Portal hypertension and variceal bleeding

2020 ◽  
pp. 3068-3080
Author(s):  
Marcus Robertson ◽  
Peter Hayes
Keyword(s):  
Portal Hypertension ◽  
Variceal Bleeding ◽  
Developed Countries ◽  
Gastric Varices ◽  
Secondary Prophylaxis ◽  
Medical Emergency ◽  
Endoscopic Management ◽  
Recurrent Bleeding ◽  
Endoscopic Variceal Ligation ◽  
Complications Of Cirrhosis

Portal hypertension refers to a pathological elevation of pressure in the veins that carry blood from the splanchnic organs to the liver which, in developed countries, most commonly results from increased intrahepatic resistance to portal flow as a result of liver cirrhosis. Portal hypertension is associated with development of many of the complications of cirrhosis and confers a poor prognosis. Acute variceal bleeding is a life-threatening medical emergency which remains a leading cause of death in patients with cirrhosis. Endoscopic variceal ligation and endoscopic variceal obturation remain the treatments of choice for bleeding oesophageal and gastric varices respectively. Advances in care including prophylactic antibiotics, vasoactive drugs, and transjugular intrahepatic portosystemic shunt in patients with bleeding refractory to early endoscopic management has improved the mortality rate, which is now estimated at 15 to 20%. Secondary prophylaxis of variceal bleeding with nonselective β‎-blockers and/or endoscopic variceal ligation reduces recurrent bleeding and has been demonstrated to improve survival.

scholarly journals Endoscopic variceal ligation combined with sclerotherapy for management of gastroesophageal variceal bleeding in pediatric patients

2021 ◽  
Author(s):  
Ming-Ming Li ◽  
Fang Sun ◽  
Man-Xiu Huai ◽  
Chun-Ying Qu ◽  
Feng Shen ◽  
...  
Keyword(s):  
Variceal Bleeding ◽  
Pediatric Patients ◽  
Median Number ◽  
Gastric Varices ◽  
Secondary Prophylaxis ◽  
Endoscopic Management ◽  
Endoscopic Variceal Ligation ◽  
Variceal Hemorrhage ◽  
Clinical Center ◽  
The Mean

Abstract Background Portal hypertension (PH) frequently gives rise to severe and life-threatening complications, including hemorrhage accompanied by the rupture of esophageal and gastric varices. In contrast to the widely studied guidelines for the management of PH in adults, there remains controversial about the optimal endoscopic management of variceal bleeding in children for secondary prophylaxis. The study aims to determine the efficacy and safety of endoscopic variceal ligation (EVL) and sclerotherapy (EST) to control bleeding in children in our clinical center. Methods The retrospective study included 21 children with gastroesophageal variceal bleeding who were treated by endoscopic variceal ligation or sclerotherapy at Xinhua Hospital, Shanghai Jiaotong University School of Medicine between January 2007 and July 2020. The treatment outcome involving short-term hemostatic rate and long-term rebleeding rate were investigated. Adverse events related to the procedures, such as esophageal ulcer, esophageal stricture, abnormal embolization, pneumonia and perforation were also observed. Results The 21 pediatric patients who were diagnosed as moderate to severe esophageal varices concurrent with gastric varices experienced EVL or EST successfully. Hemostasis was achieved in 45 of 47 (95.7%) episodes of upper gastrointestinal bleeding. The mean volume of each single aliquot of cyanoacrylate injected was 0.3 ± 0.1 mL (range: 0.1–0.5 mL). Twenty-four patients (75%) reach varices eradication in the EVL group with a median number of procedures before eradication of 2 (1–4) and a median time to eradication of 3.40 months (1.10-13.33). Eleven patients (52.4%) developed rebleeding events, with the mean duration of hemostasis being 11.1 ± 11.6 mo (range: 1.0-39.2 mo). No treatment-related complications, for example, distal embolism, were noted with the exception of abdominal pain in one patient (4.8%). Conclusions Endoscopic variceal sclerotherapy or in combination with EVL turns out to be an effective and safe approach to treat variceal hemorrhage in children for secondary prophylaxis.

scholarly journals Results of a Modified Sugiura's Devascularisation in the Management of “Unshuntable” Portal Hypertension

