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Abstract
Variceal hemorrhage is a common and devastating complication of portal hypertension and is a leading cause of death in patients with cirrhosis. The management of gastroesophageal varices has evolved over the last decade resulting in improved mortality and morbidity rates. Regarding the primary prevention of variceal hemorrhaging, nonselective β -blockers should be the first-line therapy in all patients with medium to large varices and in patients with small varices associated with high-risk features such as red wale marks and/or advanced cirrhosis. EVL should be offered in cases of intolerance or side effects to β -blockers, or for patients at high-risk for variceal bleeding who have medium or large varices with red wale marks or advanced liver cirrhosis. In acute bleeding, vasoactive agents should be initiated along with antibiotics followed by EVL or endoscopic sclerotherapy (if EVL is technically difficult) within the first 12 hours of presentation. Where available, terlipressin is the preferred agent because of its safety profile and it represents the only drug with a proven efficacy in improving survival. All patients surviving an episode of bleeding should undergo further prophylaxis to prevent rebleeding with EVL and nonselective β -blockers.
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Merkel C, Montagnese S. Secondary prophylaxis in patients who have experienced portal hypertensive bleeding. Clin Liver Dis (Hoboken) 2012; 1:155-157. [PMID: 31186877 PMCID: PMC6499288 DOI: 10.1002/cld.86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Carlo Merkel
- Department of Medicine, University of Padua, Padua, Italy
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Gluud LL, Krag A. Banding ligation versus beta-blockers for primary prevention in oesophageal varices in adults. Cochrane Database Syst Rev 2012:CD004544. [PMID: 22895942 DOI: 10.1002/14651858.cd004544.pub2] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Non-selective beta-blockers are used as a first-line treatment for primary prevention in patients with medium- to high-risk oesophageal varices. The effect of non-selective beta-blockers on mortality is debated and many patients experience adverse events. Trials on banding ligation versus non-selective beta-blockers for patients with oesophageal varices and no history of bleeding have reached equivocal results. OBJECTIVES To compare the benefits and harms of banding ligation versus non-selective beta-blockers as primary prevention in adult patients with endoscopically verified oesophageal varices that have never bled, irrespective of the underlying liver disease (cirrhosis or other cause). SEARCH METHODS In Febuary 2012, electronic searches (the Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded) and manual searches (including scanning of reference lists in relevant articles and conference proceedings) were performed. SELECTION CRITERIA Randomised trials were included irrespective of publication status, blinding, and language. DATA COLLECTION AND ANALYSIS Review authors independently extracted data. All-cause mortality was the primary outcome. Intention-to-treat random-effects and fixed-effect model meta-analyses were performed. Results were presented as risk ratios (RR) and 95% confidence intervals (CI) with I(2) statistic values as a measure of intertrial heterogeneity. Subgroup, sensitivity, regression, and trial sequential analyses were performed to evaluate the robustness of the overall results, risks of bias, sources of intertrial heterogeneity, and risks of random errors. MAIN RESULTS Nineteen randomised trials on banding ligation versus non-selective beta-blockers for primary prevention in oesophageal varices were included. Most trials specified that only patients with large or high-risk oesophageal varices were included. Bias control was unclear in most trials. In total, 176 of 731 (24%) of the patients randomised to banding ligation and 177 of 773 (23%) of patients randomised to non-selective beta-blockers died. The difference was not statistically significant in a random-effects meta-analysis (RR 1.09; 95% CI 0.92 to 1.30; I(2) = 0%). There was no evidence of bias or small study effects in regression analysis (Egger's test P = 0.997). Trial sequential analysis showed that the heterogeneity-adjusted low-bias trial relative risk estimate required an information size of 3211 patients, that none of the interventions showed superiority, and that the limits of futility have not been reached. When all trials were included, banding ligation reduced upper gastrointestinal bleeding and variceal bleeding compared with non-selective beta-blockers (RR 0.69; 95% CI 0.52 to 0.91; I(2) = 19% and RR 0.67; 95% CI 0.46 to 0.98; I(2) = 31% respectively). The beneficial effect of banding ligation on bleeding was not confirmed in subgroup analyses of trials with adequate randomisation or full paper articles. Bleeding-related mortality was not different in the two intervention arms (29/567 (5.1%) versus 37/585 (6.3%); RR 0.85; 95% CI 0.53 to 1.39; I(2) = 0%). Both interventions were associated with adverse events. AUTHORS' CONCLUSIONS This review found a beneficial effect of banding ligation on primary prevention of upper gastrointestinal bleeding in patient with oesophageal varices. The effect on bleeding did not reduce mortality. Additional evidence is needed to determine whether our results reflect that non-selective beta-blockers have other beneficial effects than on bleeding.
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Affiliation(s)
- Lise Lotte Gluud
- Department of Internal Medicine, Gentofte University Hospital, Hellerup, Denmark.
