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Abstract
Portal hypertension is a progressively debilitating complication of cirrhosis and a principal cause of mortality in patients who have hepatic decompensation. This article describes the classification system and pathophysiology of portal hypertension. It also discusses a practical approach to prevention of first variceal hemorrhage, general management of the acute bleeding episode, and secondary prophylaxis to prevent rebleeding. Pharmacologic, endoscopic, radiologic, and surgical modalities are all described in detail.
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Zhang Y, Wen T, Yan L, Chen Z, Yang H, Deng X, Liang G, Li G, Zhang X, Ran S, Liao Z. The changes of hepatic hemodynamics and functional hepatic reserve after splenectomy with periesophagogastric devascularization. HEPATO-GASTROENTEROLOGY 2009; 56:835-839. [PMID: 19621712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND/AIMS The results of much research on the variation of the hepatic hemodynamic and functional hepatic reserve after splenectomy with periesophagogastric devascularization are very different, some are even converse. The purpose of this study is to observe the variation. METHODOLOGY From July 2006 to August 2007, thirty patients with portal hypertension caused by hepatitis B cirrhosis underwent splenectomy with periesophagogastric devascularization in our medical group in West China Hospital of Sichuan University. The PVPG (portal venous pressure gradient) was measured by inductor continually during operation. Moreover, the HAF (hepatic artery flow), PVF (portal venous flow) and hepatic arterial RI (resistant index) were measured with Doppler sonography. The EHBF (effective hepatic blood flow) and ICGR15 (indocyanine green retention rate at 15 minutes) were obtained respectively by indocyanine green clearance test before and after the operation. The MELD (model for end stage liver disease) score was calculated at the same time. RESULTS The four values of PVPG after laparotomy, ligating the splenic artery, splenectomy and periesophagogastric devascularization showed a tendency to decrease progressively. The PVF decreased and HAF increased in compensation after operation. The EHBF increased, and both the ICGR15 and the MELD score decreased postoperatively. CONCLUSIONS After splenectomy with periesophagogastric devascularization, the functional hepatic reserve increases at least in the short term notwithstanding the PVPG and PVF decrease.
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Conn HO. Why do varices bleed? Rational therapy based on objective observations. ACTA MEDICA SCANDINAVICA. SUPPLEMENTUM 2009; 703:135-48. [PMID: 3879098 DOI: 10.1111/j.0954-6820.1985.tb08911.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Lu HY, Tian XL, Zhang CX, Xu XY. [Study on the relation between hemodynamics of portal system and cirrhosis portal hypertension]. ZHONGHUA GAN ZANG BING ZA ZHI = ZHONGHUA GANZANGBING ZAZHI = CHINESE JOURNAL OF HEPATOLOGY 2009; 17:306-307. [PMID: 19403033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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Kawaoka T, Takahashi S, Aikata H, Azakami T, Saneto H, Takaki S, Jeong SC, Asahara T, Ito K, Chayama K. Beneficial effects of living-donor liver transplantation on esophageal varices. J Gastroenterol 2009; 43:982-9. [PMID: 19107343 DOI: 10.1007/s00535-008-2269-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2008] [Accepted: 07/22/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND Liver transplantation (LT) is known to improve bleeding esophageal varices (EVs) and portal hypertension. However, many issues related to EVs after LT remain unresolved, such as whether LT reduces blood supply to EVs, improves the diameter of unruptured EVs, or improves or worsens EVs. The aim of this retrospective study was to determine the effects of living-donor liver transplantation (LDLT) in patients with hepatic failure on EVs and inflow vessels to EVs and the factors associated with deterioration of EVs after LDLT. METHODS The study subjects were 35 patients with cirrhosis who underwent LDLT. Endoscopy and multidetector helical computed tomography (MDCT) were performed before and after LDLT. The diameter of the inflow vessel of EVs was measured by MDCT before and after LDLT, together with the LDLT-related reduction rate of the diameter of the gastric vein (RRGV). RESULTS Endoscopic examination showed improvement of EVs in 30 of 35 (86%) patients. RRGV improved in 17/35 (49%) patients, did not change in 13/35 (37%), and deteriorated in 5/35 (14%). The cause of RRGV deterioration seemed to be either the complication of portal vein or graft failure. In patients examined endoscopically at >1 year after LDLT, improvement of EVs was associated with significant changes in the rate of reduction of the major inflow vessel diameter and Child-Pugh score, compared with those who showed no improvement. CONCLUSIONS LDLT results in improvement of EVs. EVs improved in 86% of the patients. Measurement of RRGV with MDCT is a good tool for prediction of EV improvement after LDLT.
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Alatsakis M, Ballas KD, Pavlidis TE, Psarras K, Rafailidis S, Tzioufa-Asimakopoulou V, Marakis GN, Sakantamis AK. Early propranolol administration does not prevent development of esophageal varices in cirrhotic rats. Eur Surg Res 2009; 42:11-6. [PMID: 18971580 DOI: 10.1159/000166165] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2007] [Accepted: 08/04/2008] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS Variceal bleeding is the most serious complication of portal hypertension associated with high mortality. This study was conducted to investigate any protective effect of early propranolol administration in the development and degree of esophageal varices in cirrhotic rats with portal hypertension. This topic is controversial in the literature. METHODS For the development of liver cirrhosis and esophageal varices, 60 rats underwent ligation of the left adrenal vein and complete devascularization of the left renal vein, followed by phenobarbital and carbon tetrachloride (CCl(4)) administration. This operation enhances the development of cephalad collaterals, responsible for the induction of esophageal varices. After 2 weeks of CCl(4) administration, the rats were randomly separated into 2 groups. In group I, propranolol was continuously administered intragastrically throughout the study, whereas in group II normal saline (placebo) was administered instead. Cirrhosis was detected clinically by ascites development. Hemodynamic studies and morphometric analysis of the lower esophagus were performed after complete induction of cirrhosis, measuring the following parameters: portal pressure, total number of submucosal veins, total submucosal vessel area, mean cross-sectional submucosal vessel area, relative submucosal area (percentage) occupied by vessels and area of the single most dilated submucosal vein. RESULTS The statistical analysis revealed no statistically important difference between the 2 groups for the morphometrically studied parameters. However, portal venous pressure was lower in group I. CONCLUSION Early propranolol administration did not protect rats from developing esophageal varices, despite the fact that a significant decrease in portal pressure was detected.
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Kawaguchi T, Taniguchi E, Itou M, Ibi R, Okada T, Mutou M, Shiraishi S, Uchida Y, Otsuka M, Umeki Y, Oriishi T, Hayabuchi H, Tanaka S, Takakura M, Sata M. Body cell mass is a useful parameter for assessing malnutrition and severity of disease in non-ascitic cirrhotic patients with hepatocellular carcinoma or esophageal varices. Int J Mol Med 2008; 22:589-594. [PMID: 18949378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
Body cell mass (BCM) is a nutritional parameter, however, changes in BCM in patients with non-ascitic liver cirrhosis (LC) in comparison to patients with other malnutritional diseases remains unclear. We investigated the difference in BCM between patients with LC and malnourished gastrointestinal disease controls (M.CON), and examined the relationship between BCM and the severity of LC. Results demonstrated that serum nutritional parameters were not significantly different between the LC (n=56) and M.CON groups (n=25), whereas BCM%BW was significantly lower in the LC group than in the M.CON group (50.9+/-4.6 vs. 54.4+/-7.1%, P=0.018). Furthermore, BCM%BW negatively correlated with the model for end-stage liver disease (MELD) score (P=0.04). In concluson, BCM showed a significant decrease and a negative correlation with the MELD score in the LC group. BCM may be a useful parameter for assessing malnutrition and severity of LC.
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Marques P, Maluf-Filho F, Kumar A, Matuguma SE, Sakai P, Ishioka S. Long-term outcomes of acute gastric variceal bleeding in 48 patients following treatment with cyanoacrylate. Dig Dis Sci 2008; 53:544-50. [PMID: 17597405 DOI: 10.1007/s10620-007-9882-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2007] [Accepted: 05/14/2007] [Indexed: 12/12/2022]
Abstract
OBJECTIVES (1) Study the effectiveness of intravariceal injection of n-butyl-2-cyanoacrylate to treat acute gastric variceal (GV) bleeding and (2) study the impact of the type of GV and hepatic function on endoscopic hemostasis and mortality outcomes. METHODS Fourty-eight patients with acute GV bleeding underwent intravariceal injection of n-butyl-2-cyanoacrylate and were followed until death or study conclusion (12-52 months). RESULTS Primary hemostasis (no re-bleeding within 48 h) was accomplished in 42 patients (87.5%). Appearance of the bleeding site at the time of initial endoscopy, grade of cirrhosis and location of GV were not significant predictors of immediate hemostasis. Early re-bleeding (48 h to 6 weeks) occurred in 20.5% of patients and late re-bleeding (beyond 6 weeks) in 20.5% of patients. While the Child-Pugh score was predictive of re-bleeding and mortality, the type of GV and stigmata at initial endoscopy were not significant predictors of re-bleeding and mortality. Over a mean follow-up of 18 months, mortality rates were 43.9% and bleeding was the commonest cause of death. CONCLUSION Endoscopic injection of n-butyl-2-cyanoacrylate is effective and safe for treating bleeding GV. Patients with poor hepatic function are at higher risk of re-bleeding and death after acute gastric variceal bleed.
