scholarly journals Medical Management of Variceal Bleeding in Patients with Cirrhosis

2004 ◽  
Vol 18 (2) ◽  
pp. 109-113 ◽  
Author(s):  
Juan G Abraldes ◽  
Alessandra Dell'Era ◽  
Jaime Bosch
Keyword(s):  
Variceal Bleeding ◽  
Endoscopic Therapy ◽  
Portal Pressure ◽  
Portosystemic Shunt ◽  
Factor Vii ◽  
Injection Sclerotherapy ◽  
Variceal Hemorrhage ◽  
Elastic Band ◽  
Recombinant Activated Factor Vii ◽  
Gastroesophageal Varices

Bleeding from gastroesophageal varices is a frequent and often deadly complication of cirrhosis. The key factor in the natural history of esophageal varices is increased portal pressure, which in cirrhosis is due to the combination of increased hepatic vascular resistance and increased portal collateral blood flow. The maintenance and aggravation of this situation leads to the progressive dilation of the varices and thinning of the variceal wall, until the tension exerted by the variceal wall exceeds the elastic limit of the vessel, leading to variceal hemorrhage. Mortality from a variceal bleeding episode has decreased in the last two decades from 40% to 20% due to the implementation of effective treatments and improvement in the general medical care. Initial treatment should include adequate fluid resuscitation and transfusion to maintain the hematocrit at 25% to 30%, and prophylactic antibiotics (norfloxacin or amoxicillin-clavulanic acid). It is currently recommended that a vasoactive drug be started at the time of admission. Drug therapy may be started during transferal to hospital by medical or paramedical personnel and maintained for up to five days to prevent early rebleeding. Terlipressin, a vasopressin derivative, is the preferred agent because of its safety profile and proven efficacy in improving survival. Somatostatin is as effective as terlipressin, but may require higher than the usually recommended dosage. Octreotide is effective in conjunction with endoscopic therapy, but is the second choice because it has not been shown to reduce mortality. Vasopressin may be used where terlipressin is not available, but should be given in combination with transdermal nitroglycerin. Endoscopic elastic band ligation is the recommended endoscopic treatment, but injection sclerotherapy is still employed in many centres for active variceal bleeding. Failures of medical therapy (drugs plus endoscopic therapy) should undergo a second course of endoscopic therapy before proceeding to transjugular intrahepatic portosystemic shunt or, in rare occasions, to portosystemic shunt surgery. Administration of recombinant activated factor VII may decrease the number of treatment failures among patients with advanced liver failure (Child-Pugh class B and C).

scholarly journals Esophageal Variceal Ligation Monotherapy versus Combined Ligation and Sclerotherapy for the Treatment of Esophageal Varices

2021 ◽  
Vol 2021 ◽  
pp. 1-5
Author(s):  
Jianbo Wang ◽  
Shenghui Chen ◽  
Yehia M. Naga ◽  
Junwei Liu ◽  
Mugen Dai ◽  
...  
Keyword(s):  
Chest Pain ◽  
Hospital Stay ◽  
Esophageal Varices ◽  
Length Of Hospital Stay ◽  
Injection Sclerotherapy ◽  
Endoscopic Variceal Ligation ◽  
Variceal Hemorrhage ◽  
Esophageal Variceal ◽  
Gastroesophageal Varices ◽  
Number Of Treatment

Currently, endoscopic variceal ligation (EVL) monotherapy is the standard therapy for managing esophageal variceal hemorrhage. Patients generally need several sessions of endoscopy to achieve optimal variceal ablation, and the varices can recur afterward. Endoscopic injection sclerotherapy (EIS) is an older technique, associated with certain complications. This study aimed to evaluate the clinical efficacy of EVL alone versus combined EVL and EIS in the treatment of esophageal varices. This retrospective study included 84 patients, of which 40 patients were treated with EVL monotherapy and 44 patients were treated with combined EVL + EIS. The main outcomes were rebleeding rates, recurrence at six months, number of treatment sessions, length of hospital stay, cost of hospitalization, and procedural complications. At six months, the rebleeding rate and recurrence were significantly lower in the EVL + EIS group compared to the EVL group (2.3% versus 15.0%; and 9.1% versus 27.5%, respectively). The number of treatment sessions, length of hospital stay, and cost of hospitalization were significantly lower in the EVL + EIS group compared to those in the EVL group (2.3 ± 0.6 versus 3.2 ± 0.8 times; 14.5 ± 3.4 versus 23.5 ± 5.9 days; and 23918.6 ± 4220.4 versus 26165.2 ± 4765.1 renminbi, respectively). Chest pain was significantly lower in the EVL + EIS group compared to that in the EVL group (15.9% versus 45.0%). There were no statistically significant differences in the presence of fever or esophageal stricture in both groups. In conclusion, combined EVL + EIS showed less rebleeding rates and recurrence at six months and less chest pain and was more cost effective compared to EVL alone in the treatment of gastroesophageal varices.