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de Souza AR, La Mura V, Reverter E, Seijo S, Berzigotti A, Ashkenazi E, García-Pagán JC, Abraldes JG, Bosch J, Bosch J. Patients whose first episode of bleeding occurs while taking a β-blocker have high long-term risks of rebleeding and death. Clin Gastroenterol Hepatol 2012; 10:670-6; quiz e58. [PMID: 22366180 DOI: 10.1016/j.cgh.2012.02.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 01/29/2012] [Accepted: 02/06/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients who have their first episode of variceal bleeding despite primary prophylaxis with a nonselective β-adrenergic receptor antagonist (also called a nonselective β-blocker [NSBB]) receive additional treatment by endoscopic band ligation to prevent further bleeding. However, little is known about their long-term outcomes. METHODS We collected data on 89 consecutive patients with cirrhosis who were admitted to the Liver Unit of Hospital Clínic, Barcelona, with acute esophageal variceal bleeding between June 2007 and February 2011. Thirty-four patients were receiving primary prophylaxis with NSBBs when they had their first episode of variceal bleeding, whereas 55 were not receiving NSBBs (controls). All patients were subsequently treated with a combination of endoscopic band ligation and NSBBs. Patients were examined after 1, 3, and 6 months and every 6 months thereafter until 2 years. RESULTS After 2 years, a greater proportion of patients who had their first episode of bleeding while on NSBBs had further bleeding, compared with controls (48% vs 24%; P = .01). Primary prophylaxis with NSBBs and serum levels of bilirubin were independent predictors of rebleeding. Overall, 11 patients died, and 5 underwent liver transplantation. Liver transplantation-free survival was lower among patients who had their first episode of bleeding while taking NSBBs (66% vs 88% for controls; P = .02). Primary prophylaxis with NSBBs and Child-Pugh class were independently associated with liver transplantation-free survival. CONCLUSIONS Patients who have their first episode of variceal bleeding while on primary prophylaxis with a β-blocking agent have an increased risk of further bleeding and death, despite adding endoscopic band ligation. These patients possibly require alternative treatment approaches.
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Affiliation(s)
- Andrea Ribeiro de Souza
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic-IDIBAPS, University of Barcelona and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain
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Bosch J, Abraldes JG, Albillos A, Aracil C, Bañares R, Berzigotti A, Calleja JL, de la Peña J, Escorsell A, García-Pagán JC, Genescà J, Hernández-Guerra M, Ripoll C, Planas R, Villanueva C. Hipertensión portal: recomendaciones para su evaluación y tratamiento. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 35:421-50. [DOI: 10.1016/j.gastrohep.2012.02.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 02/15/2012] [Indexed: 12/16/2022]
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56
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Thiele M, Krag A, Rohde U, Gluud LL. Meta-analysis: banding ligation and medical interventions for the prevention of rebleeding from oesophageal varices. Aliment Pharmacol Ther 2012; 35:1155-65. [PMID: 22449261 DOI: 10.1111/j.1365-2036.2012.05074.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Revised: 01/24/2012] [Accepted: 03/05/2012] [Indexed: 01/30/2023]
Abstract
BACKGROUND In patients with oesophageal varices, the combination of endoscopic variceal ligation (EVL) and medical therapy is recommended as standard of care for prevention of rebleeding. The results of previous meta-analyses on this topic are equivocal. AIM To assess the effects of EVL plus medical therapy vs. monotherapy (EVL or medical therapy alone) for secondary prevention in oesophageal varices. METHODS Electronic and manual searches were combined. The primary outcome measures were overall rebleeding (variceal and nonvariceal) and mortality. Random-effects meta-analyses were performed with subgroup, sensitivity, regression and sequential analyses to identify sources of intertrial heterogeneity and the robustness of the results. RESULTS Nine randomised trials were included. In total, 442 patients were randomised to combination therapy and 513 to monotherapy. Combination therapy reduced rebleeding (RR = 0.68; 95% CI = 0.54-0.85; number needed to treat eight patients). The result was confirmed in sequential and regression analyses, but not when limiting the analysis to trials with adequate selection bias control. No effect on overall mortality was identified (RR = 0.89; 95% CI = 0.65-1.21). Combination therapy reduced bleeding-related mortality (RR = 0.52; 95% CI 0.27-0.99; number needed to treat 33 patients) and the risk of rebleeding from oesophageal varices. Combination therapy increased the risk of serious adverse events in fixed, but not in random-effects meta-analyses. CONCLUSIONS The combination of endoscopic variceal ligation and medical therapy reduce the risk of rebleeding, but not overall mortality. Additional research is needed to determine why reduced rebleeding rates do not lead to reduced mortality.
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Affiliation(s)
- M Thiele
- Department of Internal Medicine, Copenhagen University Hospital Gentofte, Hellerup, Denmark.
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Bari K, Garcia-Tsao G. Treatment of portal hypertension. World J Gastroenterol 2012; 18:1166-75. [PMID: 22468079 PMCID: PMC3309905 DOI: 10.3748/wjg.v18.i11.1166] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2011] [Revised: 11/15/2011] [Accepted: 12/31/2011] [Indexed: 02/06/2023] Open
Abstract
Portal hypertension is the main complication of cirrhosis and is defined as an hepatic venous pressure gradient (HVPG) of more than 5 mmHg. Clinically significant portal hypertension is defined as HVPG of 10 mmHg or more. Development of gastroesophageal varices and variceal hemorrhage are the most direct consequence of portal hypertension. Over the last decades significant advancements in the field have led to standard treatment options. These clinical recommendations have evolved mostly as a result of randomized controlled trials and consensus conferences among experts where existing evidence has been reviewed and future goals for research and practice guidelines have been proposed. Management of varices/variceal hemorrhage is based on the clinical stage of portal hypertension. No specific treatment has shown to prevent the formation of varices. Prevention of first variceal hemorrhage depends on the size/characteristics of varices. In patients with small varices and high risk of bleeding, non-selective β-blockers are recommended, while patients with medium/large varices can be treated with either β-blockers or esophageal band ligation. Standard of care for acute variceal hemorrhage consists of vasoactive drugs, endoscopic band ligation and antibiotics prophylaxis. Transjugular intrahepatic portosystemic shunt (TIPS) is reserved for those who fail standard of care or for patients who are likely to fail (“early TIPS”). Prevention of recurrent variceal hemorrhage consists of the combination of β-blockers and endoscopic band ligation.
