scholarly journals Management of variceal hemorrhage: current concepts

2014 ◽  
Vol 27 (2) ◽  
pp. 138-144 ◽  
Author(s):  
Fabricio Ferreira COELHO ◽  
Marcos Vinícius PERINI ◽  
Jaime Arthur Pirola KRUGER ◽  
Gilton Marques FONSECA ◽  
Raphael Leonardo Cunha de ARAÚJO ◽  
...  
Keyword(s):  
Portal Hypertension ◽  
Surgical Treatment ◽  
Variceal Bleeding ◽  
Endoscopic Therapy ◽  
Beta Blockers ◽  
Primary Prophylaxis ◽  
Underlying Disease ◽  
Secondary Prophylaxis ◽  
Variceal Hemorrhage ◽  
Cirrhotic Patients

INTRODUCTION: The treatment of portal hypertension is complex and the the best strategy depends on the underlying disease (cirrhosis vs. schistosomiasis), patient's clinical condition and time on it is performed (during an acute episode of variceal bleeding or electively, as pre-primary, primary or secondary prophylaxis). With the advent of new pharmacological options and technical development of endoscopy and interventional radiology treatment of portal hypertension has changed in recent decades. AIM: To review the strategies employed in elective and emergency treatment of variceal bleeding in cirrhotic and schistosomotic patients. METHODS: Survey of publications in PubMed, Embase, Lilacs, SciELO and Cochrane databases through June 2013, using the headings: portal hypertension, esophageal and gastric varices, variceal bleeding, liver cirrhosis, schistosomiasis mansoni, surgical treatment, pharmacological treatment, secondary prophylaxis, primary prophylaxis, pre-primary prophylaxis. CONCLUSION: Pre-primary prophylaxis doesn't have specific treatment strategies; the best recommendation is treatment of the underlying disease. Primary prophylaxis should be performed in cirrhotic patients with beta-blockers or endoscopic variceal ligation. There is controversy regarding the effectiveness of primary prophylaxis in patients with schistosomiasis; when indicated, it is done with beta-blockers or endoscopic therapy in high-risk varices. Treatment of acute variceal bleeding is systematized in the literature, combination of vasoconstrictor drugs and endoscopic therapy, provided significant decline in mortality over the last decades. TIPS and surgical treatment are options as rescue therapy. Secondary prophylaxis plays a fundamental role in the reduction of recurrent bleeding, the best option in cirrhotic patients is the combination of pharmacological therapy with beta-blockers and endoscopic band ligation. TIPS or surgical treatment, are options for controlling rebleeding on failure of secondary prophylaxis. Despite the increasing evidence of the effectiveness of pharmacological and endoscopic treatment in schistosomotic patients, surgical therapy still plays an important role in secondary prophylaxis.

scholarly journals Motion – Prophylactic Banding of Esophageal Varices Is Useful: Arguments against the Motion

2002 ◽  
Vol 16 (10) ◽  
pp. 693-695 ◽  
Author(s):  
Kris V Kowdley
Keyword(s):  
Esophageal Varices ◽  
Variceal Bleeding ◽  
Beta Blockers ◽  
Low Cost ◽  
Cost Effective ◽  
Primary Prophylaxis ◽  
Ease Of Use ◽  
Endoscopic Sclerotherapy ◽  
Variceal Hemorrhage ◽  
Band Ligation