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Zherlov GK, Koshevoĭ AP, Sokolov SA, Zykov DV, Karpovich AV, Zherlova TG. [The function of gastric stump and duodenum after proximal gastric resection in patients with esophageal and gastric varicose veins dilatation]. Khirurgiia (Mosk) 2008:38-43. [PMID: 18833147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
The authors had developed the technique of proximal gastric resection with cardiac orifice plasty. 21 patients with esophageal and varicose veins dilatation were operated on using the technique. Follow-up period came from 2 to 23 years. Results of the operation allow proximal gastric resection with cardiac orifice plasty to be considered the effective way of prevention and treatment of gastric bleedings of portal hypertension aetiology.
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Berzigotti A, Merkel C, Magalotti D, Tiani C, Gaiani S, Sacerdoti D, Zoli M. New abdominal collaterals at ultrasound: a clue of progression of portal hypertension. Dig Liver Dis 2008; 40:62-7. [PMID: 17913603 DOI: 10.1016/j.dld.2007.08.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2007] [Revised: 08/07/2007] [Accepted: 08/22/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Abdominal ultrasound can detect non-invasively the presence of abdominal portal-systemic collaterals in patients with liver cirrhosis. Abdominal portal-systemic collaterals may be protective from the formation and growth of oesophageal varices, but available data are inconclusive. AIM We aimed at investigating the relationship between abdominal portal-systemic collaterals and variceal formation and growth. METHODS We studied 126 cirrhotic patients without (n=43) or with small (n=83) oesophageal varices who entered a protocol of serial ultrasonographic and endoscopic examinations for a median of 55 months. Presence and kind of abdominal portal-systemic collaterals was recorded on first ultrasonography and on each control thereafter. RESULTS At inclusion, abdominal portal-systemic collaterals were found in 19/43 patients without varices and in 23/83 patients with small varices (NS). There was no difference in variceal formation and growth between patients with and without abdominal portal-systemic collaterals at inclusion. However, patients developing new abdominal portal-systemic collaterals during follow-up had a significantly higher rate of variceal formation (56.2% vs. 22.2%; p=0.024) and growth (52.9% vs. 30.6%; p=0.041) compared with patients with unchanged ultrasonography. CONCLUSIONS Abdominal collaterals are not protective from the formation or growth of oesophageal varices. Conversely, new abdominal portal-systemic collaterals emergence is a non-invasive clue of formation and progression of varices. Therefore, endoscopy is probably indicated whenever new abdominal portal-systemic collaterals are detected in cirrhotic patients.
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Filipenko PS. [Hemorrhage from esophageal varices]. KLINICHESKAIA MEDITSINA 2008; 86:17-22. [PMID: 18326277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
The lecture deals with the ethiology and pathogenesis of portal hypertension (PH). Three variants of PH are distinguished. Endoscopic signs of PH and esophageal varicosis are described. The clinical picture of hemorrhage from the esophageal varices veins (EP) and kinds of pharmaceutical, endoscopic, and urgent surgical aid are described. Primary and secondary prophylaxis of hemorrhage from EV is covered.
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Zhu KS, Meng XC, Zhang JS, Guan SH, Li ZR, He KK, Pang PF, Jiang ZB, Huang MS, Shan H. [The role of multi-detector row CT in the diagnosis and hemodynamic studies of gastric varices in portal hypertension]. ZHONGHUA YI XUE ZA ZHI 2007; 87:3251-3255. [PMID: 18396618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To evaluate the value of multi-detector row CT (MDCT) in the diagnosis and hemodynamic studies of gastric varices (GV) in portal hypertension by comparison with endoscopy and DSA direct portography. METHODS Thirty-six consecutive cirrhotic patients with GV confirmed by endoscopy underwent tri-phase contrast-enhanced CT scans and CT portography (CTP) within 2 weeks after endoscopy examination. Three independent experienced radiologists, who were blinded to the patients' clinical data, analyzed the CT images, including the size and location of GV as well as afferent and efferent veins of GV, separately. Interobserver agreement among the 3 radiologists with regard to the diagnosis of submucosal and perigastric GV was determined by Kappa (k) values. The findings of endoscopy were used as standards. RESULTS Sub mucosal GV was diagnosed in 34 of the 36 patients (94.4%) and perigastric GV in all 36 patients (100%) by the observation of the 3 radiologists. MDCT showed an excellent interobserver reliability with regard to the diagnosis of submucosal GV (kappa = 0.85) and perigastric GV (kappa = 1.0). Agreement between MDCT and endoscopy with regard to the opacification of variceal size and location were 86.1% and 88.9% respectively. The sensitivity, specificity, accuracy, and positive predictive value of CTP in the opacification of afferent and efferent veins of GV were all more than 80%. The frequencies of participation of posterior gastric vein and short gastric vein in blood supply to gastric fundal varices in the isolated gastric varices and gastroesophageal varices type 2 (GEV2) were 94.1% and 70.6% respectively, both significantly higher than those in the gastroesophageal varices type 1 (GEV1, 52.6% and 31.6%, respectively, both P < 0.05). The main blood drainage route of GEV1 was via azygous system into the super vena cava (100%), whereas in the gastric fundal varices the main blood drainage route was via the gastrorenal shunts into the inferior vena cava (82.4%). CONCLUSION MDCT can be used as an important tool for detecting submucosal and perigastric GV, and can clearly reveal the size, location, and hemodynamics of GV.
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de Cleva R, Herman P, D'albuquerque LAC, Pugliese V, Santarem OL, Saad WA. Pre- and postoperative systemic hemodynamic evaluation in patients subjected to esophagogastric devascularization plus splenectomy and distal splenorenal shunt: A comparative study in schistomomal portal hypertension. World J Gastroenterol 2007; 13:5471-5. [PMID: 17907290 PMCID: PMC4171281 DOI: 10.3748/wjg.v13.i41.5471] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the systemic hemodynamic effects of two surgical procedures largely employed for treatment of schistosomal portal hypertension.
METHODS: Thirty-six patients undergoing elective surgical treatment of portal hypertension due to hepatosplenic mansonic schistosomiasis were prospectively evaluated. All patients were subjected to preoperative pulmonary artery catheterization; 17 were submitted to esophagogastric devascularization and splenectomy (EGDS) and 19 to distal splenorenal shunt (DSRS). The systemic hemodynamic assessment was repeated 4 d after the surgical procedure.
RESULTS: Preoperative evaluation revealed (mean ± SD) an increased cardiac index (4.78 ± 1.13 L/min per m2), associated with a reduction in systemic vascular resistance index (1457 ± 380.7 dynes.s/cm5.m2). The mean pulmonary artery pressure (18 ± 5.1 mmHg) as well as the right atrial pressure (7.9 ± 2.5 mmHg) were increased, while the pulmonary vascular resistance index (133 ± 62 dynes.s/cm5.m2) was decreased. Four days after EGDS, a significant reduction in cardiac index (3.80 ± 0.4 L/min per m2, P < 0.001) and increase in systemic vascular resistance index (1901.4 ± 330.2 dynes.s/cm5.m2, P < 0.001) toward normal levels were observed. There was also a significant reduction in pulmonary artery pressure (12.65 ± 4.7 mmHg, P < 0.001) and no significant changes in the pulmonary vascular resistance index (141.6 ± 102.9 dynes.s/cm5.m2). Four days after DSRS, a non-significant increase in cardiac index (5.2 ± 0.76 L/min per m2) and systemic vascular resistance index (1389 ± 311 dynes.s/cm5.m2) was observed. There was also a non-significant increase in pulmonary artery pressure (19.84 ± 5.2 mmHg), right cardiac work index (1.38 ± 0.4 kg.m/m2) and right ventricular systolic work index (16.3 ± 6.3 g.m/m2), without significant changes in the pulmonary vascular resistance index (139.7 ± 67.8 dynes.s/cm5.m2).
CONCLUSION: The hyperdynamic circulatory state observed in mansonic schistosomiasis was corrected by EGDS, but was maintained in patients who underwent DSRS. Similarly, the elevated mean pulmonary artery pressure was corrected after EGDS and maintained after DSRS. EGDS seems to be the most physiologic surgery for patients with schistosomal portal hypertension.
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Vorobioff JD, Ferretti SE, Zangroniz P, Gamen M, Picabea E, Bessone FO, Reggiardo V, Diez AR, Tanno M, Cuesta C, Tanno HE. Octreotide enhances portal pressure reduction induced by propranolol in cirrhosis: a randomized, controlled trial. Am J Gastroenterol 2007; 102:2206-13. [PMID: 17608776 DOI: 10.1111/j.1572-0241.2007.01390.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND In vitro, octreotide potentiates vasoconstriction in isolated, preconstricted, mesenteric arterial vessels. In cirrhotic patients, portal pressure (HVPG) reduction induced by propranolol is partly due to splanchnic vasoconstriction. AIM To evaluate HVPG effects of octreotide administration in cirrhotic patients receiving long-term propranolol. PATIENTS AND METHODS A randomized, controlled trial. First study: a total of 28 patients were studied at baseline and 30 and 60 minutes after octreotide (200 mug) (N = 14) or placebo (N = 14) and then treated with propranolol for approximately 30 days (106 +/- 5 mg/day). Second study: after baseline evaluation patients received octreotide or placebo as they were assigned to in the first study and measurements repeated 30 and 60 minutes later. RESULTS In the first study baseline HVPG was 18.7 +/- 0.9 mmHg and decreased to 17.1 +/- 1.1 mmHg and 17.1 +/- 1.0 mmHg (both P < 0.05 vs baseline) at 30 and 60 minutes after octreotide, respectively. Eight patients decreased their HVPG after octreotide. In the second study baseline HVPG was 15.6 +/- 1.3 mmHg (P < 0.01 vs baseline HVPG in first study) and decreased to 14.1 +/- 1.2 mmHg and 14.1 +/- 1.3 mmHg (25.7 +/- 5% lower than baseline HVPG in the first study, P < 0.01) (both P < 0.05 vs baseline) at 30 and 60 minutes after octreotide, respectively. Nine patients (2 responders/7 nonresponders to propranolol) decreased their HVPG after octreotide. Octreotide effects may be mediated by potentiation and additive mechanisms. CONCLUSIONS Octreotide enhances HVPG reduction induced by propranolol in cirrhotic patients.