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Suk KT, Baik SK, Yoon JH, Cheong JY, Paik YH, Lee CH, Kim YS, Lee JW, Kim DJ, Cho SW, Hwang SG, Sohn JH, Kim MY, Kim YB, Kim JG, Cho YK, Choi MS, Kim HJ, Lee HW, Kim SU, Kim JK, Choi JY, Jun DW, Tak WY, Lee BS, Jang BK, Chung WJ, Kim HS, Jang JY, Jeong SW, Kim SG, Kwon OS, Jung YK, Choe WH, Lee JS, Kim IH, Shim JJ, Cheon GJ, Bae SH, Seo YS, Choi DH, Jang SJ. Revision and update on clinical practice guideline for liver cirrhosis. THE KOREAN JOURNAL OF HEPATOLOGY 2012; 18:1-21. [PMID: 22511898 PMCID: PMC3326994 DOI: 10.3350/kjhep.2012.18.1.1] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Accepted: 03/05/2012] [Indexed: 12/13/2022]
Affiliation(s)
- Ki Tae Suk
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Soon Koo Baik
- Department of Internal Medicine and Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jung Hwan Yoon
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Youn Cheong
- Department of Internal Medicine, Ajou University College of Medicine, Suwon, Korea
| | - Yong Han Paik
- Department of Internal Medicine, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Chang Hyeong Lee
- Department of Internal Medicine, Catholic University of Daegu College of Medicine, Daegu, Korea
| | - Young Seok Kim
- Department of Internal Medicine, Soonchunhyang University Hospital Bucheon, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jin Woo Lee
- Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Dong Joon Kim
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Sung Won Cho
- Department of Internal Medicine, Ajou University College of Medicine, Suwon, Korea
| | - Seong Gyu Hwang
- Department of Internal Medicine, Cha University College of Medicine, Seongnam, Korea
| | - Joo Hyun Sohn
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Moon Young Kim
- Department of Internal Medicine and Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Young Bae Kim
- Department of Pathology, Ajou University College of Medicine, Suwon, Korea
| | - Jae Geun Kim
- Department of Radiology, Ajou University College of Medicine, Suwon, Korea
| | - Yong Kyun Cho
- Department of Internal Medicine, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Moon Seok Choi
- Department of Internal Medicine, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Hyung Joon Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hyun Woong Lee
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ja Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Young Choi
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Dae Won Jun
- Department of Internal Medicine, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul, Korea
| | - Won Young Tak
- Department of Internal Medicine, Kyungpook National University College of Medicine, Daegu, Korea
| | - Byung Seok Lee
- Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Byoung Kuk Jang
- Department of Internal Medicine, Keimyung University College of Medicine, Daegu, Korea
| | - Woo Jin Chung
- Department of Internal Medicine, Keimyung University College of Medicine, Daegu, Korea
| | - Hong Soo Kim
- Department of Internal Medicine, Soonchunhyang University Hospital Cheonan, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Jae Young Jang
- Department of Internal Medicine, Soonchunhyang University Hospital Seoul, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Soung Won Jeong
- Department of Internal Medicine, Soonchunhyang University Hospital Seoul, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University Hospital Bucheon, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Oh Sang Kwon
- Department of Internal Medicine, Gachon University of Medicine and Science, Incheon, Korea
| | - Young Kul Jung
- Department of Internal Medicine, Gachon University of Medicine and Science, Incheon, Korea
| | - Won Hyeok Choe
- Department of Internal Medicine, Konkuk University College of Medicine, Seoul, Korea
| | - June Sung Lee
- Department of Internal Medicine, Inje University College of Medicine, Goyang, Korea
| | - In Hee Kim
- Department of Internal Medicine, Chonbuk National University College of Medicine, Jeonju, Korea
| | - Jae Jun Shim
- Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Gab Jin Cheon
- Department of Internal Medicine, Ulsan University College of Medicine, Gangneung, Korea
| | - Si Hyun Bae
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Yeon Seok Seo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Dae Hee Choi
- Department of Internal Medicine, Kangwon National University College of Medicine, Chuncheon, Korea
| | - Se Jin Jang
- Department of Preventive Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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Guideline adherence and outcomes in esophageal variceal hemorrhage: comparison of tertiary care and non-tertiary care settings. J Clin Gastroenterol 2012; 46:235-42. [PMID: 21778893 DOI: 10.1097/mcg.0b013e318227422d] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Implementation of consensus guidelines for esophageal variceal hemorrhage yields improved outcomes. We evaluated guideline adherence and outcomes after variceal hemorrhage at a university hospital (UH) and a staff-model health maintenance organization (HMO). STUDY Factors associated with short-term bleeding, infection, and death were retrospectively identified in UH (n=160) and HMO (n=123) patients with esophageal variceal hemorrhage from January 2000 to December 2006. A second analysis of factors associated with long-term rebleeding was conducted in patients who survived ≥14 days without rebleeding. RESULTS UH patients were younger, with more severe liver disease and overall illness (P<0.01). UH patients more often received vasoactive agents and prophylactic antibiotics (P<0.01), however the rate of endoscopic therapy did not differ. Infections at 14-days were similar (18.2% vs. 13.0%, P=0.25), but UH patients had greater in-hospital rebleeding (16.4% vs. 5.7%, P<0.01) and mortality (15.2% vs. 4.1%, P<0.01). Poor liver function and overall illness predicted infection, rebleeding, and death (adjusted odds ratio 2.75 to 13.39). Long-term rebleeding occurred in 36.1% of UH patients and 25.9% of HMO patients. Secondary prophylaxis reduced late rebleeding (hazard ratio 0.37 to 0.41). Poor liver function did not predict late rebleeding. Adherence to secondary prophylaxis was greater at the HMO (P<0.05), but late rebleeding did not differ (36% vs. 26%, P=0.13). CONCLUSIONS Irrespective of practice setting, poor liver function and critical illness predicted short-term bleeding, infection, and death after esophageal variceal hemorrhage, and secondary prophylaxis prevented long-term rebleeding. Differing guideline adherence did not influence outcomes between tertiary care and non-tertiary care centers.