HPB Surgery ◽  
1999 ◽  
Vol 11 (4) ◽  
pp. 235-239 ◽  
Author(s):  
S. R. Shah ◽  
S. S. Nagral ◽  
S. K. Mathur
Keyword(s):  
Portal Hypertension ◽  
Variceal Bleeding ◽  
Splenic Vein ◽  
Gastric Varices ◽  
Recurrent Bleeding ◽  
Variceal Hemorrhage ◽  
Medium Term ◽  
Venous Anatomy ◽  
Esophageal Variceal

The results of a modified Sugiura devascularisation procedure were assessed in 14 patients with thrombosis of the portal and splenic vein requiring surgery for variceal hemorrhage, with no vein suitable for orthodox shunt surgery. The venous anatomy was determined by ultrasonography with Doppler studies and portovenography. Liver biochemistry as well as liver architecture on histopathology was normal in all. The surgery was elective in 9 cases for documented bleed from diffuse fundal gastric varices (FGV) and emergency in 5 cases, 3 having bleeding FGV and 2 for failure of emergency esophageal variceal sclerotherapy. All were subjected to a transabdominal extensive devascularisation of the upper two third of the stomach and lower 7–10cm of the esophagus. Stapled esophageal transection (n=11) or esophageal variceal under-running (n=1) was performed in all with esophageal varices. FGV were underrun. Follow up endoscopies were done six monthly. There were 9 males and 5 females with a mean age of 17.2 years (SD 12.8). There was no operative mortality. Acute variceal bleeding was controlled in all patients. Over a mean follow up of 38 months, all but one remain free of recurrent bleeding. We conclude that a modified Sugiura devascularisation procedure is effective in the immediate and medium term control of variceal bleeding in patients with “unshuntable” portal hypertension.

scholarly journals ROLE OF STAGE ENDOSCOPIC VARICEAL BAND LIGATION IN TREATMENT OF CHILDREN WITH PORTAL HYPERTENSION

2020 ◽  
Vol 73 (10) ◽  
pp. 2133-2137
Author(s):  
Dariia I. Voroniak ◽  
Oleg S. Godik ◽  
Larysa Ya. Fedoniuk ◽  
Olena М. Shapoval ◽  
Viktoriia V. Piliponova
Keyword(s):  
Portal Hypertension ◽  
Esophageal Varices ◽  
Variceal Bleeding ◽  
Gastric Varices ◽  
Secondary Prophylaxis ◽  
Band Ligation ◽  
Bleeding Prophylaxis

The aim: To evaluate the efficacy of endoscopic variceal band ligation (EVL) after the first esophageal EVL session in children with PH according to endoscopic data. Materials and methods: EVL was performed to 39 patients with PH for the purpose of variceal bleeding primary and secondary prophylaxis. Results: Esophageal varices grade decrease was observed in 22 (56.41%) children. Cases of early rebleeding (within 14 days after EVL) were not registered. Eradication of varices was successful in 11 (28.2%) of patients. In 1 (2.56%) case the complication (bleeding) occurred while banding procedure. 1 (2.56%) patients had bleeding from gastric varices prior to a control endoscopy. Portal gastropathy grade changes were observed in 17 (43.59%) patients. Conclusions: EVL is a safe and effective method of esophageal varices bleeding prophylaxis. This method allows control the esophageal varices grade at different phases of PH treatment in children. Even one EVL session can decrease the grade of esophageal varices (р<0.001). The EVL effect on the severity of portal gastropathy (p=0.02) and on the red marks presence (p=0.005) was also determined. EVL reduced the risk of variceal rebleeding (р=0.05, RR=0.05 (95%CI 0.01-0.32)).

scholarly journals Endoscopic Management of Portal Hypertension

2012 ◽  
Vol 2012 ◽  
pp. 1-12 ◽  
Author(s):  
Said A. Al-Busafi ◽  
Peter Ghali ◽  
Philip Wong ◽  
Marc Deschenes
Keyword(s):  
Portal Hypertension ◽  
Endoscopic Ultrasound ◽  
Capsule Endoscopy ◽  
Interventional Therapy ◽  
Gastric Varices ◽  
Active Management ◽  
Endoscopic Management ◽  
Diagnostic Modality ◽  
Gastroesophageal Varices ◽  
Life Threatening

