Pre-emptive TIPS should be considered in high-risk patients with both acute variceal bleeding and severe alcohol-related hepatitis

Background & Aims: Severe alcohol-related hepatitis (AH) and acute variceal bleeding (AVB) may occur simultaneously. The impact of a pre-emptive transjugular intrahepatic portosystemic shunt (pTIPS) in high-risk patients (patients with Child–Pugh (CP) B and active bleeding or CP C10–13 cirrhosis) with AVB and concomitant severe AH is unknown. The objective of the study was to compare the outcomes of severe AH in patients with high-risk AVB treated with pTIPS or endoscopic and drug treatment (Endo+drugs). Methods: Patients were screened in four existing cohorts of patients with cirrhosis and AVB treated either with pTIPS or Endo+drugs. The inclusion criteria were AVB, high-risk patients, suspected severe AH (recent onset of jaundice, alcohol-related liver disease, absence of abstinence, model for end-stage liver disease score >20 and aspartate aminotransferase <500 UI/L). The primary endpoint was 42-day mortality, considering liver transplantation as a competing event. Secondary endpoints were rebleeding and further development of ascites or hepatic encephalopathy at 6 months. Results: A total of 142 patients with AVB were included (pTIPS: n = 47, Endo+drugs: n = 95). Baseline characteristics (age 53, male sex 84%, model for end-stage liver disease score 23.4) were similar between the two groups. Overall, 56% had histologically proven AH. The 42-day mortality was 16% in the pTIPS group vs. 30% in the Endo+drugs group (p = 0.2). The cumulative incidence of rebleeding and ascites was significantly lower in the pTIPS group (2.8% vs. 24%, p = 0.026, and 6% vs. 52%, p <0.001, respectively), whereas hepatic encephalopathy occurrence was similar in the two groups (p = 0.2). Corticosteroid therapy was given in 55% and 46% of patients in the pTIPS and Endo+drugs groups, respectively (p = 0.3). Conclusions: In severe AH, pTIPS is associated with better outcomes than Endo+drugs, and should not be contraindicated. Impact and implications: Severe alcohol-related hepatitis and acute variceal bleeding may occur concomitantly, yet the role of pre-emptive transjugular intrahepatic portosystemic shunt (pTIPS) placement in this setting remains unclear. In this study, compared to standard of care, pTIPS treatment was associated with lower mortality, although this difference did not reach statistical significance, as well as a significantly reduced risk of rebleeding and recurrent ascites. These findings suggest that severe alcohol-related hepatitis should not be viewed as a contraindication to pTIPS placement when otherwise indicated, such as in patients with Child–Pugh B cirrhosis with a score greater than 7 and active bleeding, or Child–Pugh C10–13 disease.