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Adding banding ligation is effective as rescue therapy to prevent variceal rebleeding in haemodynamic non-responders to pharmacological therapy. Dig Liver Dis 2012; 44:55-60. [PMID: 21890439 DOI: 10.1016/j.dld.2011.07.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Revised: 05/20/2011] [Accepted: 07/26/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND It is unknown which is the best therapy to treat haemodynamic non-responders to pharmacological therapy after variceal bleeding. AIM To evaluate the efficacy of adding banding ligation to drugs to prevent variceal rebleeding in haemodynamic non-responders to drugs. METHODS Fifty-three cirrhotic patients with variceal bleeding underwent a hepatic venous pressure gradient (HVPG) measurement 5 days after the episode. Nadolol and nitrates were then titrated to maximum tolerated doses. A second HVPG was taken 14 days later. Responders (HVPG ≤12 mm Hg or ≥20% decrease from baseline) were maintained on drugs and non-responders had banding ligation added to drugs. RESULTS Mean follow-up was 28 months. In 5 patients the second HVPG could not be performed because of early rebleeding. The remaining 48 patients were classified as responders (n=24) and non-responders (n=24), who had banding added. No baseline differences were observed between groups. Variceal rebleeding occurred in 12% of the 48 patients whose haemodynamic response was assessed. Responders on drug therapy presented a 16% rebleeding rate, whilst non-responders rescued with banding showed an 8% rebleeding rate. Rebleeding-related mortality was not different between groups. CONCLUSION In a HVPG-guided strategy, adding banding ligation to drugs is an effective rescue strategy to prevent rebleeding in haemodynamic non-responders to drug therapy.
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Prevention and management of gastroesophageal varices in cirrhosis. Int J Hepatol 2012; 2012:750150. [PMID: 22577563 PMCID: PMC3346976 DOI: 10.1155/2012/750150] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 03/05/2012] [Indexed: 02/08/2023] Open
Abstract
Variceal hemorrhage is one of the major complications of liver cirrhosis associated with significant mortality and morbidity. Its management has evolved over the past decade and has substantially reduced the rate of first and recurrent bleeding while decreasing mortality. In general, treatment of esophageal varices can be divided into three categories: primary prophylaxis (prevention of first episode of bleeding), management of acute bleeding, and secondary prophylaxis (prevention of recurrent hemorrhage). The goal of this paper is to describe the current evidence behind the management of esophageal varices. We will discuss indications for primary prophylaxis and the different modes of therapy, pharmacological and interventional treatment in acute bleeding, and therapeutic options in preventing recurrent bleeding. The indications for TIPS will also be reviewed including its possible benefits in acute variceal hemorrhage.
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Abstract
Care of the liver transplant candidate is one of the most challenging, yet rewarding aspects of hepatology. Anticipation and intervention for the major complications of advanced liver disease increase the likelihood of survival until transplant.
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Affiliation(s)
- Hui-Hui Tan
- Department of Gastroenterology & Hepatology, Singapore General Hospital.
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63
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Abstract
Drugs are the most frequent cause of hypoglycaemia in adults. Although hypoglycaemia is a well known adverse effect of antidiabetic agents, it may occasionally develop in the course of treatment with drugs used in everyday clinical practice, including NSAIDs, analgesics, antibacterials, antimalarials, antiarrhythmics, antidepressants and other miscellaneous agents. They induce hypoglycaemia by stimulating insulin release, reducing insulin clearance or interfering with glucose metabolism. Several drugs may also potentiate the hypoglycaemic effect of antidiabetic agents. Administration of these agents to individuals with diabetes mellitus is of most concern. Many of these drugs, and depending on clinical setting, may also induce hyperglycaemia. Drug-induced hepatotoxicity and nephrotoxicity may lead in certain circumstances to hypoglycaemia. Some drugs may also induce hypoglycaemia by causing pancreatitis. Drug-induced hypoglycaemia is usually mild but may be severe. Effective clinical management can be handled through awareness of this drug-induced adverse effect on blood glucose levels. Herein, we review pertinent clinical information on the incidence of drug-induced hypoglycaemia and discuss the underlying pathophysiological mechanisms, and prevention and management.