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Biecker E, Roth F, Heller J, Schild HH, Sauerbruch T, Schepke M. Prognostic role of the initial portal pressure gradient reduction after TIPS in patients with cirrhosis. Eur J Gastroenterol Hepatol 2007; 19:846-52. [PMID: 17873607 DOI: 10.1097/meg.0b013e3282eeb488] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The aim of this study was to determine the prognostic relevance of the portal pressure gradient (PPG) before and after transjugular intrahepatic portosystemic stent shunt (TIPS) insertion in patients with liver cirrhosis and recurrent oesophageal variceal bleeding. METHODS 118 cirrhotic patients (Child A/B/C, 41/56/21; Child score, 7.7+/-2.0; baseline PPG, 21.8+/-4.7 mmHg) underwent TIPS for the prevention of variceal rebleeding. A multivariate logistic regression analysis was applied to identify the independent determinants of rebleeding and survival. The estimated rebleeding rate and the estimated survival were compared by log-rank testing. RESULTS TIPS insertion reduced the PPG by 53.2+/-17.7%. During follow-up 21 patients suffered significant rebleeding (17.8%); bleeding-related mortality was 3.4% (four patients). The median survival [95% confidence intervals (CI)] was 48.2 (39.8; 60.8) months. The multivariate Cox model identified creatinine as the only independent predictor of survival, and the initial decrease of the PPG after TIPS as the only independent predictor of rebleeding. PPG before TIPS (21.8+/-4.7 mmHg) and the gradient at the time of rebleeding (22.0+/-2.9 mmHg) did not differ significantly. Patients with an initial decrease of the PPG after TIPS <30% were at the highest risk for rebleeding. Patients with an initial decrease of the PPG >60% rarely suffered from rebleeding. CONCLUSIONS The initial decrease in the PPG after TIPS is a predictor for the risk of rebleeding but not for survival after TIPS. For that reason, in patients undergoing TIPS placement for the prevention of recurrent bleeding from oesophageal varices, an initial reduction of the PPG of 30-50% should be attempted.
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Kogo M, Sato N, Yoneyama K, Imawari M, Kiuchi Y. Bleeding index after the first course of endoscopic treatment for esophageal varices in liver cirrhotic patients with and without hepatocellular carcinoma. HEPATO-GASTROENTEROLOGY 2007; 54:2049-2054. [PMID: 18251158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND/AIMS We retrospectively evaluated variable clinical data on admission to reliably predict bleeding from esophageal varices after the first course of endoscopic treatment in liver cirrhosis patients with and without hepatocellular carcinoma. METHODOLOGY We analyzed 27 clinical factors from the medical records of 118 patients who received their first course of endoscopic treatment for esophageal varices. Factors significantly related to bleeding were extracted using Cox's regression model, and the bleeding index was prepared by combining these factors. RESULTS The cumulative nonbleeding rates after treatment for esophageal varices were 82.1% at 1 year, 64.6% at 3 years and 53.7% at 5 years. By the multivariate analysis, age, the presence of hepatocellular carcinoma, hemoglobin, lactate dehydrogenase and alpha-fetoprotein were selected as significant factors that contributed independently to the post-therapeutic bleeding from esophageal varices (P<0.05). The bleeding index was calculated using the following formula: bleeding index = - 0.045 x Age + 0.934 x hepatocellular carcinoma - 0.151 x hemoglobin + 0.108 x lactate dehydrogenase + 0.842 x alpha-fetoprotein. CONCLUSIONS The bleeding index, based on 5 factors, will in future be an appropriate index to predict the post-therapeutic bleeding from esophageal varices.
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Bellis L, Nicodemo S, Galossi A, Guarisco R, Spilabotti L, Durola L, Dell'Unto O, Puoti C. Hepatic venous pressure gradient does not correlate with the presence and the severity of portal hypertensive gastropathy in patients with liver cirrhosis. JOURNAL OF GASTROINTESTINAL AND LIVER DISEASES : JGLD 2007; 16:273-277. [PMID: 17925921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND AND AIMS To evaluate whether the hepatic venous pressure gradient (HVPG) differs between cirrhotic patients with severe portal hypertensive gastropathy (PHG) and those with mild or absent PHG. METHODS 59 cirrhotic patients with portal hypertension underwent hepatic vein catheterisation. 44 patients (76%) had PHG (16 mild and 28 severe). SETTING tertiary care setting (Liver Unit, Internal Medicine). RESULTS HVPG values did not differ between the patients without PHG (21.6 +/- 10.1 mmHg) and those with PHG (18.6 +/- 9.1 mmHg), nor between those with mild (19.3 +/- 4.3 mmHg) or severe PHG (17.7 +/- 4.6 mmHg; p = 0.26). The overall prevalence of PHG and the proportion of patients with severe PHG did not differ regarding the Child Pugh classification. The etiology of the cirrhosis did not influence the HVPG. No correlations were found between HVPG values and Child Pugh score, age, platelet count, prothrombin time, bilirubin levels and ALT values. The HVPG did not differ between patients with small, medium or large esophageal varices, nor between subjects with or without gastric varices. CONCLUSIONS Our data show that PHG does not correlate with the degree of portal pressure, and that the prevalence and the severity of this condition are not influenced by the severity of underlying liver disease or by the size of varices.
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Bureau C, Garcia Pagan JC, Layrargues GP, Metivier S, Bellot P, Perreault P, Otal P, Abraldes JG, Peron JM, Rousseau H, Bosch J, Vinel JP. Patency of stents covered with polytetrafluoroethylene in patients treated by transjugular intrahepatic portosystemic shunts: long-term results of a randomized multicentre study. Liver Int 2007; 27:742-7. [PMID: 17617116 DOI: 10.1111/j.1478-3231.2007.01522.x] [Citation(s) in RCA: 206] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
An 80% dysfunction rate at 2 years limits the use of transjugular intrahepatic portosystemic shunts (TIPS) in the treatment of complications of portal hypertension. The use of covered stents could improve shunt patency; however, long-term effect and safety remain unknown. Eighty patients randomized to be treated by TIPS either with a covered stent (Group 1) or an uncovered prosthesis (Group 2) were followed-up for 2 years. Doppler US was performed every 3 months. Angiography and portosystemic pressure gradient measurement were performed every 6 months or whenever dysfunction was suspected. Actuarial rates of primary patency in Groups 1 and 2 were 76% and 36% respectively (P=0.001). Clinical relapse occurred in four patients (10%) in Group 1 and 12 (29%) in Group 2 (P<0.05). Actuarial rates of being free of encephalopathy were 67% in Group 1 and 51% in Group 2 (P<0.05). Probability of survival was 58% and 45% at 2 years, respectively, in Groups 1 and 2 (NS). The mean Child-Pugh score improved only in Group 1 (from 8.1+/-1.6 to 7+/-2.2 at 2 years -P<0.05). We also compared the Doppler-US parameters between patent and dysfunctioning shunts. In patent shunts, the mean velocity within the portal vein was significantly higher but the performance of Doppler-US was not accurate enough to predict shunt dysfunction. In conclusion, the improvement in TIPS patency by using covered prostheses is maintained over time with a decreased risk of encephalopathy, while the risk of death was not increased.
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Ripoll C, Groszmann R, Garcia-Tsao G, Grace N, Burroughs A, Planas R, Escorsell A, Garcia-Pagan JC, Makuch R, Patch D, Matloff DS, Bosch J. Hepatic venous pressure gradient predicts clinical decompensation in patients with compensated cirrhosis. Gastroenterology 2007; 133:481-8. [PMID: 17681169 DOI: 10.1053/j.gastro.2007.05.024] [Citation(s) in RCA: 703] [Impact Index Per Article: 41.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2006] [Accepted: 04/26/2007] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Our aim was to identify predictors of clinical decompensation (defined as the development of ascites, variceal hemorrhage [VH], or hepatic encephalopathy [HE]) in patients with compensated cirrhosis and with portal hypertension as determined by the hepatic venous pressure gradient (HVPG). METHODS We analyzed 213 patients with compensated cirrhosis and portal hypertension but without varices included in a trial evaluating the use of beta-blockers in preventing varices. All had baseline laboratory tests and HVPG. Patients were followed prospectively every 3 months until development of varices or VH or end of study. To have complete information, until study termination, about clinical decompensation, medical record review was done. Patients who underwent liver transplantation without decompensation were censored at transplantation. Cox regression models were developed to identify predictors of clinical decompensation. Receiver operating characteristic (ROC) curves were constructed to evaluate diagnostic capacity of HVPG. RESULTS Median follow-up time of 51.1 months. Sixty-two (29%) of 213 patients developed decompensation: 46 (21.6%) ascites, 6 (3%) VH, 17 (8%) HE. Ten patients received a transplant and 12 died without clinical decompensation. Median HVPG at baseline was 11 mm Hg (range, 6-25 mm Hg). On multivariate analysis, 3 predictors of decompensation were identified: HVPG (hazard ratio [HR], 1.11; 95% confidence interval [CI], 1.05-1.17), model of end-stage liver disease (MELD) (HR, 1.15; 95% CI, 1.03-1.29), and albumin (HR, 0.37; 95% CI, 0.22-0.62). Diagnostic capacity of HVPG was greater than for MELD or Child-Pugh score. CONCLUSIONS HVPG, MELD, and albumin independently predict clinical decompensation in patients with compensated cirrhosis. Patients with an HVPG <10 mm Hg have a 90% probability of not developing clinical decompensation in a median follow-up of 4 years.