Bleeding from esophageal varices leads to substantial morbidity and mortality. Despite advances in pharmacological and endoscopic therapy, as well as general supportive care, the mortality rate associated with acute variceal hemorrhage has not improved significantly over the past two decades. Prophylactic therapy with nonselective beta-blockers or long acting nitrates reduces the incidence of variceal bleeding in patients with cirrhosis, is cost effective and may improve survival. Surgical portosystemic shunting reduces the risk of bleeding but is associated with significant operative mortality and a high risk of portosystemic encephalopathy. Endoscopic sclerotherapy causes adverse effects in a large proportion of patients and is, therefore, not suitable for primary prophylaxis of bleeding. Although variceal band ligation is effective in reducing the rate of bleeding and is safer than sclerotherapy, it has not been shown to provide a survival advantage compared with beta-blockers. A significant reduction in the rate of variceal bleeding with band ligation, compared with beta-blockers, was shown in only one study. Beta-blockers offer several advantages, including low cost, ease of use and safety. The available data do not yet support the prophylactic use of variceal band ligation, and this procedure should be reserved for patients who are either unwilling or unable to take beta-blockers. It is hoped that additional large, multicentre trials of band ligation versus beta-blockers will examine the efficacy, cost effectiveness and impact on quality of life among patients with cirrhosis.

scholarly journals Efficacy of long-acting somatostatin analogs in recurrent variceal bleeding in a patient with pre-hepatic portal vein thrombosis

2015 ◽  
Vol 72 (3) ◽  
pp. 283-286
Author(s):  
Tamara Alempijevic ◽  
Ana Balovic ◽  
Aleksandra Pavlovic-Markovic ◽  
Dino Tarabar ◽  
Miodrag Krstic ◽  
...  
Keyword(s):  
Portal Hypertension ◽  
Surgical Treatment ◽  
High Risk ◽  
General Condition ◽  
Variceal Bleeding ◽  
Somatostatin Analogue ◽  
Variceal Hemorrhage ◽  
Gastroesophageal Varices ◽  
Vein Thrombosis ◽  
Long Acting

Introduction. Bleeding from esophageal varices is a serious medical problem because of the risk of recurrent bleeding and high mortality rate (17-54%). Gastroesophageal varices develop in 50% of cirrhotic patients with portal hypertension, but can also develop in other pre- or post-hepatic causes of portal hypertension. Case report. We reported a 48-year-old female patient with portal hypertension caused by mesenterial vein thrombosis due to congenital thrombophilia. The patient was hospitalized several times because of recurrent gastroesophageal bleeding. Thrombosis of portal, lienal and mesenteric veins was diagnosed using multislice computed tomography (MSCT) angiography. Sclerotherapy and/or variceal ligation could not be used due to variceal size and distribution. Beta blockers were ineffective. Balloon tamponade and octreotide were used in each massive bleeding episode. Carvedilol therapy was introduced but rebleeding occured. Surgical treatment was considered a high risk procedure due to massive thrombosis of mesenterial veins, patient's general condition and high risk of postoperative thrombotic events. Thus, long-acting somatostatin analogue - Sandostatin? LAR was initiated at a dose of 30 mg im/month. The patient responded to the therapy well and variceal bleeding did not occur for the following 3 months. After 3 months another episode of gastric variceal hemorrhage occurred and surgical treatment was reconsidered. Total gastrectomy was performed in order to prevent repeated bleeding from large gastric varices and the patient recovered successfully, and after 1 year is symptom-free. Conclusion. Long-lasting somatostatin analogue was used for the first time in treatment of gastroesophageal variceal hemorrhage in the patient with prehepatic portal hyperten-sion. It was effective as temporary therapeutic option allowing the improvement of the patients general condition and adequate planning of elective surgical procedure. Futher reports are needed in order to compare efficacy in treatment of patients with variceal bleeding, where poor outcome is expected.

scholarly journals Hepatic venous pressure gradient-guided laparoscopic splenectomy and pericardial devascularisation versus endoscopic therapy for secondary prophylaxis for variceal rebleeding in portal hypertension (CHESS1803): study protocol of a multicenter randomised controlled trial in China

BMJ Open ◽  
2020 ◽  
Vol 10 (6) ◽  
pp. e030960
Author(s):  
Ruoyang Shao ◽  
Zhiwei Li ◽  
Jitao Wang ◽  
Ruizhao Qi ◽  
Qingbo Liu ◽  
...  
Keyword(s):  
Portal Hypertension ◽  
Pressure Gradient ◽  
Outcome Measures ◽  
Variceal Bleeding ◽  
Endoscopic Therapy ◽  
Venous Pressure ◽  
Secondary Outcome ◽  
Laparoscopic Therapy ◽  
Cirrhotic Patients ◽  
Randomised Controlled