Cirrhosis is the leading cause of portal hypertension worldwide, with the development of bleeding gastroesophageal varices being one of the most life-threatening consequences. Endoscopy plays an indispensible role in the diagnosis, staging, and prophylactic or active management of varices. With the expected future refinements in endoscopic technology, capsule endoscopy may one day replace traditional gastroscopy as a diagnostic modality, whereas endoscopic ultrasound may more precisely guide interventional therapy for gastric varices.

TIPS: a new alternative for the variceal bleeder

1993 ◽  
Vol 2 (3) ◽  
pp. 196-201 ◽  
Author(s):  
L Adams ◽  
MC Soulen
Keyword(s):  
Portal Hypertension ◽  
Hepatic Vein ◽  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Variceal Bleeding ◽  
Balloon Catheter ◽  
Portosystemic Shunt ◽  
Recurrent Bleeding ◽  
Secondary Patency ◽  
Secondary Patency Rate ◽  
Intrahepatic Portosystemic Shunt

BACKGROUND: Standard medical therapies for variceal bleeding secondary to portal hypertension (vasopressin, esophagogastric balloon tamponade and sclerotherapy) are associated with high rates of recurrent bleeding. Surgical shunting has a mortality rate of 15% to 50%. The transjugular intrahepatic portosystemic shunt offers a novel, minimally invasive procedure for nonsurgical portal decompression. METHOD: Following catheterization of the hepatic vein from a jugular vein approach, a needle is directed fluoroscopically from the hepatic vein into a branch of the portal vein along an intrahepatic tract. The intrahepatic tract is then dilated and held open with a stainless steel stent delivered on a balloon catheter. This creates a portosystemic shunt entirely within the liver. RESULTS: The collective experience of more than 300 cases from several centers has been reported. The technical success rate for the transjugular intrahepatic portosystemic shunt is 92% to 96%. Thirty-day mortality rates range from 0% to 14%, with less than 3% attributed to procedural complications. Primary shunt patency is about 90%, with a secondary patency rate of 100%. Rates of encephalopathy and rebleeding are 9% to 14%. Ascites resolves in 80% to 90% of patients. CONCLUSION: The transjugular intrahepatic portosystemic shunt appears to be a safe and effective procedure for management of variceal bleeding and holds promise for becoming the treatment of choice for portal hypertension.

scholarly journals Beyond the scope and the glue: update on evaluation and management of gastric varices

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Cyriac Abby Philips ◽  
Rizwan Ahamed ◽  
Sasidharan Rajesh ◽  
Tom George ◽  
Meera Mohanan ◽  
...  
Keyword(s):  
Portal Hypertension ◽  
Variceal Bleeding ◽  
Endovascular Procedures ◽  
Gastric Varices ◽  
Current Evidence ◽  
Ultrasound Guided ◽  
Algorithmic Approach ◽  
Evidence Based Treatments ◽  
Intrahepatic Portosystemic Shunt ◽  
Shed Light

Abstract Gastric varices are encountered less frequently than esophageal varices. Nonetheless, gastric variceal bleeding is more severe and associated with worse outcomes. Conventionally, gastric varices have been described based on the location and extent and endoscopic treatments offered based on these descriptions. With improved understanding of portal hypertension and the dynamic physiology of collateral circulation, gastric variceal classification has been refined to include inflow and outflow based hemodynamic pathways. These have led to an improvement in the management of gastric variceal disease through newer modalities of treatment such as endoscopic ultrasound-guided glue-coiling combination therapy and the emergence of highly effective endovascular treatments such as shunt and variceal complex embolization with or without transjugular intrahepatic portosystemic shunt (TIPS) placement in patients who are deemed ‘difficult’ to manage the traditional way. Furthermore, the decisions regarding TIPS and additional endovascular procedures in patients with gastric variceal bleeding have changed after the emergence of ‘portal hypertension theories’ of proximity, throughput, and recruitment. The hemodynamic classification, grounded on novel theories and its cognizance, can help in identifying patients at baseline, in whom conventional treatment could fail. In this exhaustive review, we discuss the conventional and hemodynamic diagnosis of gastric varices concerning new classifications; explore and illustrate new ‘portal hypertension theories’ of gastric variceal disease and corresponding management and shed light on current evidence-based treatments through a ‘new’ algorithmic approach, established on hemodynamic physiology of gastric varices.

