A patient with continued variceal bleeding after pharmacologic and endoscopic therapy requires a procedure that lowers portal pressure. Which procedure is indicated?

• A. Balloon tamponade
• B. Transjugular intrahepatic portosystemic shunting (TIPS)
• C. Vasopressin (Pitressin)
• D. Sclerotherapy

Answer: (B)

Lowering portal pressure is the goal when variceal bleeding persists despite medical and endoscopic therapy. Varices form and bleed because high pressure in the portal venous system forces blood into the esophageal and gastric veins. The most effective procedural way to reduce that pressure is to create a shunt that diverts blood from the portal system to the systemic circulation, bypassing the liver's high resistance. A transjugular intrahepatic portosystemic shunt accomplishes this by connecting a branch of the portal vein to a hepatic vein inside the liver, decompressing the portal system and decreasing variceal pressure, which helps control ongoing bleeding and reduces the risk of rebleeding. Balloon tamponade, while useful for temporary stabilization, does not provide durable portal decompression and carries risks. Vasopressin can acutely reduce portal inflow but is not a long-term solution and is not a definitive procedure. Sclerotherapy treats the varices themselves without lowering portal pressure. Thus, the procedure that best lowers portal pressure in refractory variceal bleeding is creating a TIPS shunt.