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Maruyama H, Yokosuka O. Current management of gastric varices. JNMA J Nepal Med Assoc 2007; 46:143-150. [PMID: 18274572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
Gastric varices are a major hemodynamic feature in patients with portal hypertension. Its incidence as well as bleeding rate is lower than that of esophageal varices. However, rupture of gastric varices sometimes results in very serious consequences in the clinical course and its management is very important. Recent developments in imaging technology have made it possible to evaluate the portal hemodynamics in detail by less invasive procedure. Furthermore, advancements in medical instruments and technologies have led to the development of endoscopic ligation devices, interventional radiology techniques like transjugular intrahepatic portosystemic shunt and balloon-occluded retrograde transvenous obliteration, and skills in surgical treatments. This overview will focus on the classification, pathophysiology, current management of gastric varices, and treatments in patient with portal hypertension.
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Tanoue S, Kiyosue H, Matsumoto S, Hori Y, Okahara M, Kashiwagi J, Mori H. Development of a new coaxial balloon catheter system for balloon-occluded retrograde transvenous obliteration (B-RTO). Cardiovasc Intervent Radiol 2007; 29:991-6. [PMID: 16736100 DOI: 10.1007/s00270-005-0039-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To develop a new coaxial balloon catheter system and evaluate its clinical feasibility for balloon-occluded retrograde transvenous obliteration (B-RTO). METHODS A coaxial balloon catheter system was constructed with 9 Fr guiding balloon catheter and 5 Fr balloon catheter. A 5 Fr catheter has a high flexibility and can be coaxially inserted into the guiding catheter in advance. The catheter balloons are made of natural rubber and can be inflated to 2 cm (guiding) and 1 cm (5 Fr) maximum diameter. Between July 2003 and April 2005, 8 consecutive patients (6 men, 2 women; age range 33-72 years, mean age 55.5 years) underwent B-RTO using the balloon catheter system. Five percent ethanolamine oleate iopamidol (EOI) was used as sclerosing agent. The procedures, including maneuverability of the catheter, amount of injected sclerosing agent, necessity for coil embolization of collateral draining veins, and initial clinical results, were evaluated retrospectively. The occlusion rate was assessed by postcontrast CT within 2 weeks after B-RTO. RESULTS The balloon catheter could be advanced into the proximal potion of the gastrorenal shunt beyond the collateral draining vein in all cases. The amount of injected EOI ranged from 3 to 34 ml. Coil embolization of the collateral draining vein was required in 2 cases. Complete obliteration of gastric varices on initial follow-up CT was obtained in 7 cases. The remaining case required re-treatment that resulted in complete obstruction of the varices after the second B-RTO. No procedure-related complications were observed. CONCLUSION B-RTO using the new coaxial balloon catheter is feasible. Gastric varices can be treated more simply by using this catheter system.
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Zuberi BF. Hemodynamic effects of terlipressin in patients with bleeding esophageal varices secondary to cirrhosis of liver. J Coll Physicians Surg Pak 2007; 17:385; author reply 385-6. [PMID: 17623601 DOI: 06.2007/jcpsp.388389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
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Kong D, Xu J, Fu Z, He B, Sun B, Zhang L, Xie Y. [A study of manometry of esophageal varices based on computer vision]. SHENG WU YI XUE GONG CHENG XUE ZA ZHI = JOURNAL OF BIOMEDICAL ENGINEERING = SHENGWU YIXUE GONGCHENGXUE ZAZHI 2007; 24:519-21. [PMID: 17713252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Non-invasive manometry of esophageal varices is a cynosure of researchers. This paper develops a method based on computer vision. Experiments results reveal that correct pressure value can be got quickly.
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Albillos A, Bañares R, González M, Ripoll C, Gonzalez R, Catalina MV, Molinero LM. Value of the hepatic venous pressure gradient to monitor drug therapy for portal hypertension: a meta-analysis. Am J Gastroenterol 2007; 102:1116-26. [PMID: 17391317 DOI: 10.1111/j.1572-0241.2007.01191.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The use of the hepatic venous pressure gradient (HVPG) to assess the efficacy of the pharmacological treatment of portal hypertension in cirrhosis is controversial. Our aim was to establish whether target HVPG reduction predicts variceal bleeding in cirrhotic patients receiving variceal bleeding prophylaxis. METHODS Data sources were MEDLINE, EMBASE, Cochrane Controlled Trials Register, citation lists, and abstracts (most recent search March 2006). Cohorts of patients on drug therapy from randomized and nonrandomized studies correlating variceal bleeding and HVPG change were used. Heterogeneity was explored by metaregression analysis. RESULTS Ten studies totaling 595 patients undergoing two HVPG measurements were identified. The RR of bleeding was lower in patients achieving an overall (HVPG <or=12 mmHg or decrease >or=20%) (0.27, 95% CI 0.14-0.52), complete (HVPG <or=12 mmHg) (0.48, CI 0.28-0.81), or partial (HVPG decrease >or=20%) (0.41, CI 0.20-0.81) response, with significant heterogeneity. Regression analysis identified the interval between the HVPG measurements significantly associated with the RR of bleeding. Heterogeneity was no longer significant after exclusion of an outlier trial, which showed the longest interval to HVPG remeasurement and the lowest quality score. Even considering nonvaluable patients because of bleeding as HVPG responders, the RR of bleeding was lower in overall responders than in nonresponders (0.66, CI 0.51-0.86). Overall response was associated with lower liver-related mortality (RR 0.58, CI 0.37-0.91). CONCLUSIONS Current evidence supports the validity of HVPG end points to monitor drug therapy efficacy for variceal bleeding prophylaxis. HVPG monitoring also provides valuable prognostic information.
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Javvaji S, Kumar A, Madan K, Garg PK, Acharya SK. Management of gastric variceal bleeding. TROPICAL GASTROENTEROLOGY : OFFICIAL JOURNAL OF THE DIGESTIVE DISEASES FOUNDATION 2007; 28:51-57. [PMID: 18050839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Abstract
Variceal bleeding is a frequent and life-threatening complication of portal hypertension. The first episode of variceal bleeding is associated not only with a high mortality, but also with a high recurrence rate in those who survive. Therefore, management should focus on different therapeutic strategies aiming to prevent the first episode of variceal bleeding (primary prophylaxis), to control hemorrhage during the acute bleeding episode (emergency treatment), and to prevent rebleeding (secondary prophylaxis). These strategies involve pharmacological, endoscopic, surgical, and interventional radiological modalities. This article reviews management of acute variceal bleeding.
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Wong RCK, Farooq FT, Chak A. Endoscopic Doppler US probe for the diagnosis of gastric varices (with videos). Gastrointest Endosc 2007; 65:491-6. [PMID: 17321253 DOI: 10.1016/j.gie.2006.11.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2006] [Accepted: 11/04/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastric varices may appear similar to enlarged gastric folds and submucosal neoplasms at endoscopy. A simple endoscopic method to diagnose variceal blood flow without formal EUS could be clinically useful. OBJECTIVE To demonstrate the use of Doppler US (DOP-US) in the diagnosis of gastric varices. DESIGN Case series. SETTING A tertiary-care U.S. academic medical center. PATIENTS Eight patients with findings of gastric submucosal lesions of uncertain etiology on EGD. INTERVENTIONS EGD with DOP-US examination, with or without standard EUS. MAIN OUTCOME MEASUREMENTS Presence or absence of audible DOP-US signal and EUS findings for gastric submucosal lesions. RESULTS DOP-US demonstrated a reproducible continuous venous hum in 5 cases of gastric varices (confirmed by EUS in 2 cases). A sixth case of gastric varices demonstrated pulsatile flow with DOP-US (confirmed by EUS). In 1 case of a GI stromal tumor (GIST) in the stomach, no signal was heard when the lesion itself was examined by DOP-US. In a final case of Menetrier's disease, no signal was heard when the giant gastric folds were examined. CONCLUSIONS DOP-US can help differentiate gastric varices from other gastric submucosal lesions. The use of DOP-US may obviate the need for EUS to confirm gastric varices when the EGD diagnosis is uncertain.