scholarly journals Transjugular Intrahepatic Portosystemic Shunt (TIPS): Pathophysiologic Basics, Actual Indications and Results with Review of the Literature

2018 ◽  
Vol 190 (08) ◽  
pp. 701-711 ◽  
Author(s):  
Holger Strunk ◽  
Milka Marinova
Keyword(s):  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Endoscopic Therapy ◽  
Secondary Prophylaxis ◽  
Portosystemic Shunt ◽  
Refractory Ascites ◽  
Variceal Hemorrhage ◽  
Line Therapy ◽  
Intrahepatic Portosystemic Shunt ◽  
Pugh Class ◽  
Early Tips

Background Transjugular intrahepatic portosystemic shunt (TIPS) is a non-selective portosystemic shunt created using endovascular techniques. During recent years technical improvements and new insights into pathophysiology have modified indications for TIPS placement. In this article we therefore want to discuss current knowledge. Method A literature review was performed to review and discuss the pathophysiology, indications and results of the TIPS procedure. Results Established TIPS indications are persistent bleeding despite combined pharmacological and endoscopic therapy and rebleeding during the first five days. A new indication in the European recommendations is early TIPS placement within 72 hours, ideally within 24 hours, in patients bleeding from esophageal or gastroesophageal varices at high risk for treatment failure (e. g. Child-Pugh class C < 14 points or Child-Pugh class B with active bleeding) after initial pharmacological and endoscopic therapy. For prevention of recurrent variceal hemorrhage in the recommendations, covered TIPS placement is the treatment of choice only after failed first-line therapy, although numerous TIPS studies show a prolonged time to rebleeding and a reduction of mortality. Similarly for secondary prophylaxis in patients with refractory ascites, covered TIPS placement may be considered only if the patient continues to be intolerant to NSBBs and is an appropriate TIPS candidate even though studies show that the TIPS procedure controls ascites, improves survival and renal function better than paracentesis. Potential indications for TIPS implantation are Budd-Chiari syndrome, acute portal vein thromboses, hydrothorax, hepatopulmonary and hepatorenal syndrome (Typ 2), portal hypertensive gastropathy (PHG) and prophylaxis of complications of abdominal surgery, very rarely bleeding in ectopic varices or in patients with chylothorax or chylous ascites. Conclusion TIPS placement is an established procedure with a new indication as “early TIPS”. In the European recommendations it is only the second-line therapy for prevention of recurrent variceal hemorrhage and for secondary prophylaxis in patients with refractory ascites although several studies showed a clear benefit of the TIPS procedure compared to ligation and NSBBs. Key Points  Citation Format

scholarly journals Emergent Transjugular Intrahepatic Portosystemic Shunt Creation in Acute Variceal Bleeding

2020 ◽  
Vol 37 (01) ◽  
pp. 003-013
Author(s):  
Mithil B. Pandhi ◽  
Andrew J. Kuei ◽  
Andrew J. Lipnik ◽  
Ron C. Gaba
Keyword(s):  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Portosystemic Shunt ◽  
Pharmacologic Therapy ◽  
Variceal Hemorrhage ◽  
Gastroesophageal Varices ◽  
Portal Decompression ◽  
Intrahepatic Portosystemic Shunt ◽  
History Of ◽  
Early Tips

AbstractEmergent transjugular intrahepatic portosystemic shunt (TIPS) creation is most commonly employed in the setting of acute variceal hemorrhage. Given a propensity for decompensation, these patients often require a multidisciplinary, multimodal approach involving prompt diagnosis, pharmacologic therapy, and endoscopic intervention. While successful in the majority of cases, failure to medically control initial bleeding can prompt interventional radiology consultation for emergent portal decompression via TIPS creation. This article discusses TIPS creation in emergent, acute variceal hemorrhage, reviewing the natural history of gastroesophageal varices, presentation and diagnosis of acute variceal hemorrhage, pharmacologic therapy, endoscopic approaches, patient selection and risk stratification for TIPS, technical considerations for TIPS creation, adjunctive embolotherapy, and the role of salvage TIPS versus early TIPS in acute variceal hemorrhage.

TIPS in the Treatment of Variceal Bleeding

2017 ◽  
Vol 01 (04) ◽  
pp. 265-271
Author(s):  
Joseph Morrison ◽  
Andrew Lipnik ◽  
Ron Gaba
Keyword(s):  
Variceal Bleeding ◽  
Selection Criteria ◽  
Gastric Varices ◽  
Portosystemic Shunt ◽  
Variceal Hemorrhage ◽  
Life Threatening ◽  
Intrahepatic Portosystemic Shunt ◽  
Patient Selection Criteria ◽  
Early Tips

AbstractVariceal bleeding is a life-threatening complication of portal hypertension. In recent years, transjugular intrahepatic portosystemic shunt (TIPS) creation has cemented a role in the management of acute refractory bleeding and recurrent variceal hemorrhage. This article aims to review the use of TIPS in patients with variceal bleeding, with a focus on accepted procedure indications, patient selection criteria, TIPS technique, clinical outcomes, and contemporary issues, such as early TIPS in acute variceal hemorrhage, the role of adjuvant embolotherapy, and TIPS utility for gastric varices.