IntroductionGastro-oesophageal variceal bleeding is one of the most common and severe complications with high mortality in cirrhotic patients who developed portal hypertension. Hepatic venous pressure gradient (HVPG) is a globally recommended golden standard for the portal pressure assessment and an HVPG ≥16 mm Hg indicates a higher risk of death and rebleeding. This study aims to compare the effectiveness and safety of splenectomy and pericardial devascularisation (laparoscopic therapy) plus propranolol and endoscopic therapy plus propranolol for variceal rebleeding in cirrhotic patients with HVPG between 16 and 20 mm Hg.Methods and analysisThis is a multicenter, randomised, controlled clinical trial. Participants will be 1:1 assigned randomly into either laparoscopic or endoscopic groups. Forty participants whose transjugular HVPG lies between 16 and 20 mm Hg with a history of gastro-oesophageal variceal bleeding will be recruited from three sites in China. Participants will receive either endoscopic therapy plus propranolol or laparoscopic therapy plus propranolol. The primary outcome measure will be the occurrence of gastro-oesophageal variceal rebleeding. Secondary outcome measures will include overall survival, occurrence of hepatocellular carcinoma, the occurrence of venous thrombosis, the occurrence of adverse events, quality of life and tolerability of treatment. Outcome measures will be evaluated at baseline, 12 weeks, 24 weeks, 36 weeks, 48 weeks and 60 weeks. Multivariate COX regression model will be introduced for analyses of occurrence data and Kaplan-Meier analysis with the log-rank test for intergroup comparison.Ethics and disseminationEthical approval was obtained from all three participating sites. Primary and secondary outcome data will be submitted for publication in peer-reviewed journals and widely disseminated.Trial registration numberNCT03783065; Pre-results.Trial statusRecruitment for this study started in December 2018 while the first participant was randomised in January 2019. Recruitment is estimated to stop in October 2019.

scholarly journals Clinical Features and Outcomes of Repeated Endoscopic Therapy for Esophagogastric Variceal Hemorrhage in Cirrhotic Patients: Ten-Year Real-World Analysis

2020 ◽  
Vol 2020 ◽  
pp. 1-10
Author(s):  
Jia-li Ma ◽  
Ling-ling He ◽  
Ping Li ◽  
Yu Jiang ◽  
Ju-long Hu ◽  
...  
Keyword(s):  
Clinical Features ◽  
Variceal Bleeding ◽  
Endoscopic Therapy ◽  
Survival Rates ◽  
Variceal Hemorrhage ◽  
Term Survival ◽  
Long Term Survival ◽  
Cirrhotic Patients ◽  
One Year

Objective. This study is aimed at evaluating the survival of cirrhotic patients with different etiologies after endoscopic therapy for acute variceal bleeding and the effect of repeated endotherapy on patients’ prognosis. Methods. We retrospectively evaluated the clinical features and outcomes between cirrhotic patients with chronic HBV or HCV infections and other etiologies. The 3-year and 5-year survival rates and rehemorrhage rate in one year between the viral and nonviral cirrhosis patients were compared by Kaplan-Meier curves and log-rank test. Cox analysis was used to identify the impact factors that affect the long-term survival of patients with cirrhosis and variceal bleeding after endotherapy. Results. Out of 2665 patients with liver cirrhosis and variceal hemorrhage selected from our medical center between September 2008 and December 2017, a total of 1342 patients were included for analysis. The median follow-up duration was 32.9 months (range 0.16-111.4 months), the 3- and 5-year cumulative survival rates were 75.3% and 52.8%, respectively. The median survival time was significantly longer in viral cirrhosis patients (47.1 months [95% CI: 24.9-69.1]) compared with nonviral cirrhosis patients (37.0 months [95% CI: 25.0-56.0], p=0.001). The 3-year and 5-year survival rates of the viral group were higher than the nonviral group. The rehemorrhage rate at one year was higher in nonviral patients than in viral patients (p<0.001). Conclusion. Repeated endotherapy combined with effective antiviral therapy is helpful for long-term survival of cirrhotic population with variceal hemorrhage and HBV or HCV infection.