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Kuramochi A, Imazu H, Kakutani H, Uchiyama Y, Hino S, Urashima M. Color Doppler endoscopic ultrasonography in identifying groups at a high-risk of recurrence of esophageal varices after endoscopic treatment. J Gastroenterol 2007; 42:219-24. [PMID: 17380280 DOI: 10.1007/s00535-006-1992-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2006] [Accepted: 12/04/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND Our preliminary study indicated that either a high hepatofugal flow velocity in the left gastric vein (LGV) or an anterior branch dominant pattern seen under color Doppler EUS (CD-EUS) were possible contributing risk factors for variceal recurrence after endoscopic treatment. However, the sample size was too small, and in this study we aimed to validate the results of the preliminary study. METHODS Sixty-eight patients treated for moderate or large esophageal varices between 2001 and 2004 at a single university hospital were enrolled in this study. CD-EUS was followed by endoscopic variceal ligation and sclerotherapy. RESULTS Patients were classified into either a high-risk group, which exhibited anterior branch dominance and flow velocity of 12 cm/s or more, or a low-risk group, which included all other patients. Half of the patients in the high-risk group exhibited a recurrence within half a year, whereas it took almost 2 years for half of the patients in the other group to exhibit a recurrence (P=0.0044). Using the Cox proportional hazard model with multivariate analysis, only the features of the high-risk group were significant in triggering recurrence of varices (hazard ratio [HR], 3.00; 95% confidence interval [CI], 1.35-6.65; P<0.001). CONCLUSIONS These results suggest that patients showing anterior branch dominance and rapid hepatofugal flow velocity in the LGV on CD-EUS examination may have a high risk of an early recurrence of esophageal varices.
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Thalheimer U, Leandro G, Mela M, Patch D, Burroughs AK. Systematic review of HVPG measurement: statistics versus clinical applicability. Gastroenterology 2007; 132:1201-2; author reply 1202-4. [PMID: 17383448 DOI: 10.1053/j.gastro.2007.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Vitális Z, Papp M, Tornai I, Altorjay I. [Prevention and treatment of esophageal variceal bleeding]. Orv Hetil 2006; 147:2455-63. [PMID: 17378164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Portal hypertension leads to special complications, which tend to progression. Increase in the size of varices, and variceal-wall tension may cause life-threatening bleeding, which affects mortality. Therefore the reduction of portal hypertension is essential. For prevention of the first bleeding (primary prevention) beta-blockers must be given. For estimation of the effectiveness of this drug, patients should be followed. In case of inefficiency or intolerability variceal ligation or sclerotherapy can prevent bleeding. In case of acute variceal hemorrhage, hemodynamic stabilization of the patient is the first step. Transfusion if necessary, somatostatin or terlipressin should be given for reduction of portal hypertension and also endoscopic treatment of varices is mandatory. Early antibiotic administration for prophylaxis or treatment of infections is associated with a significant reduction in mortality. Up to now in absence of exact data, correction of haemostasis is suggested by the administration of fresh frozen plasma. For secondary prevention i. e. to prevent repeated bleeding beta-blockers (probably with nitrates) can be used. If necessary, drug administration should be complemented with varix ligation or sclerotherapy. In case of inefficiency TIPS implantation or liver transplantation must be considered.
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Nishiwaki S, Araki H, Goto N, Niwa Y, Kubota M, Iwashita M, Onogi N, Hatakeyama H, Hayashi T, Maeda T, Saitoh K. Clinical analysis of gastroesophageal reflux after PEG. Gastrointest Endosc 2006; 64:890-6. [PMID: 17140893 DOI: 10.1016/j.gie.2006.06.086] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2005] [Accepted: 06/30/2006] [Indexed: 12/10/2022]
Abstract
BACKGROUND It is difficult to predict whether or not gastroesophageal reflux (GER), such as aspiration or vomiting, will occur after PEG. OBJECTIVE To identify factors that would support the prediction of aspiration after PEG. DESIGN Case-control study. SETTING Patients who underwent PEG from February 1998 to June 2005 in our hospital. PATIENTS The study included 178 patients. INTERVENTIONS Endoscopic observation was carried out during PEG tube placement and at PEG tube replacement to determine the presence of hiatus hernia and/or reflux esophagitis. MAIN OUTCOME MEASUREMENTS Gastric emptying and GER index (GERI) were measured by using a radioisotope technique. RESULTS The patients were divided into 2 groups: the non-GER (NGER) group (n = 108), who had no symptoms of GER, and the GER group (n = 70), who showed these symptoms. No significant differences were observed between the groups in age, sex, morbidity, the presence of reflux esophagitis at PEG tube placement, gastric emptying, or serum albumin levels. The presence of a hiatus hernia (P = .028) and reflux esophagitis grading Los Angeles classification C or D (P = .008) were significantly more frequent in the GER group compared with the NGER group. The GERI was also significantly higher in the GER group than in the NGER group (P < .0001). CONCLUSIONS The presence of hiatus hernia, severe reflux esophagitis, and a high GERI might be predictive factors of aspiration or vomiting after PEG tube placement.
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Badruddin AH, Rasool G, Chaudhry MA. Hemodynamic effects of terlipressin in patients with bleeding esophageal varices secondary to cirrhosis of liver. J Coll Physicians Surg Pak 2006; 16:755-9. [PMID: 17125633 DOI: 12.2006/jcpsp.755759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2005] [Accepted: 10/03/2006] [Indexed: 05/12/2023]
Abstract
OBJECTIVE To study the hemodynamics of terlipressin in bleeding esophageal varices due to cirrhosis of the liver. DESIGN A quasi-experimental study. PLACE AND DURATION OF STUDY Medical-ICU, Jinnah Postgraduate Medical Centre, Karachi from February to July 2005. PATIENTS AND METHODS Seventy-eight consecutive patients with bleeding esophageal varices were evaluated. The diagnosis of cirrhosis was based on history, physical examination, laboratory data and abdominal ultrasound. Blood-pressure and pulse rate were monitored. Injection terlipressin 2 mg intravenous bolus was given followed by 2 mg i/v 6 hourly. Intravenous plasma expanders, whole blood, fresh frozen plasma and platelet concentrates were transfused as needed. Upper gastrointestinal endoscopy was performed for evaluation and grading of varices, detection of portal gastropathy, and banding. Descriptive and inferential statistics were applied as applicable. RESULTS Seventy patients of either gender, aged 18 - 95 years were included in the study. Systolic blood-pressure(SP) increased by 7.77 mmHg (mean SP: 108.1 mmHg, SD + 9.84, 95% CI: 105.77 - 110.43 mmHg; p-value: 0.0002); diastolic blood-pressure(DP) by 21.57 mmHg (mean DP: 79.71 mmHg, SD + 7.35, 95% CI: 77.97 - 81.45 mmHg; p-value: 0.001) and mean arterial pressure by 9.42 mmHg(mean MAP: 89.12 mmHg, SD + 6.98, 95% CI: 87.45 - 90.78 mmHg; p-value: 0.0007) within 24 hours of initiating terlipressin in majority of patients. The pulse rate decreased in 34 (48.5%) patients by 6-24 beats/min in 30 min, and by 2-12 beats/min in 24 hours; and increased in 30 (42.85)% patients by 10-15 beats/min at 30 min and by 2-8 beats/min at 24 hours. CONCLUSION Terlipressin had an overall benefit in significant number of patients with bleeding esophageal varices in this series and only a few adverse effects when given at recommended doses.
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Liu B, Deng MH, Lin N, Pan WD, Ling YB, Xu RY. Evaluation of the effects of combined endoscopic variceal ligation and splenectomy with pericardial devascularization on esophageal varices. World J Gastroenterol 2006; 12:6889-92. [PMID: 17106943 PMCID: PMC4087449 DOI: 10.3748/wjg.v12.i42.6889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To detect the hemodynamic alterations in collateral circulation before and after combined endoscopic variceal ligation (EVL) and splenectomy with pericardial devascularization by ultrasonography, and to evaluate their effect using hemodynamic parameters.
METHODS: Forty-three patients with esophageal varices received combined EVL and splenectomy with pericardial devascularization for variceal eradication. The esophageal vein structures and azygos blood flow (AZBF) were detected by endoscopic ultrasonography and color Doppler ultrasound. The recurrence and rebleeding of esophageal varices were followed up.
RESULTS: Patients with moderate or severe varices in the esophageal wall and those with severe peri-esophageal collateral vein varices had improvements after treatment, while the percentage of patients with severe para-esophageal collateral vein varices decreased from 54.49% to 2.33%, and the percentage of patients with detectable perforating veins decreased from 79.07% to 4.65% (P < 0.01). Color Doppler flowmetry showed a significant decrease both in AZBF (43.00%, P < 0.05) and in diameter of the azygos vein (28.85%, P < 0.05), while the blood flow rate was unchanged. The recurrence rate of esophageal varices was 2.5% (1/40, mild), while no re-bleeding cases were recorded.
CONCLUSION: EVL in combination with splenectomy with pericardial devascularization can block the collateral veins both inside and outside of the esophageal wall, and is more advantagious over splenectomy in combination with pericardial devascularization or EVL in preventing recurrence and re-bleeding of varices.