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Affiliation(s)
- Chaker Ben Salem
- Department of Clinical Pharmacology, Faculty of Medicine of Sousse, and Medical Intensive Care Unit, Sahloul University Hospital, Sousse, Tunisia.
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64
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Abstract
Variceal bleeding is a major event in the natural history of end-stage liver disease with a subsequent high mortality rate. Non-selective β-blockers are currently the drugs of choice for preventing first variceal bleeding. Endoscopic rubber band ligation of high risk varices features as a first line option if cirrhotic patients cannot tolerate β-blockers. Despite adequate β-blockade, some patients may still present with variceal bleeding. The effect of carvedilol, a non-selective β and α-1 receptor-blocker, on lowering portal pressure has been investigated in several clinical trials and found to be superior to propranolol in both acute and chronic hemodynamic studies. Recently, carvedilol has also been compared with band ligation for primary prophylaxis against variceal bleeding with equivalent results to band ligation. Patient tolerance to carvedilol in advanced liver disease remains a source of concern. This review examines the place of carvedilol as an alternative to the currently recommended pharmacological therapy in prophylaxis against variceal bleeding.
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Affiliation(s)
- Hamdan Al-Ghamdi
- Department of Hepatobiliary Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
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Thalheimer U, Triantos C, Goulis J, Burroughs AK. Management of varices in cirrhosis. Expert Opin Pharmacother 2011; 12:721-35. [PMID: 21269241 DOI: 10.1517/14656566.2011.537258] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Acute variceal bleeding is a medical emergency and one of the main causes of mortality in patients with cirrhosis. Timely and effective treatment of the acute bleeding episode results in increased survival, and appropriate prophylactic treatment can prevent bleeding or rebleeding from varices. AREAS COVERED We discuss the prevention of development and growth of varices, the primary and secondary prophylaxis of bleeding, the treatment of acute bleeding, and the management of gastric varices. We systematically reviewed studies, without time limits, identified through Medline and searches of reference lists, and provide an overview of the evidence underlying the -treatment options in the management of varices in cirrhosis. EXPERT OPINION The management of variceal hemorrhage relies on nonspecific interventions (e.g., adequate fluid resuscitation, airway protection) and on specific interventions. These are routine prophylactic antibiotics, vasoactive drugs and endoscopic treatment. Procedures such as the placement of a Sengstaken-Blakemore tube or a transjugular intrahepatic portosystemic shunt (TIPS) can be lifesaving. The primary and secondary prophylaxis of bleeding is based on nonselective beta-blockers and endoscopy, even though TIPS or, less frequently, surgery have a role in selected cases.
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Affiliation(s)
- Ulrich Thalheimer
- The Royal Free Sheila Sherlock Liver Centre, University Department of Surgery, Royal Free Hospital, Pond Street, NW3 2QG, London, UK.
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Bittencourt PL, Farias AQ, Strauss E, Mattos AAD. Variceal bleeding: consensus meeting report from the Brazilian Society of Hepatology. ARQUIVOS DE GASTROENTEROLOGIA 2010; 47:202-16. [PMID: 20721469 DOI: 10.1590/s0004-28032010000200017] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Accepted: 08/17/2009] [Indexed: 02/06/2023]
Abstract
In the last decades, several improvements in the management of variceal bleeding have resulted in a significant decrease in morbidity and mortality of patients with cirrhosis and bleeding varices. Progress in the multidisciplinary approach to these patients has led to a better management of this disease by critical care physicians, hepatologists, gastroenterologists, endoscopists, radiologists and surgeons. In this respect, the Brazilian Society of Hepatology has, recently, sponsored a consensus meeting in order to draw evidence-based recommendations on the management of these difficult-to-treat subjects. An organizing committee comprised of four people was elected by the Governing Board and was responsible to invite 27 researchers from distinct regions of the country to make a systematic review of the subject and to present topics related to variceal bleeding, including prevention, diagnosis, management and treatment, according to evidence-based medicine. After the meeting, all participants met together for discussion of the topics and the elaboration of the aforementioned recommendations. The organizing committee was responsible for writing the final document. The meeting was held at Salvador, May 6th, 2009 and the present manuscript is the summary of the systematic review that was presented during the meeting, organized in topics, followed by the recommendations of the Brazilian Society of Hepatology.
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Funakoshi N, Ségalas-Largey F, Duny Y, Oberti F, Valats JC, Bismuth M, Daurès JP, Blanc P. Benefit of combination β-blocker and endoscopic treatment to prevent variceal rebleeding: A meta-analysis. World J Gastroenterol 2010; 16:5982-92. [PMID: 21157975 PMCID: PMC3007113 DOI: 10.3748/wjg.v16.i47.5982] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine whether the association of β-blockers with endoscopic treatment is superior to endoscopic treatment alone for the secondary prophylaxis of oesophageal variceal bleeding.
METHODS: Randomised controlled trials comparing sclerotherapy (SCL) with SCL plus β-blockers (BB) or banding ligation (BL) with BL plus BB were identified. Main outcomes were overall and 6, 12 and 24 mo rebleeding rates, as well as overall and 6, 12 and 24 mo mortality. Two statistical methods were used: Yusuf-Peto, and Der Simonian and Laird. Inter-trial heterogeneity was systematically taken into account.
