[Laura Turco]

Dear Antonio and dear VALDIG friends,
Happy New Year!
I would treat the patient with a combination therapy of BRTO (in order to avoid any further bleeding due to gastric varices) plus anticoagulation (the latter due to a procoagulant diathesis, a suspected PSVD and the presence of thrombosis likely causing the bleeding).
The presence of TIPS, with a non-occlusive thrombosis of the portal vein trunk should mitigate the effects of a further increase in portal hypertension due to BRTO.
However, it would be useful, as already mentioned, to revise the TIPS in order to exclude any disfunction and to assess the degree of portal hypertension. I would suggest to perform TIPS revision at the same time of BRTO (measuring portal pressure before BRTO, then temporary occluding the gastric varix with the balloon and rechecking portal pressure before definitively occluding the varix). In case of important increase of portal pressure, and without any disfunction in TIPS, I would proceed by performing BRTO and adding NSBB to decrease portal pressure as recently suggested.
Moreover, despite this patient still has a good liver function as demonstrated by her MELD, taking into account the multiple episodes of decompensation in a young patient, I would start screening her for liver transplantation in order to be prepared in case of a further rapid deterioration of her liver function.
Best regards,
Laura Turco

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