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Bolondi L, Piscaglia F, Gatta A, Salerno F, Bernardi M, Ascione A, Ferraù O, Sacerdoti D, Visentin S, Trevisani F, Mazzanti R, Donati G, Arena U, Gentilini P. Effect of potassium canrenoate, an anti-aldosterone agent, on incidence of ascites and variceal progression in cirrhosis. Clin Gastroenterol Hepatol 2006; 4:1395-402. [PMID: 16931172 DOI: 10.1016/j.cgh.2006.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Because aldosterone-dependent sodium and water retention contribute to portal hypertension, the safety and effect of an antialdosteronic drug (Kcanrenoate) have been evaluated on the occurrence of de novo appearance of ascites and the development of esophageal varices or the progression of small varices. METHODS Inclusion criteria were as follows: Child-Pugh A viral pre-ascitic cirrhosis, with either F1 esophageal varices or no varices, but endoscopic and/or ultrasound evidence of portal hypertension. Thirteen Italian Liver Units prospectively enrolled 120 patients randomized to receive double-blind either Kcanrenoate (100 mg/day; 66 patients) or placebo (54 patients). Endoscopy and sonography were performed at entry and at 52 weeks unless the patient developed ascites earlier, whereas laboratory examinations were performed at entry and every 3 months thereafter. An intention-to-treat analysis was performed, with each end point assessed by the Fisher exact test; the cumulative risk for the appearance of any end point was analyzed by the adjusted log-rank test (Tarone-Ware), with censoring for drop-outs. RESULTS The progression of variceal status or appearance of ascites, analyzed independently, was not significantly more frequent on placebo (24.1% and 9.2%, respectively) than on Kcanrenoate (12.1% and 1.5%, respectively), whereas the cumulative occurrence of end points was decreased on Kcanrenoate (17.6% vs 38.3% with placebo; P < .05, Tarone-Ware test). The incidence of adverse events was negligible and did not differ between groups. CONCLUSIONS This preliminary study shows that 100 mg/day of Kcanrenoate is well tolerated and does not reduce the individual incidence of ascites and/or the appearance or progression of esophageal varices in preascitc cirrhosis, but may decrease their 1-year cumulative occurrence.
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Berry PA, Wendon JA. The management of severe alcoholic liver disease and variceal bleeding in the intensive care unit. Curr Opin Crit Care 2006; 12:171-7. [PMID: 16543796 DOI: 10.1097/01.ccx.0000216587.62125.24] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW To address recent advances in the understanding and management of alcohol-related chronic liver disease and its acute complications. RECENT FINDINGS Refinements have been made in the prognosis and treatment of alcoholic hepatitis, and new insights have been gained into the pathophysiology of the hepatorenal syndrome. Further trial evidence has emerged concerning therapy in the hepatorenal syndrome, and there has been some clarification of the benefits and risks relating to albumin dialysis/extracorporeal liver support, and consensus in the early management of variceal haemorrhage. SUMMARY Recent developments have led to modifications in the standard of care of patients with severe alcoholic liver disease, many of which are highly applicable to the general critical care setting. These changes apply specifically to alcoholic hepatitis, the hepatorenal syndrome and variceal bleeding, common conditions with a high mortality rate, upon which changes in practice can have a significant impact.
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Abstract
Bleeding from gastric varices has been successfully treated by endoscopic modalities. Once the bleeding from the gastric varices is stabilized, endoscopic treatment and/or interventional radiology should be performed to eradicate varices completely. Partial splenic artery embolization is a supplemental treatment to prolong the obliteration of the veins feeding and/or draining the varices. The overall incidence of bleeding from gastric varices is lower than that from esophageal varices. No studies to date have definitively characterized the causal factors behind bleeding from gastric varices. The initial episodes of bleeding from esophageal varices or gastric varices without prior treatment may be at least partly triggered by a violation of the mucosal barrier overlying varices. This is especially likely in the case of varices of the fundus. In view of the high rate of hemostasis achieved among bleeding gastric varices, treatment should be administered in selective cases. Among untreated cases, steps to prevent gastric mucosal injury confer very important protection against gastric variceal bleeding.
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Nakayama H, Takayama T, Hemmi A. [Review of relationship between alcohol drinking and esophageal varices]. NIHON ARUKORU YAKUBUTSU IGAKKAI ZASSHI = JAPANESE JOURNAL OF ALCOHOL STUDIES & DRUG DEPENDENCE 2006; 41:419-23. [PMID: 17176847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
The adequate treatment for patients with thrombocytopenia, encephalopathy, ascites and esophagogastric varices due to portal hypertension are very important. This review explains the relations between heavy drinkers and symptoms of portal hypertension, especially with regard to the form of esophageal varices. Between heavy drinker and non-heavy drinker, there was no significant differences for form, color and red color sign of varices. In heavy drinker, the ratio of strong red color sign might be higher than non-heavy drinker. Value of portal pressure in heavy drinker might be higher. These results can bring sudden variceal bleeding in heavy drinkers.
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Baik SK, Kim JW, Kim HS, Kwon SO, Kim YJ, Park JW, Kim SH, Chang SJ, Lee DK, Han KH, Um SH, Lee SS. Recent variceal bleeding: Doppler US hepatic vein waveform in assessment of severity of portal hypertension and vasoactive drug response. Radiology 2006; 240:574-80. [PMID: 16864678 DOI: 10.1148/radiol.2402051142] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To prospectively evaluate both the correlation between abnormal Doppler ultrasonography (US) hepatic vein waveforms and the hepatic venous pressure gradient (HVPG) and the response to drug treatment in patients with cirrhosis. MATERIALS AND METHODS Ethics committee approval and informed consent of patients and control subjects were obtained. In 78 patients with cirrhosis (70 men, eight women; mean age, 49.4 years +/- 9.7 [standard deviation]) and a history of variceal bleeding, both the hepatic vein waveform--as measured with Doppler US--and the HVPG were measured, and the relationship between them was analyzed. Hepatic vein Doppler waveforms were classified as triphasic, biphasic, or monophasic. Severe portal hypertension was defined as an HVPG of more than 15 mm Hg. In a subgroup of 21 patients, changes in hepatic vein waveform and HVPG were evaluated after intravenous administration of 2 mg of terlipressin. Statistical analyses were performed with Spearman rank correlation, logistic regression analysis, and cross tabulation. RESULTS Abnormal hepatic vein waveforms were seen in 72 patients (92%). Forty-four patients (56%) had biphasic waveforms, 28 (36%) had monophasic waveforms, and six (8%) had triphasic waveforms. A positive correlation was found between the extent of abnormalities in hepatic vein waveforms and the increase in HVPG (P < .05). Monophasic waveforms were associated with severe portal hypertension, with a sensitivity of 74% and a specificity of 95%. Twenty patients in the terlipressin subgroup had abnormal baseline waveforms; the baseline waveform improved in 18 patients in association with the HVPG reduction after injection of terlipressin. CONCLUSION Doppler US hepatic vein waveform assessment is useful in the noninvasive evaluation of the severity of portal hypertension and the response to vasoactive drugs in patients with portal hypertension and variceal bleeding.
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Spahr L, Giostra E, Morard I, Mentha G, Hadengue A. Perendoscopic variceal pressure measurement. ACTA ACUST UNITED AC 2006; 30:1012-8. [PMID: 17075452 DOI: 10.1016/s0399-8320(06)73376-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES In patients with cirrhosis, the hepatic venous pressure gradient (HVPG) is the reference method for the assessment of portal hypertension (PHT). Variceal pressure (VP) may be measured at endoscopy, but its relationship to the HVPG remains controversial. The aim of the study was to retrospectively compare HVPG and VP values obtained in a cohort of patients with cirrhosis and PHT. METHODS Within 8 days (range: 6-10 days), 64 patients in a stable condition with biopsy-proven cirrhosis [alcoholic: 47; other 17; mean age: 56.5 yrs (35-70); mean Child-Pugh's score: 9.4 +/- 1.9; ascites: 37/64; previous variceal bleeding (="bleeders"): 24/64) and oesophageal varices (grade 2: 49; grade 3: 15)] underwent both measurement of the HVPG during transjugular liver biopsy and VP at endoscopy using a "home made" pressure sensitive gauge in the absence of needle puncture of the varix. Alcoholic hepatitis was present in 28 patients with alcoholic cirrhosis. RESULTS The pressure sensitive gauge was well tolerated. The mean HVPG and VP values were 18.5 +/- 3.4 mmHg and 19 +/- 3.7 mmHg, respectively. A significant difference was observed between "bleeders" (n=24) and non "bleeders" (n=40) in terms of VP values (21.4 +/- 3.3 vs 17.2 +/- 3.2 mmHg, P<0.001), but not for HVPG values (19.4 +/- 4.1 vs 17.9 +/- 2.8 mmHg, P=0.075). A positive correlation was observed between VP and HVPG values (r=0.62, P<0.0001). CONCLUSIONS In this group of patients with cirrhosis and oesophageal varices, a "home-made" pressure sensitive gauge allowed a non invasive perendoscopic measurement of VP. The positive correlation between VP and HVPG values suggests that measurement of VP may be a reliable estimate of portal pressure in these patients.