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.

Portal pressure, presence of gastroesophageal varices and variceal bleeding

Hepatology ◽  
1985 ◽  
Vol 5 (3) ◽  
pp. 419-424 ◽  
Author(s):  
Guadalupe Garcia-Tsao ◽  
Roberto J. Groszmann ◽  
Rosemarie L. Fisher ◽  
Harold O. Conn ◽  
Colin E. Atterbury ◽  
...  
Keyword(s):  
Variceal Bleeding ◽  
Portal Pressure ◽  
Gastroesophageal Varices

Therapies: Drugs, Scopes and Transjugular Intrahepatic Portosystemic Shunt - When and How?

2015 ◽  
Vol 33 (4) ◽  
pp. 524-533 ◽  
Author(s):  
Juan G. Abraldes ◽  
Puneeta Tandon
Keyword(s):  
High Risk ◽  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Variceal Bleeding ◽  
Portosystemic Shunt ◽  
Variceal Hemorrhage ◽  
Band Ligation ◽  
First Choice ◽  
Intrahepatic Portosystemic Shunt ◽  
Endoscopic Band Ligation ◽  
Β Blockers

Variceal bleeding is the most serious complication of portal hypertension. All cirrhotic patients should be screened endoscopically for varices which are present in about 30% of compensated and 60% of decompensated patients at diagnosis. In patients without varices, endoscopy surveillance should be continued every 2 years. Patients with high-risk varices (moderate or large in size, or with red color signs, or in Child-Pugh C patients) should be treated with a nonselective β-blocker to prevent bleeding (propranolol, nadolol or carvedilol). Endoscopic banding ligation is also effective for the prevention of first bleeding, and it is the first choice in patients with contraindications or intolerance to β-blockers. Acute variceal hemorrhage still has a high mortality rate (around 15%) and requires intensive care management and conservative blood transfusion policy. Treatment is based on the combined use of vasoactive drugs, endoscopic band ligation and prophylactic antibiotics. Failures are best managed by transjugular intrahepatic portosystemic shunt (TIPS). Balloon tamponade or specifically designed covered esophageal stents can be used as a bridge to definitive therapy in unstable patients. Early, preemptive TIPS might be the first choice in patients at high risk of failure (Child-Pugh B with active bleeding or Child-Pugh C up to 13 points). Patients surviving a variceal bleeding are at high risk of rebleeding. A combination of β-blockers and endoscopic band ligation is the most effective therapeutic approach. Preliminary data suggest that the addition of simvastatin increases survival in these patients.

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 Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt in Patients with Recurrent Variceal Hemorrhage

2013 ◽  
Vol 2013 ◽  
pp. 1-5 ◽  
Author(s):  
Popovič Peter ◽  
Zore Andrej ◽  
Šurlan Popovič Katarina ◽  
Garbajs Manca ◽  
Skok Pavel
Keyword(s):  
Hepatic Encephalopathy ◽  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Endoscopic Therapy ◽  
Observation Time ◽  
Portosystemic Shunt ◽  
Variceal Hemorrhage ◽  
Portosystemic Encephalopathy ◽  
Elective Treatment ◽  
Intrahepatic Portosystemic Shunt ◽  
The Difference

Purpose. The purpose of this study was to determine the incidence and predictors of hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) and endoscopic therapy (ET) in the elective treatment of recurrent variceal hemorrhage.Methods. Seventy patients were treated with elective TIPS and fifty-six patients with ET. Median observation time was 46.28 months in the TIPS group and 42.31 months in the ET group.Results. 30 patients (42.8%) developed clinically evident portosystemic encephalopathy in TIPS group and 20 patients (35.6%) in ET group. The difference between the groups was not statistically significant (P=0.542;χ2test). The incidence of new or worsening portosystemic encephalopathy was 24.3% in TIPS group and 10.7% in ET group. Multivariate analysis showed that ET treatment (P=0.031), age of>65years (P=0.022), pre-existing HE (P=0.045), and Child's class C (P=0.051) values were independent predictors for the occurrence of HE.Conclusions. Procedure-related HE is a complication in a minority of patients treated with TIPS or ET. Patients with increased age, preexisting HE, and higher Child-Pugh score should be carefully observed after TIPS procedure because the risk of post-TIPS HE in these patients is higher.

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