplatin. Finally, we recommend regular follow-up with endoscopy and radiologic examination for checking the development of varices and for screening of varices and splenomegaly in patients with colo-rectal cancer who receive oxaliplatin-based chemotherapy.

A Case of Portal Hypertension after the Treatment of Oxaliplatin Based Adjuvant-Chemotherapy for Rectal Cancer / 대한소화기학회지

We report herein a case of 35-years-old woman in whom portal hypertension (esophageal varix and splenomegaly) developed after 12 cycles of oxaliplatin based adjuvant chemotherapy for rectal cancer. She was transferred for the evaluation of etiology of new-onset portal hypertension. The esophageal varix and splenomegaly were absent before the oxaliplatin based adjuvant chemotherapy. Thorough history taking and serological exam revealed no evidence of chronic liver disease. Liver biopsy was done and there was no cirrhotic nodule formation. Instead, perivenular fibrosis was noted. Considering new development of esophageal varices and splenomegaly after 12 cycles of oxaliplatin-based adjuvant chemotherapy, we could conclude that portal hypertension in this patient were due to sinusoidal injury by oxaliplatin. Finally, we recommend regular follow-up with endoscopy and radiologic examination for checking the development of varices and for screening of varices and splenomegaly in patients with colo-rectal cancer who receive oxaliplatin-based chemotherapy.

The experience about the endoscopic variceal ligation combining more amount dose lauromacrogol in treatment of esophageal varix recurrence / 中国医师进修杂志

Objective To investigate the preventing and curative value of endoscopic injectim sclerotherapy underlying endoscopic variceal ligations in the treatment of the patients suffering form esophageal varix recurrence.Methods The endoscopic injection sclerotherapy was performed to the patients whose esophageal varix varnished or nearly varnished after the endoscopic variceal ligation.Results There were sinificant differences (P ＜ 0.05 ) between the group of the endoscopic variceal ligation combining more dose laurornacrogol and the group of the single endoscopic variceal ligation at the recurrence rate of bleeding.No severe complications were observed during the treatments.Conclusion The endoscopic injection clerotherapy of more amount doses lauromacrogol after the endoscopic variceal ligation can signiticantly reduce residual esophageal varix after the endoscopic variceal ligation and dday esophageal varix recurrrence.

Long Journey of Sclerosant From the Esophagus to the Right Atrium

A 34-year-old man, who had been treated with an endoscopic injection of a mixture of n-butyl-2-cyanoacrylate (Histoacryl) and Lipiodol for control of variceal bleeding 6 months previously, presented with an intracardiac mass in the right atrium (RA). Two-dimensional echocardiography revealed an intracardiac mass in the RA that appeared to extend from the inferior vena cava. The origin of the sclerosant was traced by computed tomography (CT). This is a very rare case in which the sclerosant migration route was demonstrated by CT scan. The findings of this case suggest that the systemic migration of sclerosant into an intracardiac chamber should be considered in patients with an intracardiac mass, especially with a history of previous sclerotherapy for variceal bleeding.

Comparison of Terlipressin and Octreotide with Variceal Ligation for Controlling Acute Esophageal Variceal Bleeding: a Randomized Prospective Study / 대한간학회지

BACKGROUND/AIMS: Terlipressin and octreotide had been used to control acute variceal bleeding and to prevent early rebleeding after endoscopic hemostasis. We compared the efficacy and safety of terlipressin and octreotide combined with endoscopic variceal ligation (EVL) for the treatment of acute esophageal variceal bleeding and we evaluated their clinical significance as related to rebleeding. METHODS: The eighty eight cirrhotic patients were randomized to the terlipressin group (n=43; 2 mg i.v. initially and 1 mg i.v. at every 4 hours for 3 days) or the octreotide group (n=45; continuous infusion of 25 microgram/h for 5 days) combined with EVL for the treatment of acute esophageal variceal bleeding. RESULTS: The initial hemostasis rates were 98% (42/43 cases) in the terlipressin group and 96% (43/45 cases) in the octreotide group. The 5-day and 42-day rebleeding rates were 12% (5/43 cases) and 28% (12/43 cases), respectively, in the terlipressin group and 9% (4/45 cases) and 24% (11/45 cases), respectively, in the octreotide group. No significant difference was demonstrated between the terlipressin and octreotide groups. The mortality at 42 days was similar in both group, but a high mortality rate (48%) was shown to be related to 42-day rebleeding. The risk factors related to 42-day rebleeding were Child-Pugh class C (aOR=30.2, 95% CI=7.7-117.9), ascites above grade II (aOR=6.6, 95% CI=2.2-19.2) and advanced hepatocellular carcinoma (aOR=4.6, 95% CI=1.1-18.9). CONCLUSIONS: Comparing terlipressin and octreotide combined with EVL showed them to be equally safe and effective therapeutic agents in patients with acute esophageal variceal bleeding. The high risk factors related to early rebleeding were poor liver function and advanced hepatocellular carcinoma.