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Berzigotti A, Casadei A, Magalotti D, Castaldini N, Losinno F, Rossi C, Zoli M. Renovascular Impedance Correlates with Portal Pressure in Patients with Liver Cirrhosis. Radiology 2006; 240:581-6. [PMID: 16801365 DOI: 10.1148/radiol.2401050585] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE To prospectively evaluate, in patients with liver cirrhosis, the correlation between the renovascular impedance measured by using color flow and pulsed wave Doppler ultrasonography (US) and the portal pressure measured by using the hepatic venous pressure gradient (HVPG). MATERIALS AND METHODS The study was approved by the senior staff committee (comparable to institutional review board) of the university hospital, and written informed consent was obtained from all patients. Thirty-one patients with cirrhosis (22 men, nine women; mean age, 57.6 years +/- 8.8 [standard deviation]) and esophageal varices were consecutively enrolled in the study. Having fasted, the patients underwent color flow and pulsed wave Doppler US of the right interlobar renal artery (RRA) and the left interlobar renal artery (LRA). The resistance index (RI) and pulsatility index (PI) were determined. On the same day, with fluoroscopic guidance, a 5-F balloon-tipped catheter was advanced, via the right basilic vein, into the right hepatic vein; HVPG was calculated as the difference between the wedged and free hepatic pressures. All measurements were performed in triplicate, and permanent tracings were recorded. Correlations were made by using the Pearson test. The positive predictive value of renovascular impedance for detection of severe portal hypertension was determined. RESULTS Mean RI and PI values were 0.67 +/- 0.07 and 1.21 +/- 0.25, respectively, for the RRA, and 0.68 +/- 0.07 and 1.24 +/- 0.26, respectively, for the LRA. All patients had portal hypertension (mean HVPG, 19.3 mm Hg +/- 4.7; range, 11.5-33.5 mm Hg). Neither portal pressure nor renal impedance correlated with Child-Pugh score for cirrhosis. Renal artery impedance indexes correlated with the HVPG (for RRA RI: R = 0.424, P = .03; for RRA PI: R = 0.402, P = .04; for LRA RI: R = 0.352, P = .05; for LRA PI: R = 0.393, P = .02). A higher-than-normal renal impedance had a high positive predictive value (RRA RI and PI, 100%; LRA RI, 92%; LRA PI, 84%) for the detection of severe portal hypertension. CONCLUSION Renovascular impedance had a direct correlation with HVPG.
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Sharma BC, Sarin SK. Hepatic Venous Pressure Gradient in Cirrhosis: Role in Variceal Bleeding, Non-bleeding Complications and Outcome. Asian J Surg 2006; 29:113-9. [PMID: 16877206 DOI: 10.1016/s1015-9584(09)60068-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Arai H, Abe T, Takagi H, Mori M. Efficacy of balloon-occluded retrograde transvenous obliteration, percutaneous transhepatic obliteration and combined techniques for the management of gastric fundal varices. World J Gastroenterol 2006; 12:3866-73. [PMID: 16804972 PMCID: PMC4087935 DOI: 10.3748/wjg.v12.i24.3866] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the effect of three interventional treatments involving transvenous obliteration for the treatment of gastric varices, and to compare the efficacy and adverse effects of these methods.
METHODS: From 1995 to 2004, 93 patients with gastric fundal varices underwent interventional radiologic embolotherapy at our hospital. Of the 93 patients, 75 were treated with the balloon-occluded retrograde transvenous obliteration (BRTO) procedure; 8 were with the percutaneous transhepatic obliteration (PTO) procedure; and 10 were with the combined BRTO and PTO therapy. A follow-up evaluation examined the rates of survival, recurrence and rebleeding of the gastric varices, worsening of esophageal varices and complications in each group.
RESULTS: The BRTO, PTO, and combined therapy were technically successful in 81% (75/93), 44% (8/18), and 100% (10/10) patients, respectively. Recurrence of gastric varices was found in 3 patients in the BRTO group and in 3 patients in the PTO group. Rebleeding was observed in 1 patient in the BRTO group and in 1 patient in the PTO group. The 1- and 3-year survival rates were 98% and 87% in the patients without hepatocellular carcinoma (HCC) in the BRTO group, 100% and 100% in the PTO group, and 90% and 75% in the combined therapy group, respectively.
CONCLUSION: Combined BRTO and PTO therapy may rescue cases with uncontrollable gastric fundal varices that remained even after treatment with BRTO and/or PTO, though there were limitations of our study, including retrospective nature and discrepancy in sample size between the BRTO, PTO and combined therapy groups.
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Dib N, Konate A, Oberti F, Calès P. [Non-invasive diagnosis of portal hypertension in cirrhosis. Application to the primary prevention of varices]. ACTA ACUST UNITED AC 2006; 29:975-87. [PMID: 16435503 DOI: 10.1016/s0399-8320(05)88170-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
One of the major complications of cirrhosis is the occurrence of portal hypertension and esophageal varices. At present, universal endoscopic screening of esophageal varices is recommended in association to primary prophylaxis in patients at high risk of variceal bleeding. But this screening is invasive and could be not cost-effective. Besides, pre-primary phrophylaxis is not effective and hampared by side effects. So, non invasive diagnosis of portal hypertension might be useful. This one could depend on non invasive measurement of hepatic venous pressure gradient, but its application to screening is not well-documented and its use in treatment monitoring is debated. A second way could be non invasive diagnosis of large esophageal varices because of prognostic and economic issues. Indirect echographic markers of portal hypertension and esophageal varices (ascites, portal vein diameter > or = 13 mm, spleen length, maximal and mean velocimetry of portal vein flow, respectively < 20 cm/s and < 12 cm/s) could be useful. Among this parameters, spleen length is an independent predictive marker of esophageal varices. Besides, several direct or indirect blood markers of fibrosis have been tested. Platelet count is repeatedly a predictive marker of esophageal varices in multivariate analysis. The other predictive factors of esophageal varices could be: prothrombin time, splenomegaly, spider naevi, Child-Pugh class, bilirubinemia, platelet count/spleen diameter ratio and Fibrotest, but these data require validation. In summary, in regard to actual results, non invasive diagnosis of portal hypertension might be useful in esophageal varices screening, but the substitutes to endoscopy have limited place actually in clinical practice, and exclusive non invasive diagnosis of portal hypertension is not applicable; the only test that seems to be useful in clinical practice is conventional endoscopy awaiting the results of videocapsule.
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Liu TT, Wong WJ, Hou MC, Lin HC, Chang FY, Lee SD. Hemorheology in patients with liver cirrhosis: special emphasis on its relation to severity of esophageal variceal bleeding. J Gastroenterol Hepatol 2006; 21:908-13. [PMID: 16704544 DOI: 10.1111/j.1440-1746.2006.04266.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Patients with decreased blood viscosity are supposed to have a higher risk of bleeding and increased severity of bleeding (severity of bleeding proportional to transmural pressure x area of variceal tear/blood viscosity). However, the hemorheological factors have never been assessed in patients with esophageal variceal bleeding. Therefore, the purpose of the present study was to examine the hemorheological factors in liver cirrhotic patients with special emphasis on the outcome of variceal bleeding. METHODS Forty-two liver cirrhosis patients with variceal bleeding and another 44 matched patients without bleeding were enrolled. The hemorheological and hemostatic factors of their peripheral blood were examined. The clinical course was under careful surveillance. RESULTS Patients with poor hepatic reserve (Child B + C vs A) had lower whole blood viscosity (4.34 +/- 0.56 mPa.s vs 5.06 +/- 1.35 mPa.s, P < 0.05), lower hematocrit levels (32.86 +/- 5.97% vs 36.62 +/- 5.44%, P < 0.05), lower platelet counts (79.7 +/- 47.6 x 10(3)/mL vs 108.0 +/- 71.2 x 10(3)/mL, P < 0.05) and prolonged prothrombin time (2.88 +/- 2.33 s vs 1.27 +/- 1.37 s, P < 0.05). Patients with bleeding (vs non-bleeding group) had lower hematocrit levels (31.44 +/- 5.75% vs 36.57 +/- 5.19%, P < 0.01) and lower fibrinogen levels (226.7 +/- 92.7 mg/dL vs 286.4 +/- 111.8 mg/dL, P < 0.05). Patients with bleeding with shock had worse liver cirrhosis (Child A/B/C = 0/5/4 vs 11/18/4, P < 0.05), lower whole blood viscosity (4.01 +/- 0.17 mPa.s vs 4.57 +/- 0.76 mPa.s, P < 0.05), reduced erythrocyte aggregability (2.94 +/- 0.41 vs 3.54 +/- 0.61, P < 0.001), and lower platelet counts (56.22 +/- 17.05 x 10(3)/mL vs 88.87 +/- 38.12 x 10(3)/mL, P < 0.001). The Child-Pugh grade and erythrocyte aggregability were two independent factors associated with bleeding shock. CONCLUSIONS Whole blood viscosity, hematocrit levels and platelet counts were lower in patients with advanced liver cirrhosis. Advanced liver cirrhosis and reduced erythrocyte aggregability were independent factors for hypovolemic shock in cirrhotic patients with esophageal variceal bleeding. However, the causal relationship between hemorheology and bleeding needs to be clarified in further studies.