scholarly journals Effects of Proton Pump Inhibitor on Gastroesophageal Varices of Cirrhosis: A Randomized Controlled Trial

2021 ◽  
Author(s):  
Xiaoning Chen ◽  
Tao Zhou ◽  
Ting Zhou ◽  
Yueyue Li ◽  
Xin Sun ◽  
...  
Keyword(s):  
Proton Pump Inhibitor ◽  
Adverse Events ◽  
Proton Pump ◽  
Variceal Bleeding ◽  
Endoscopic Therapy ◽  
Controlled Trial ◽  
Primary Prophylaxis ◽  
Secondary Prophylaxis ◽  
Gastroesophageal Varices ◽  
Acute Bleeding

Abstract BackgroundThe use of proton pump inhibitor (PPI) for gastroesophageal varices in patients with cirrhosis after endoscopic therapy remains controversial. This study aimed to evaluate the effect of PPI on gastroesophageal varices in patients with cirrhosis after endoscopic therapy, including variceal bleeding and adverse events.MethodsBetween May 2017 and June 2019, cirrhotic patients with gastroesophageal varices confirmed by endoscopy were considered for enrollment in this study. Eligible subjects were randomized into two groups: one group received PPI for 14 days and the other group did not undergo PPI treatment. Patients were followed up for 8 weeks.ResultsDuring the follow-up period, three patients (3/53, 5.66%) in the PPI group experienced variceal bleeding on day 9, 16, and 25 after endoscopic therapy, including one patient with primary prophylaxis and two with acute bleeding. In the non-PPI group, three patients (3/56, 5.66%) suffered from variceal bleeding on day 7, 42, and 56 after endoscopic therapy, including two patients with secondary prophylaxis and one with acute bleeding (P>0.99). The rate of adverse events was similar between the two groups (38% vs. 28%, P=0.30). Furthermore, the average hospitalization expense of patients in the PPI group was higher than that of patients in the non-PPI group ($2305 vs. $3096, P<0.001).ConclusionsPPI does not appear to reduce variceal bleeding and adverse events in patients with cirrhosis after endoscopic therapy.Trial registration: This trial was registered with ClinicalTrials.gov (NCT 03175731, 05/06/2017).

scholarly journals Use and Safety of Prophylactic Endoscopy From a Single Center Serving Urban and Rural Children With Portal Hypertension

2021 ◽  
Author(s):  
Voytek Slowik ◽  
Anissa Bernardez ◽  
Heather Wasserkrug ◽  
Ryan T. Fischer ◽  
James F. Daniel ◽  
...  
Keyword(s):  
Portal Hypertension ◽  
Watchful Waiting ◽  
Patient Characteristics ◽  
Primary Prophylaxis ◽  
Secondary Prophylaxis ◽  
Rural Children ◽  
Variceal Hemorrhage ◽  
Limited Data ◽  
Surveillance Endoscopy ◽  
Versus Treatment