RESULTS: Seventeen randomised controlled trials were included, 14 with SCL and 3 with BL. Combination β-blocker and endoscopic treatment significantly reduced rebleeding rates at 6, 12 and 24 mo and overall [odds ratio (OR): 2.20, 95% confidence interval (CI): 1.69-2.85, P < 0.0001] compared to endoscopic treatment alone. Mortality at 24 mo was significantly lower for the combined treatment group (OR: 1.83, 95% CI: 1.16-2.90, P = 0.009), as well as overall mortality (OR: 1.43, 95% CI: 1.03-1.98, P = 0.03).
CONCLUSION: Combination therapy should thus be recommended as the first line treatment for secondary prophylaxis of oesophageal variceal bleeding.
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Mishin I, Ghidirim G, Dolghii A, Bunic G, Zastavnitsky G. Implantation of self-expanding metal stent in the treatment of severe bleeding from esophageal ulcer after endoscopic band ligation. Dis Esophagus 2010; 23:E35-8. [PMID: 20731698 DOI: 10.1111/j.1442-2050.2010.01090.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Endoscopic variceal ligation is superior to sclerotherapy because of its lower rebleeding and complication rates. However, ligation may be associated with life-threatening bleeding from postbanding esophageal ulcer. We report a case of a 49-year-old male with massive hemorrhage from esophageal ulcer on 8th day after successful band ligation of bleeding esophageal varices caused by postviral liver cirrhosis (Child-Pugh class C). A removable polyurethane membrane-covered self-expanding metal stent (SX-ELLA stent Danis, 135 mm × 25 mm, ELLA-CS, Hradec-Kralove, Czech Republic) was inserted in ICU for preventing fatal hemorrhage. Complete hemostasis was achieved and stent was removed after 8 days without rebleeding or any complications. To the best of our knowledge, this is the first report in English literature regarding life-threatening hemorrhage from postbanding esophageal ulcer successfully treated by self-expanding metal stent in a patient with portal hypertension.
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Affiliation(s)
- I Mishin
- First Department of Surgery N. Anestiadi, Laboratory of Hepato-Pancreato-Biliary Surgery, Medical University N. Testemitsanu, National Center of Emergency Medicine, Kishinev, Moldova.
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Abstract
Portal hypertension is an increase in pressure in the portal vein and its tributaries. It is defined as a portal pressure gradient (the difference in pressure between the portal vein and the hepatic veins) greater than 5 mm Hg. Although this gradient defines portal hypertension, a gradient of 10 mm Hg or greater defines clinically significant portal hypertension, because this pressure gradient predicts the development of varices, decompensation of cirrhosis, and hepatocellular carcinoma. The most direct consequence of portal hypertension is the development of gastroesophageal varices that may rupture and lead to the development of variceal hemorrhage. This article reviews the pathophysiologic bases of the different pharmacologic treatments for portal hypertension in patients with cirrhosis and places them in the context of the natural history of varices and variceal hemorrhage.
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Affiliation(s)
- Cecilia Miñano
- Section of Digestive Diseases, Yale University School of Medicine, 333 Cedar Street, LMP 1080, New Haven, CT 06520, USA
- Section of Digestive Diseases, VA-Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University School of Medicine, 333 Cedar Street, LMP 1080, New Haven, CT 06520, USA
- Section of Digestive Diseases, VA-Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
- Corresponding author. Section of Digestive Diseases, Yale University School of Medicine, 333 Cedar Street, LMP 1080, New Haven, CT 06520.
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70
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Lo GH, Chen WC, Wang HM, Lee CC. Controlled trial of ligation plus nadolol versus nadolol alone for the prevention of first variceal bleeding. Hepatology 2010; 52:230-7. [PMID: 20578138 DOI: 10.1002/hep.23617] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
UNLABELLED Both nadolol and ligation have proved to be effective in the prophylaxis of first variceal bleeding. This study was conducted to evaluate the effects and safety of combining nadolol with ligation. Cirrhotic patients with high-risk esophageal varices but without a bleeding history were considered for enrolment. Eligible patients were randomized to receive band ligation plus nadolol (Combined group, 70 patients) or nadolol alone (Nadolol group, 70 patients). In the Combined group multiligators were applied. Patients received regular ligation treatment at an interval of 4 weeks until variceal obliteration. Nadolol was administered at a dose to reduce 25% of the pulse rate in both the Combined group and the Nadolol group. Both groups were comparable in baseline data. In the Combined group 50 patients (71%) achieved variceal obliteration. The mean dose of nadolol was 52 +/- 16 mg in the Combined group and 56 +/- 19 mg in the Nadolol group. During a median follow-up of 26 months, 18 patients (26%) in the Combined group and 13 patients (18%) in the Nadolol group experienced upper gastrointestinal bleeding (P = NS). Esophageal variceal bleeding occurred in 10 patients (14%) in the Combined group and nine patients (13%) in the Nadolol group (P = NS). Adverse events were noted in 48 patients (68%) in the Combined group and 28 patients (40%) in the Nadolol group (P = 0.06). Sixteen patients in each group died. CONCLUSION The addition of ligation to nadolol may increase adverse events and did not enhance effectiveness in the prophylaxis of first variceal bleeding.
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Affiliation(s)
- Gin-Ho Lo
- Department of Medical Education, Digestive Center, E-DA Hospital, Kaohsiung, Taiwan.
