Reply to: “Failure to control variceal bleeding: Definition matters”

We thank Baiges et al.[1]Baiges A. Bureau C. Garcia-Pagan J.C. Failure to control variceal bleeding: definition matters.J Hepatol. 2021; 74: 1491-1492Abstract Full Text PDF PubMed Scopus (1) Google Scholar for their keen interest and observations regarding our study.[2]Kumar R. Kerbert A.J.C. Sheikh M.F. Roth N. Calvao J.A.F. Mesquita M.D. al.Determinants of mortality in patients with cirrhosis uncontrolled bleeding.J 66-79Abstract (22) completely agree that the ‘failure bleeding’ is difficult apply individual clinical cases general its interpretation dependent upon many factors including how sick is, whether they have ongoing bleeding during an endoscopy session severity bleeding. In study,[2]Kumar we defined strictly as failure achieve haemostasis despite 2 endoscopies or need adjuncts such Sengstaken-Blakemore tube (SBT) a stent within 5 days first bleed combination vasoactive drugs. al. raise several important questions.1.What role transjugular intrahepatic portosystemic shunt (TIPS) without acute-on-chronic liver (ACLF) bleeding’? believe paper underpowered make any new conclusions about rescue TIPS but ACLF. As current practice, these should be offered TIPS.2.How was controlled TIPS? large proportion were referred from other centres, found still had endoscopic options. Out 174 study, further therapeutic successful achieving satisfactory 82 (47.1%).3.Whether there sub-group whom futile? reported paper[2]Kumar correctly observed by Baiges[1]Baiges al., none who grade 2-3 ACLF “prior acute episode bleeding” survived, irrespective status. Of developed following bleeding, all survivors CLIF-C score 62 below. This confirms previous futility cut-off transplantation not option. Patients >64 after 48 hours intensive care unit are at high risk death those >70 almost invariably die aetiology precipitant.[3]Engelmann Thomsen K. Zakeri M. Agarwal B. Jalan al.Validation define threshold support failure.Crit Care. 2018; 22: 254Crossref (54) Although criteria provide strong guide, needs decided on case-by-case basis.4.Would preemptive (pTIPS) prevented The population studied highly selected patient group, most centres. It extremely analyse this complex retrospective study come meaningful conclusion pTIPS would TIPS. Despite quality published data,[4]Garcia-Pagan Caca Laleman W. Appenrodt Luca al.Early use bleeding.N Engl J Med. 2010; 362: 2370-2379Crossref (801) Scholar,[5]Trebicka J. Gu Ibanez-Samaniego L. Hernandez-Gea V. Pitarch Garcia E. al.Rebleeding increased reduced pre-emptive TIPS.J 2020; 73: 1082-1091Abstract (57) matter debate UK, which has been fuelled recent negative trial Hayes group.[6]Dunne P.D.J. Sinha Stanley A.J. Lalchan Ireland H. Shams al.Randomised trial: standard versus early-transjugular porto-systemic oesophageal bleeding.Aliment Pharmacol Ther. 52: 98-106Crossref (27) A UK process being set up definitively address issue. authors received no financial produce manuscript. RK drafted letter, RJ did critical review Rajiv research collaborations Yaqrit Takeda. inventor OPA, patented UCL licensed Mallinckrodt Pharma. He also founder Ltd, spin out company University College London. Founder Thoeris Ltd. Please refer accompanying ICMJE disclosure forms details. supplementary data article: Download .pdf (.26 MB) Help pdf files Definition mattersJournal HepatologyVol. 74Issue 6PreviewAcute (AVB) recognized leading cause cirrhosis.1 Importantly, AVB comprises only re-bleeding triggering complications, among stands out.2–5 term defines abrupt worsening hepatic extrahepatic organ underlying disease. On side, effective tool treat portal hypertension thus markedly reducing rebleeding, decompensation death. Full-Text Determinants bleedingJournal 1PreviewFailure oesophago-gastric (OGVB) both prognostic cirrhosis. aims determine OGVB insertion improves survival