Quality standard

Quality statement 9: Management of variceal bleeding using transjugular intrahepatic portosystemic shunts (TIPS)

Quality statement 9: Management of variceal bleeding using transjugular intrahepatic portosystemic shunts (TIPS)

Quality statement

People with uncontrolled acute upper gastrointestinal bleeding from varices are given transjugular intrahepatic portosystemic shunts (TIPS).

Rationale

In some cases, variceal bleeding cannot be controlled with endoscopic treatment. In these instances, TIPS can be used to stop the bleeding.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Structure

Evidence of local arrangements to ensure that people with uncontrolled acute upper gastrointestinal bleeding from varices are given TIPS.

Data source: Local data collection.

Process

The proportion of people with uncontrolled acute upper gastrointestinal bleeding from varices who receive TIPS.

Numerator – the number of people in the denominator who receive TIPS.

Denominator – the number of people with uncontrolled acute upper gastrointestinal bleeding from varices.

Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place for people with uncontrolled acute upper gastrointestinal bleeding from varices to be given TIPS.

Healthcare practitioners perform TIPS in people with uncontrolled acute upper gastrointestinal bleeding from varices.

Commissioners ensure that they commission services that give TIPS to people with uncontrolled acute upper gastrointestinal bleeding from varices.

People with uncontrolled acute upper gastrointestinal bleeding caused by enlarged veins are given a procedure called transjugular intrahepatic portosystemic shunts (also called TIPS). In a TIPS procedure, the veins feeding into the liver and those draining it are connected so that the blood flow is redirected and the pressure in the enlarged veins is lowered.

Source guidance

Acute upper gastrointestinal bleeding in over 16s: management. NICE guideline CG141 (2012, updated 2016), recommendations 1.5.4 (key priority for implementation) and 1.5.6

Definitions of terms used in this quality statement

Transjugular intrahepatic portosystemic shunts

In a transjugular intrahepatic portosystemic shunts (TIPS) procedure, the veins feeding into the liver and those draining it are connected so that the blood flow is redirected and the pressure in the enlarged veins is lowered.

Before using TIPS, attempts should first be made to stop bleeding using the alternative methods described in quality statements 7 and 8. NICE's guideline on acute gastrointestinal bleeding states:

  • Consider transjugular intrahepatic portosystemic shunts (TIPS) if bleeding from oesophageal varices is not controlled by band ligation.

  • Offer TIPS if bleeding from gastric varices is not controlled by endoscopic injection of N‑butyl‑2‑cyanoacrylate.

[NICE's guideline on acute upper gastrointestinal bleeding, recommendations 1.5.4 and 1.5.6]