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Harrod-Kim P, Waldman DL. Abnormal portal venous flow at sonography predicts reduced survival after transjugular intrahepatic portosystemic shunt creation. J Vasc Interv Radiol 2006; 16:1459-64. [PMID: 16319151 DOI: 10.1097/01.rvi.0000175328.72653.ca] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To determine if ultrasound (US) findings of abnormal portal venous flow (APVF) before transjugular intrahepatic portosystemic shunt (TIPS) creation are predictive of increased mortality risk after TIPS creation. MATERIALS AND METHODS Retrospective review of 141 patients with US before TIPS creation was performed. APVF was defined by (i) bidirectional flow, (ii) thrombus, and/or (iii) reversed flow. Model for End-stage Liver Disease (MELD) scores were calculated. Kaplan-Meier survival curves and log-rank tests were used to detect survival differences based on the presence of APVF. Multivariate analysis included APVF, MELD, Child-Pugh class, International Normalized Ratio, creatinine level, total bilirubin level, ascites, hepatocellular carcinoma, low serum sodium level, congestive heart failure, and myocardial infarction. RESULTS Twenty-six percent of patients (36 of 141) exhibited APVF on US before TIPS creation. Patients with APVF had lower survival rates at 3 and 6 months after TIPS procedures in comparison with patients with normal portal flow (P = .02 at 3 months and P = .04 at 6 months). In patients with MELD scores lower than 18, there was decreased survival based on APVF at 1, 3, and 6 months (P = .04, P = .02, and P = .04, respectively). In patients with MELD scores of 18 or greater, there was a trend for lower survival rates with APVF, but it did not reach statistical significance. Multivariate analysis of patients with MELD scores lower than 18 demonstrated only APVF and low serum sodium levels as independent predictors of outcome, with APVF resulting in a greater than six-fold increased likelihood of mortality. CONCLUSION US findings of APVF before TIPS creation are associated with increased mortality risk and may be useful in identifying patients otherwise considered safe candidates based on MELD score alone.
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Papp M, Udvardy M, Vitális Z, Tornai I, Altorjay I. [Gastroesophageal variceal haemorrhage--new advances in pathophysiology]. Orv Hetil 2006; 147:309-14. [PMID: 17489158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Ruptured gastroesophageal varices are the most severe and frequent causes of upper gastrointestinal bleeding in patients suffering from liver cirrhosis, accounting for 80% of all bleeding episodes. Despite recent progress in treatment strategies, variceal bleeding is still considered the most severe type of gastrointestinal bleeding associated with a mortality of 20% at 6 weeks. The most widely accepted explanation for the rupture is the "explosion hypothesis": bleeding is a result of the elevated intravariceal pressure and increased wall-straining due to a rapid increase in the portal pressure gradient. The rupture of the varices and the early rebleeding cannot be attributed solely to mechanical changes. Furthermore, the factors involved in the sudden increase of portal pressure gradient are yet to be discovered. Recently it was postulated that various humoral factors may also play an important role in the pathomechanism of the rupture. The pivotal role of bacterial infection and consequent endotoxaemia must be emphasized. Passage of both viable microbes and microbial products, such as endotoxins from the intestinal lumen to peripheral and portal circulation in cirrhotic patients can be explained by the intestinal bacterial overgrowth, the intestinal dysmotility and the increased intestinal permeability. Endotoxaemia can be a critical factor that triggers a cascade of humoral events, resulting in a further increase of portal pressure, impairment of liver function and worsening of haemostasis, and eventually leads to variceal bleeding. Early administration of prophylactic antibiotics to variceal bleeders recently became an integral and important part of therapeutic strategy. Antibiotics are not only useful in the prevention of early rebleeding but also they are proven to significantly decrease the rate of mortality. The improvement in mortality is equivalent to that seen with terlipressine.
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Benko L, Danis J, Shamiyeh A, Czompo M, Gasz B, Ferencz A, Jancsó G, Roth E. [Laparoscopic devascularization of the stomach and the abdominal esophagus with the LigaSure instrument in a porcine model]. Magy Seb 2006; 59:45-9. [PMID: 16637391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
OBJECTIVES In this study we proved the feasibility of a new minimally invasive procedure for the devascularisation of the proximal stomach and the abdominal esophagus to prevent recurrent variceal bleeding in portal hypertension in a new animal model. MATERIALS AND METHODS Experiments were performed on 12 female pigs, in two animal groups. In the first step (I. group n=6) portal hypertension was created by controlled laparoscopic clip ligation of the portal vein. The increased portal pressure was established by the needle puncture of the portal vein and the spleen. Two weeks later, the dilated veins were sealed along the lesser and greater curvature and the transhiatal esophagus with the 10 mm LigaSure instrument. Successful of the experimental model had encouraged us to perform this method on other animals (II. group, n=6), using the 5 mm instrument. RESULTS There was no intraoperative bleeding after using both LigaSure instruments. Autopsy (2 weeks later) showed correct placed clips with partial occlusion of the portal vein without portal vein thrombosis. There was no evidence of postoperative bleeding. Histological investigation of the gastric surface confirmed complete sealing of the extended varices. CONCLUSION The laparoscopic LigaSure instrument was found to be safe and suitable equipment for the ligation of the dilated veins along the gastric surface and the abdominal esophagus, and this method could be an alternate choice for the patients with recurrent variceal bleeding.
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Lin ZY, Chen SC, Hsieh MY, Wang CW, Chuang WL, Wang LY. Incidence and clinical significance of spontaneous intrahepatic portosystemic venous shunts detected by sonography in adults without potential cause. JOURNAL OF CLINICAL ULTRASOUND : JCU 2006; 34:22-6. [PMID: 16353230 DOI: 10.1002/jcu.20176] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
PURPOSE B-mode and color Doppler sonography were used to assess the incidence and clinical significance of spontaneous intrahepatic portosystemic venous shunt in adults without detectable cause. METHODS A total of 25,579 adults without potential cause of intrahepatic portosystemic venous shunt were screened using B-mode sonography. Suspicion of shunt was confirmed by color Doppler sonography. Patients with shunt were followed up with sonography at 6- to 12-month intervals and received dietary education to prevent the ingestion of extra-large amounts of protein. During each sonography session, the patients were asked to report any experience of consciousness disturbance. RESULTS Six patients (0.0235%) showed evidence of shunt on color Doppler sonography. Direct communication between a right portal branch and the inferior vena cava was found in 3 patients; a small aneurysm connecting a peripheral portal branch to the hepatic vein was found in the remaining 3 patients. Five patients were followed up (range, 12-60 months) and showed no change in the size of the shunt. None of the patients with shunt reported an experience of consciousness disturbance. CONCLUSIONS The incidence of spontaneous intrahepatic portosystemic venous shunt is extremely low in asymptomatic adult patients. Follow-up and dietary control seen to be suitable for their management.
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Sato T, Yamazaki K, Toyota J, Karino Y, Ohmura T, Akaike J, Kuwata Y, Suga T. Usefulness of electronic radial endoscopic color Doppler ultrasonography in esophageal varices: comparison with convex type. J Gastroenterol 2006; 41:28-33. [PMID: 16501854 DOI: 10.1007/s00535-005-1719-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2005] [Accepted: 08/18/2005] [Indexed: 02/04/2023]
Abstract
BACKGROUND Endoscopic color Doppler ultrasonography (ECDUS) is a method for detecting color flow images in blood vessels. We previously reported on the usefulness of ECDUS (convex-type scanning instruments with forward--oblique viewing) for evaluating the hemodynamics of esophageal varices. In the present study, we report the usefulness of new electronic radial ECDUS in cases of esophageal varices by comparison with convex-type ECDUS. METHODS Twenty-six patients with esophageal varices were identified and studied. The underlying pathologies of portal hypertension included liver cirrhosis (15 patients) and cirrhosis associated with hepatocellular carcinoma (11 patients). Endoscopic findings of esophageal varices were as follows: Cb, F3, and Ls varices in four patients; Cb, F2, and Lm varices in 21 patients; and Cb, Lm, and F1 varices in one patient. RC1 was observed in the esophagus in 14 of the 26 patients. RC2 was noted in 11 cases, and RC0 was seen in one patient. ECDUS was performed using a Pentax EG-3630UR (forward view) with a distal tip diameter of 12 mm. The instrument (electronic radial array) has a curved array scanning transducer with variable frequency (5.0, 7.5, 10.0 MHz). A Hitachi EUB 6500,8500 was used for the display, providing 270 degrees images. We monitored the color flow images of esophageal varices, paraesophageal veins, palisade veins, perforating veins, and pulsatile waves using this technique. As a control, 110 patients were examined by convex-type ECDUS. RESULTS (1) Color flow images of esophageal varices and paraesophageal veins were obtained in 26 of the 26 patients, whereas color flow images of perforating veins were obtained in 18 of the 26 patients (69.2%). Color flow images of palisade veins were obtained in 12 of the 26 patients (46.2%). (2) Color flow images of pulsatile waves were obtained in 10 of the 26 patients (38.5%). Color flow images of pulsatile waves were detected in zero (0%) of the 4 F3 varices, in nine (42.9%) of the 21 F2 varices, and in the 1 (100%) case of F1 varices. Also, color flow images of pulsatile waves were detected in seven (50.0%) of the 14 RC1 varices, in two (18.2%) of the 11 RC2 varices, and in the 1 (100%) case of RC0 varices. (3) As a control, 110 patients were examined by convex-type ECDUS. Color flow images of esophageal varices and paraesophageal veins were obtained in 110 of the 110 patients, whereas color flow images of perforating veins were obtained in 74 of 110 (67.3%) with convex-type ECDUS. The detection rate of palisade veins with electronic radial ECDUS (12 of the 26 patients, 46.2%) was significantly higher than with convex-type ECDUS (28 of the 110 patients, 25.5%) (P<0.05). The detection rate of pulsatile waves with electronic radial ECDUS (10 of the 26 cases, 38.5%) was significantly higher than with convex-type ECDUS (3 of the 110 cases, 2.7%) (P<0.0001). CONCLUSIONS Electronic radial ECDUS provides clear color flow images of blood vessels in esophageal varices with the additional advantages of forward-view optics and extended 270 degrees views. Electronic radial ECDUS was superior to convex-type ECDUS in detecting palisade veins and pulsatile waves.
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