Management of Portal Hypertension

First-Line Management

The American College of Radiology recommends early administration of vasoactive agents followed by endoscopic therapy for acute variceal bleeding 3
Combination therapy with endoscopic treatment plus vasoactive drugs significantly improves 5-day hemostasis rates (77% vs 58% with endoscopy alone) 3
Antibiotic prophylaxis in cirrhotic patients with acute upper gastrointestinal bleeding reduces mortality, bacterial infections, and rebleeding 3
Medical management with diuretics is first-line for ascites, as recommended by the European Association for the Study of the Liver 4
For portal hypertensive gastropathy, non-selective beta blockers and iron therapy are recommended as initial treatment by the European Association for the Study of the Liver 4

TIPSS is strongly recommended for gastro-oesophageal variceal bleeding refractory to endoscopic and drug therapy (as defined by Baveno 6 criteria), according to the European Association for the Study of the Liver 4, 2
Early or pre-emptive TIPSS should be considered within 72 hours of a variceal bleed in patients with Child's C disease or MELD ≥19, as recommended by the European Association for the Study of the Liver 4
In selected patients with refractory or recurrent ascites, TIPSS is strongly recommended by the European Association for the Study of the Liver, provided there are no contraindications 2
Contraindications for TIPSS in ascites include bilirubin >50 μmol/L, platelets <75×10^9, pre-existing encephalopathy, active infection, severe cardiac failure, and severe pulmonary hypertension, as stated by the European Association for the Study of the Liver 6, 3, 2

Covered stents are preferred over bare metal stents due to superior patency rates, according to the Journal of the American College of Radiology 7
A Doppler ultrasound is recommended one week after TIPSS implantation in patients with prothrombotic conditions, as recommended by the European Association for the Study of the Liver 1
Regular Doppler ultrasound follow-up at 6-12 month intervals is recommended by the European Association for the Study of the Liver 1
The main complications of TIPSS include hepatic encephalopathy (affecting approximately one-third of patients), bleeding, infection, heart failure, liver failure, and kidney failure, as reported by the European Association for the Study of the Liver 8

Portal vein thrombosis is not an absolute contraindication to TIPSS placement, although cavernoma presence is associated with higher failure rates, according to the European Association for the Study of the Liver 6
In patients with esophageal varices or history of variceal bleeding, appropriate prophylaxis should be maintained with non-selective beta blockers or endoscopic band ligation, as recommended by the American Association for the Study of Liver Diseases 5
The role of TIPSS in idiopathic non-cirrhotic portal hypertension should follow similar indications as in cirrhosis, according to the European Association for the Study of the Liver 6