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71
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Abstract
Gastroesophageal variceal hemorrhage is a major complication of portal hypertension in 50% to 60% of patients with liver cirrhosis and is a frequent cause of mortality in these patients. The prevalence of variceal hemorrhage is approximately 5% to 15% yearly, and early variceal rebleeding has a rate of occurrence of 30% to 40% within the first 6 weeks. More than 50% of patients who survive after the first bleeding episode will experience recurrent bleeding within 1 year. Management of gastroesophageal varices should include prevention of initial and recurrent bleeding episodes and control of active hemorrhage. Therapies used in the management of gastroesophageal variceal hemorrhage may include pharmacologic therapy (vasoactive agents, nonselective b-blockers, and antibiotic prophylaxis), endoscopic therapy, transjugular intrahepatic portosystemic shunt, and shunt surgery. This article focuses primarily on pharmacologic management of acute variceal hemorrhage.
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Affiliation(s)
- Tram B Cat
- Critical Care, Department of Pharmacy, Antelope Valley Hospital, 1600 West Avenue, Lancaster, CA 93534, USA.
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72
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Abstract
The rate of rebleeding from esophageal varices remains appreciably high after cessation of acute esophageal variceal hemorrhage. Many measures have been developed to prevent the occurrence of rebleeding. Endoscopic therapy plays a central role in the prevention of variceal bleeding. In the 1980s sclerotherapy played a pivotal role in the prevention of variceal rebleeding, but now yields to endoscopic variceal ligation. Compared with sclerotherapy, a lower incidence of complications and rebleeding is associated with banding ligation. On the other hand, beta-blockers are also noted to be able to reduce portal pressure, leading to the reduction of variceal rebleeding. The reduction of variceal rebleeding with beta-blockers plus nitrates is as effective as banding ligation. The combination of beta-blockers and endoscopic variceal ligation has proven to be more efficacious than banding ligation alone in the reduction of variceal rebleeding and is the treatment of choice for patients with failure in either medical or endoscopic therapy. Patients with repeated rebleeding despite endoscopic therapies may require transjugular intrahepatic portosystemic stent shunt or shunt operation as a rescue therapy.
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Affiliation(s)
- Gin-Ho Lo
- Department of Medical Education, Digestive Center, E-DA Hospital, Kaohsiung County, Taiwan, Republic of China.
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73
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Variceal bleeding in an adolescent with HIV diagnosed with hepatoportal sclerosis and nodular regenerative hyperplasia. J Pediatr Gastroenterol Nutr 2010; 50:340-3. [PMID: 19841596 DOI: 10.1097/mpg.0b013e3181a70f63] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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74
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Kravetz D. Gastrointestinal bleeding: Secondary prophylaxis for variceal bleeding. Nat Rev Gastroenterol Hepatol 2010; 7:10-1. [PMID: 20051968 DOI: 10.1038/nrgastro.2009.216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- David Kravetz
- VA San Diego Healthcare System, GI Section, MC 9-111D, San Diego, CA 92161, USA.
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PillCam ESO versus esophagogastroduodenoscopy in esophageal variceal screening: A decision analysis. J Clin Gastroenterol 2009; 43:975-81. [PMID: 19661814 DOI: 10.1097/mcg.0b013e3181a7ed09] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES PillCam ESO has been evaluated as a possible strategy to screen patients with cirrhosis for esophageal varices, but current guidelines recommend patients undergo screening with esophagogastroduodenoscopy (EGD), as it is currently the gold standard. Although recent data have suggested that PillCam ESO may be an acceptable alternative for screening, there is limited data on its cost-effectiveness compared with other screening modalities. This study was performed to compare the cost-effectiveness of PillCam ESO versus EGD for esophageal variceal screening. METHODS Markov models were constructed to compare 2 screening strategies: PillCam ESO versus EGD. In each arm, patients were followed for a time horizon of 15 years in 1-year transition intervals. All variables, transition probabilities, and costs were derived from the medical literature, and sensitivity analyses were performed on the different variables in the model. RESULTS Base-case analysis shows that PillCam ESO is associated with an average expected cost of $22,589 and an average expected effectiveness measure of 12.81 life-years. EGD is associated with an average expected cost of $23,083 and an average expected effectiveness measure of 12.67 life-years. PillCam ESO was found to dominate EGD as a screening strategy for patients with cirrhosis. Sensitivity analyses found several variables within the model to have influential effects on the results. CONCLUSIONS PillCam ESO is the dominant strategy for screening patients with cirrhosis for esophageal varices. However, based on a small difference in costs and effectiveness between each strategy, the results would suggest that PillCam ESO and EGD are essentially equivalent strategies.