Abstract Background: Prophylactic endoscopy is routine in adults with portal hypertension (PHTN), but there is limited data in pediatrics. We sought to describe our experience with prophylactic endoscopy in pediatric PHTNMethods: Retrospective cohort study of 87 children who began surveillance endoscopy prior to gastrointestinal bleeding (primary prophylaxis) and 52 who began after an episode of bleeding (secondary prophylaxis) from 01/01/1994 – 07/01/2019. Results: Patients who underwent primary prophylaxis had a lower mean number of endoscopies (3.897 vs 6.269, p = 0.001). The primary prophylaxis group was less likely to require a portosystemic shunt (6% vs 15%, p < 0.001) with no difference in immediate complications (1% vs 2%, p = 0.173), 2-week complications (1% vs 2%, p = 0.097), need for transplant (24% vs 27%, p = 0.0819) or death (5% vs 13%, p = 0.061). No deaths were related to variceal bleeding or endoscopy. Conclusions: Primary and secondary endoscopic prophylaxis should be considered safe for the prevention of variceal hemorrhage in pediatric portal hypertension. There are differences in outcomes in primary and secondary prophylaxis, but unclear if this is due to patient characteristics versus treatment strategy. Further study is needed to compare safety and efficacy to watchful waiting.

scholarly journals Use and safety of prophylactic endoscopy from a single center serving urban and rural children with portal hypertension

2022 ◽  
Vol 12 (1) ◽  
Author(s):  
Voytek Slowik ◽  
Anissa Bernardez ◽  
Heather Wasserkrug ◽  
Ryan T. Fischer ◽  
James F. Daniel ◽  
...  
Keyword(s):  
Portal Hypertension ◽  
Survival Curve ◽  
Patient Characteristics ◽  
Primary Prophylaxis ◽  
Secondary Prophylaxis ◽  
Rural Children ◽  
Variceal Hemorrhage ◽  
Prophylaxis Group ◽  
Kaplan Meier ◽  
Surveillance Endoscopy

AbstractProphylactic endoscopy is routine in adults with portal hypertension (PHTN), but there is limited data in pediatrics. We sought to describe our experience with prophylactic endoscopy in pediatric PHTN. This is a retrospective study of 87 children who began surveillance endoscopy prior to gastrointestinal bleeding (primary prophylaxis) and 52 who began after an episode of bleeding (secondary prophylaxis) from 01/01/1994 to 07/01/2019. Patients who underwent primary prophylaxis had a lower mean number of endoscopies (3.897 vs 6.269, p = 0.001). The primary prophylaxis group was less likely to require a portosystemic shunt (6% vs 15%, p < 0.001) with no difference in immediate complications (1% vs 2%, p = 0.173) or 2-week complications (1% vs 2%, p = 0.097). No deaths were related to variceal bleeding or endoscopy. Kaplan–Meier Survival Curve suggests improved transplant and shunt free survival in the primary prophylaxis group (log-rank p < 0.001). Primary and secondary endoscopic prophylaxis should be considered safe for the prevention of variceal hemorrhage in pediatric portal hypertension. There are differences in outcomes in primary and secondary prophylaxis, but unclear if this is due to patient characteristics versus treatment strategy. Further study is needed to compare safety and efficacy to watchful waiting.

scholarly journals Pediatric Portal Hypertension

2021 ◽  
Author(s):  
Reda A. Zbaida
Keyword(s):  
Portal Hypertension ◽  
Variceal Bleeding ◽  
Age Groups ◽  
Primary Prophylaxis ◽  
Secondary Prophylaxis ◽  
Age Group ◽  
Pediatric Age ◽  
Pediatric Age Group ◽  
Rex Shunt ◽  
Hepatic Portal

Portal hypertension is increased intravascular pressure of the portal vein. The prevalence of causes in children is different from adults ones. The commonest cause of pediatric portal hypertension is the extra-hepatic portal hypertension, comparing with an adult where liver cirrhosis is the comments cause. Also, taking into consideration, the fundamental physiological differences between the two age groups. These elements are making the attempt to extrapolate the adult guidelines to the pediatric age group unpractical. On the other hand, the limitation of well-designed studies in the pediatric age group makes reaching a consensus about the safety and efficiency of primary prophylaxis of variceal bleeding difficult. In contrast, there were enough data to recommend the secondary prophylaxis of variceal bleeding and the safety and efficiency of Meso-Rex shunt for portal hypertension have been confirmed. These indicate the necessity of further studies to reach a complete algorithm of guidelines for pediatric portal hypertension.

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