Esophago-Gastric Devascularization in Portal Hypertension

PURPOSE: Bleeding from esophago-gastric varices needs urgent treatment. Esophageal varix bleeding usually was controlled by intervention, but rebleeding rate was high. Gastric varix bleeding is unable to be controlled by intervention. Recently, newly developed methods for varix bleeding controll have been used, but surgical intervention is still advocated. We report our experience with esophago-gastric devascularization for bleeding control in portal hypertension and its effectiveness. METHODS: This retrospective study was performed on 32 cases who underwent esophago-gastric devascularization in portal hypertension at Kyuung Hee University Hospital from Nov. 1990 to Feb. 2004. Author analyzed characteristics & patients, causes of portal hypertension, liver function reserve, operation methods, perioperative finding, complications and factors determining postoperative mortality. RESULTS: Sex ratios of male to female was 5.4:1. The ages were ranged from 25 to 70 years old with mean age of 50.5. Postoperative complication rate was 40.6% (13/32) and those were recovered by conservative management. There was one case of recurrent bleeding at 9months postperatively (3%). Mortality rate was 4% in Child-Pugh group A and B, and 57% in group C. The overall mortality rate was 15%. Preoperative hepatic reserve (P<0.05) & preoperative blood pressure (P<0.05) was a significant factors. A mean follow up period is 18.7 months. CONCLUSION: In our study, esophago-gastric devascularization in portal hypertension showed good results with 3% rebleeding rate and 85% overall survival rate. Esophago-gastric devascularization was effective method for esophago-gastric varix bleeding.

A Case of Congenital Hepatic Fibrosis with Variceal Bleeding / 대한소아소화기영양학회지

Congenital hepatic fibrosis is an inherited, congenital disorder of the liver characterized by portal hypertension and hepatic fibrosis. We experienced a case of congenital hepatic fibrosis with esophageal varix in a 9-year-old male. He complained hematemesis, hematochezia, dizziness. In laboratory examination, AST/ALT was slightly increased. Esophageal varix was noted by an endoscopic examination. Hepatosplenomegaly and hypoechoic lesion of periportal area were seen by abdominal CT scanning. Histologic finding of liver biopsy showed fibrous tracts containing dilated bile ductules connecting adjacent portal spaces that were widened by mature fibrosis. Endocopic sclerotherpy and ligation was done. We summarized a case with review of literatures.

Safety and Effect of the Perigastric Devascularization with Transection of Esophagus for Treatment of Esophageal Varices

PURPOSE: There are a variety of approaches to the treatment of esophageal varix. This study evaluates the value of perigastric devascularization with transection of the esophagus, a non-shunt operation, for the management of bleeding esophageal varices. METHODS: We retrospectively analyzed the medical records of 16 patients with esophageal varix bleeding who had undergone perigastric devascularization with transection of the esophagus from 1990 through 2000. RESULTS: The mean age of the patients was 40.8 years and the most common underlying pathology was viral hepatitis. All patients had a history of previous variceal bleeding. Elective and prophylactic surgery was done in 8 and 5 patients respectively, and emergency surgery in 3 patients. One patient in Child group C and underwent emergency surgery, died after operation (mortality rate 6.3%). In the remaining 15 patients, two patients died of hepatocellular carcinoma. None of the patients demonstrated rebleeding or recurrence of the varix in the follow-up period. In 8 patients, the liver function, as measured by Child-Pugh classification, was improved following surgery as compared with measurements at the time of admission. CONCLUSION: According to this study, in spite of the small number of patients, we suggest that perigastric devascularization with transection of the esophagus is a very safe and effective treatment modality for esophageal varix bleeding, particularly if it can be done for an elective or prophylactic purpose. Furthermore, we propose that the operation should be carried out in an elective rather than in emergency manner following the improvement of liver function by non- invasive medical treatment.

The Effect of Initial Ligation Numbers on the Eradication of Esophageal Varix with Endoscopic Variceal Ligation / 대한소화기내시경학회지

BACKGROUND AND AIMS: Eradication of esophagogastric varix is the most important goal of endoscopic variceal treatment. However, the effect of initial ligation numbers with endo-scopic variceal ligation has not been widely studied. The purpose of this retrospective study was to evaluate the effect of initial ligation numbers on the eradication of esophageal varix. METHODS: The mean number of sessions to variceal eradication was compared according to initial ligation numbers, and varix grade by the North Italian Endoscopy Club, and the Child-Pugh class in 212 patients. Initial ligation numbers were divided into three groups; more than 11, 6 ~10, and fewer than 5. RESULTS: Except with grade I, esophageal varix was eradicated earlier in the two groups of more than 6 ligations (p <0.01). The mean number of sessions in the group of more than 11 ligations was significantly different from that of the group of 6 ~10 ligations in grade II patients (p <0.05). The mean number of sessions was not significantly different when compared by the Child-Pugh class. CONCLUSION: It is suggested that patients with more initial ligation numbers may result in earlier eradication of esophageal varix with endoscopic ligation.

