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Model for end‐stage liver disease (MELD) exception for portal hypertensive gastrointestinal bleeding

Portal hypertensive bleeding of the gastrointestinal (GI) tract is a complication of end-stage liver disease. Bleeding can be controlled endoscopically and pharmacologically in up to 90% of patients. 1 Transjugular intrahepatic portal systemic shunt (TIPS), or less often surgery, are alternative treatments for patients with recurrent or refractory variceal bleeding or bleeding from portal hypertensive gastropathy who have a contraindication to TIPS or who bleed despite a patent TIPS. The mortality rate in patients with recurrent or refractory variceal bleeding or bleeding from portal hypertensive gastropathy is close to 100%, but these clinical situations are difficult to quantify for the purpose of organ distribution. TIPS may be contraindicated in a number of patients with end-stage liver disease. Despite its minimally invasive nature, TIPS has been associated with a 30-day mortality rate as high as 48%. 2 Many authors have looked at various factors associated with a poor prognosis after TIPS, which include serum bilirubin and creatinine levels, Child-Pugh score, and encephalopathy. The development of the Model for End-Stage Liver Disease (MELD) was based on predicting mortality in patients with a TIPS. This system has now been modified and applied to liver organ distribution in the United States. 3 The ability to predict mortality was not improved by including GI bleeding in the MELD. 4 Bilirubin has been shown by a number of investigators to be a good predictor of mortality after TIPS. Rajan and colleagues 5 have shown that an “elevated pre-TIPS