Risk stratification for secondary prophylaxis of gastric varices due to portal hypertension

2019 ◽  
Vol 51 (12) ◽  
pp. 1678-1684 ◽  
Author(s):  
Lili Ma ◽  
Yujen Tseng ◽  
Tiancheng Luo ◽  
Jian Wang ◽  
Jingjing Lian ◽  
...  
Keyword(s):  
Portal Hypertension ◽  
Risk Stratification ◽  
Gastric Varices ◽  
Secondary Prophylaxis

scholarly journals External Hemorrhage from a Portacaval Anastomosis in a Patient with Liver Cirrhosis

2014 ◽  
Vol 2014 ◽  
pp. 1-2
Author(s):  
Murat Biyik ◽  
Ramazan Ucar ◽  
Sami Cifci ◽  
Orhan Ozbek ◽  
Gokhan Gungor ◽  
...  
Keyword(s):  
Liver Cirrhosis ◽  
Portal Hypertension ◽  
Abdominal Wall ◽  
Variceal Bleeding ◽  
Anterior Abdominal Wall ◽  
Major Complication ◽  
Gastric Varices ◽  
Portacaval Anastomosis ◽  
Esophageal And Gastric Varices

Variceal bleeding is the major complication of portal hypertension in patients with liver cirrhosis. Hemorrhage mainly occurs in gastrointestinal lumen. Extraluminal hemorrhages are quite rare, such as intraperitoneal hemorrhages. We aimed to present a variceal bleeding case from the anastomosis on the anterior abdominal wall, as an extraordinary bleeding location, in a patient with portal hypertension in whom there were no esophageal and gastric varices.

scholarly journals Non-cirrhotic portal hypertension: current concepts and modern management

2016 ◽  
Vol 43 (3) ◽  
pp. 170-176
Author(s):  
Md Ismail Patwary ◽  
Matiur Rahman ◽  
Kaushik Mojumder
Keyword(s):  
Portal Hypertension ◽  
Portal Vein ◽  
Variceal Bleeding ◽  
Gastric Varices ◽  
Idiopathic Portal Hypertension ◽  
Endoscopic Sclerotherapy ◽  
Cyanoacrylate Glue ◽  
Portal Fibrosis ◽  
Vascular Origin ◽  
Glue Injection

Non-cirrhotic portal hypertension (NCPH) is a heterogeneous group of liver disorders of vascular origin, leading to portal hypertension (PHTN) in the absence of cirrhosis.The lesions are generallyvascular, either in the portal vein, its branches or in the peri-sinusoidal area. The majority of diseases included in the category of NCPH are well-characterized disease entities where PHTN is a late manifestation. Two diseases that present only with features of PHTN and are common in developing countries are non-cirrhotic portal fibrosis (NCPF) and extrahepatic portal vein obstruction (EHPVO). Non-cirrhotic portal fibrosis is a syndrome of obscure etiology, characterized by ‘obliterative-portovenopathy’ leading to PHT, massive splenomegaly and well-tolerated episodes of variceal bleeding in young adults from low socioeconomic backgrounds, having near normal hepatic functions. In some parts of the world, NCPFis called idiopathic portal hypertension in Japan or ‘hepatoportalsclerosis’in USA. Because 85–95% of patient with NCPF and EHPVO present with variceal bleeding, treatment involves management with endoscopic sclerotherapy (EST) or variceal ligation (EVL). These therapies are effective in approximately 90–95% of patients. Gastric varices are another common cause of upper gastrointestinal bleeding in these patients and these can be managed with cyanoacrylate glue injection or surgery. The prognosis of patients with NCPF is good and 5 years survival in patients in whom variceal bleeding can be controlled has been reported to be approximately 95–100%.Bangladesh Med J. 2014 Sep; 43 (3): 170-176

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