N-utyl--yanoacrylate (Histoacryl) in the Treatment of Esophageal Variceal Bleeding: Comparison with Band Ligation / 대한간학회지

BACKGROUND/AIMS: Endoscopic sclerotherapy and band ligation have been well documented beneficial therapeutic options of esophageal variceal bleeding. But acute variceal bleeding is refractory to sclerotherapy in upto one-hird of patients, and rebleeding occurs in 30% to 50%. Recently alternative endoscopic modality, N-utyl--yanoacrylate (Histoacryl) injection is performed in intravariceal sclerotherapy but its efficacy and safty are not clearly established. We evaluated the efficacy of Histoacryl on esophageal variceal bleeding and compared with that of endoscopic band ligation in the present study. MATERIALS/METHODS: From March 1994 to March 1998, ninety seven patients with endoscopically documented esophageal variceal bleeding were enrolled. Histoacryl injection (Histoacryl group, n=33) or endoscopic band ligation (EVL group, n=64) was done for esophageal variceal bleeding. We evaluated the rebleeding rate and in-ospital mortality in both groups. RESULTS: Baseline characteristics were similar but active bleeding on first endoscopic session was significantly higher in Histoacryl group (Histoacryl group; 90.7%, EVL group; 26.6%, p=0.002). Successful hemostasis was done at 87.9% in Histoacryl group, 95.3% in EVL group (not significant). There were no significant differences on early rebleeding rate (18.2% vs 23.4%), late rebleeding rate (39.4% vs 37.5%) and in-ospital mortality (24.2% vs 15.6%) between Histoacryl group and EVL group. There were no technique-elated fatal complications at Histoacryl injection group. CONCLUSION: Therapeutic efficacy of Histoacryl injection was similar to the endoscopic band ligation in patients with esophageal varix bleeding in terms of hemostasis and rebleeding. Histoacryl is effective therapeutic option for esophageal variceal bleeding as well as gastric variceal bleeding.

Bronchial Hyperresponsiveness in Liver Cirrhosis / 결핵

BACKGROUND: Arterial hypoxemia has been noted in patients with liver cirrhosis because of bronchial vessel dilatation. Cabenes et al. reported that bronchial hyperresponsiveness to the metacholine inhalation was observed in patients of left side heart failure, he suggested that one of the mechanism was bronchial vessel dilatation. We hypothesized that patients of liver cirrhosis might have bronchial hyperresponsiveness to metacholine inhalation due to portal hypertension. We evaluate the relationship between bronchial responsiveness and severity of liver cirrhosirs, severity of portal hypertension. METHODS: In the 22 patients of the liver cirrhosis with clinical portal hypertension metacholine provocation test was done and determined PC20 FEV1. We classified lifter cirrhosis according to Pugh- Child classification Esophagogastroscopies were performed for the evaluation of the relationship between bronchial hyperresponsiveness and severity of esophageal varix. RESULTS: In the 22 cases of the liver cirrhosis with clinical portal hypertension. The causes of liver cirrhosis, alcoholic hepatitis was 9 cases. hepatitis B virus was 12 cases, hepatitis C virus was 1 case. and 151 cases (68.18%) of total 22 cases were positive in metacholine provocation test. In positive cases There was no significant relationship between PC20FEV1 and severity of liver cirrhosis which were classified by Pugh-Child classification or severity of esophageal varix(p<0.05). CONCLUSION: we observed that bronchial responsiveness to metacholine increased in the patients of liver cirrhosis and there was no significant relationship between the severity of liver cirrhosis and the severity of esophageal varix.

The Results of Long-term Follow-up after Transjugular Intrahepatic Portosystemic Shunt for Gastric and Esophageal Bleeding / 대한간학회지

BACKGROUND/AIMS: Transjugular intrahepatic portosystemic shunt(TIPS) is a promising method of treatment for gastric and esophageall variceal bleeding. Immediate technical and short-term clinical results have been reportn!. This study is performed to evaluate long-term outcome after TIPS in patients who underwent the pracedure for variceal bleeding. METHODS: Forty patients who underwent TIPS hetween August 1991 and February 199S were followed up by clinical examination, upper gastrointestina! Endoscopy and Duplex sonogrphy. RESULTS: The mean portohepatic pressure gradient prior to TIPS was 30.1+/-8.7cmH ancl dropped to 16.6+/-6.7cmH2O after shunt(p<0.001). The cumulative survival rate was 67.5% at 6 months. 57.4% at 1 year, 37.1% at 2 years and 26.8% at 3 years. Survival after TIPS was inversely related to Child-Pugh class. The incidence of recurrent variceal bleeding was 25%. The causes of death were hepatic failure(53.6 %), recurrent variceal bleeding(28.6'%), sepsis(7.1 %) and unknown causes(10.7'%). CONCLUSION: TIPS is an effective method for treatment of variceal bleeding in unsuccessful cases by other treatments including endoscopic therapy and the most important prognostic factor is preprocedual hepatic resenre(Child-Pugh class), TIPS by itself is not defioite therapy, but in combination with careful follow-up surveillance and percutaneous shunt revision is very effective therapeutic strategy. TIPS is particularly valuable in tlreating patients with variceal bleeding hefor liver transplantation and in treating patients with poor liver function.