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76
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Ayoub WS, Nguyen MH. Combination of pharmacologic and endoscopic therapy for the secondary prevention of esophageal variceal bleeding. Gastrointest Endosc 2009; 70:665-7. [PMID: 19788982 DOI: 10.1016/j.gie.2009.05.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Accepted: 05/29/2009] [Indexed: 02/08/2023]
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Ravipati M, Katragadda S, Swaminathan PD, Molnar J, Zarling E. Pharmacotherapy plus endoscopic intervention is more effective than pharmacotherapy or endoscopy alone in the secondary prevention of esophageal variceal bleeding: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 2009; 70:658-664.e5. [PMID: 19643407 DOI: 10.1016/j.gie.2009.02.029] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2008] [Accepted: 02/26/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous clinical trials on the treatment of esophageal variceal bleeding yielded mixed results regarding the efficacy of endoscopic procedures compared with pharmacotherapy only. OBJECTIVE To compare the efficacy of endoscopic procedures with that of pharmacotherapy in the prevention of mortality and rebleeding. DESIGN AND SETTING A systematic literature review was performed to identify randomized, controlled trials of the efficacy of pharmacotherapy and endoscopic therapy. A meta-analysis was performed by using the Comprehensive MetaAnalysis software package. A 2-sided alpha error <.05 was considered statistically significant (P < .05). PATIENTS Twenty-five clinical trials with a total of 2159 patients were eligible for meta-analysis. OUTCOME MEASUREMENTS Relative risk (RR) with 95% confidence interval (CI) was computed for all-cause mortality, mortality from rebleeding, all-cause rebleeding, and rebleeding caused by varices. RESULTS Pharmacotherapy was as effective as endoscopic procedures in preventing rebleeding (RR 1.067; 95% CI, 0.865-1.316; P = .546), variceal rebleeding (RR 1.143; 95% CI, 0.791-1.651; P = .476), all-cause mortality (RR 0.997; 95% CI, 0.827-1.202, P = .978), and mortality from rebleeding (RR 1.171; 95% CI, 0.816-1.679; P = .39). Pharmacotherapy combined with endoscopic procedures did not reduce all-cause mortality (RR 0.787; 95% CI, 0.587-1.054; P = .108) or mortality caused by rebleeding (RR 0.786; 95% CI, 0.445-1.387; P = .405) compared with endoscopic procedures. However, combination therapy (endoscopic procedure plus pharmacotherapy) significantly reduced the incidence of all rebleeding (RR 0.623; 95% CI, 0.523-0.741; P < .001) and variceal rebleeding (RR 0.601; 95% CI, 0.440-0.820; P < .001). LIMITATIONS Heterogeneity of patient population and different treatment protocols may have affected our meta-analysis. CONCLUSION Pharmacotherapy may be as effective as endoscopic therapy in reducing rebleeding rates and all-cause mortality. Pharmacotherapy plus endoscopic intervention is more effective than endoscopic intervention alone.
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78
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Cheung J, Zeman M, van Zanten SV, Tandon P. Systematic review: secondary prevention with band ligation, pharmacotherapy or combination therapy after bleeding from oesophageal varices. Aliment Pharmacol Ther 2009; 30:577-88. [PMID: 19558563 DOI: 10.1111/j.1365-2036.2009.04075.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Variable methods are available for secondary prevention after oesophageal variceal bleeding (EVB). AIM To compare band ligation (BL), pharmacotherapy (PT) and BL+PT for EVB secondary prevention. METHODS A systematic search of databases, references and meeting abstracts was conducted for randomized trials of BL, PT or BL+PT. The outcomes were mortality, rebleeding and adverse events. A random-effects model was used for meta-analyses. RESULTS Twelve trials were included (6 BL vs. PT, 4 BL+PT vs. BL, 2 BL+PT vs. PT). All trials used beta-blockers +/- isosorbide mononitrate (ISMN) as PT. Mortality was not significantly different among trials. Rebleeding was not significantly different for BL vs. PT (RR 1.00, 95% CI 0.73-1.37). BL reduced rebleeding compared with PT for trials with mean beta-blocker dose <80 mg/day (RR 0.67, 95% CI 0.49-0.91). There were nonsignificant differences in rebleeding for BL+PT vs. BL (RR 0.57, 95% CI 0.31-1.08) and BL+PT vs. PT (RR 0.76, 95% CI 0.56-1.03). There was no difference in adverse events between BL vs. PT, but was higher with BL+PT vs. BL. CONCLUSION Band ligation and PT alone are comparable for secondary prevention of rebleeding after EVB. Further trials with adequate PT dosing are required to determine the efficacy of combination BL+PT therapy.
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Affiliation(s)
- J Cheung
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada.
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79
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Kumar A, Jha SK, Sharma P, Dubey S, Tyagi P, Sharma BC, Sarin SK. Addition of propranolol and isosorbide mononitrate to endoscopic variceal ligation does not reduce variceal rebleeding incidence. Gastroenterology 2009; 137:892-901, 901.e1. [PMID: 19481079 DOI: 10.1053/j.gastro.2009.05.049] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Revised: 04/08/2009] [Accepted: 05/20/2009] [Indexed: 01/06/2023]
Abstract
BACKGROUND & AIMS Endoscopic variceal ligation (EVL) and propranolol are standard secondary prophylaxis therapies for variceal bleeding. Addition of isosorbide mononitrate (ISMN) to propranolol improves its hemodynamic efficacy; we investigated whether a combination of EVL and propranolol/ISMN was more effective than EVL alone for secondary prophylaxis. METHODS Patients with a prior variceal bleed were randomly assigned to groups given a combination (n = 88) of EVL, propranolol (dose titrated to reduce heart rate to 55 beats per minute), and ISMN (40 mg/day) or EVL alone (n = 89). Primary end points were rebleeding or death; secondary end points were new complications of portal hypertension or serious adverse effects. RESULTS The actuarial probabilities of rebleeding 2 years after therapy were 27% in the combination group and 31% in the EVL alone group (P = .822). Two patients in the combination group and 3 patients in the EVL alone group died during the study period (P = .682); no deaths were caused by variceal hemorrhage. In cirrhotic patients, the actuarial probabilities of rebleeding were 24% and 30%, respectively (P = .720). Secondary end points were comparable between groups. In multivariate analyses, presence of ascites (P = .003), serum albumin < 3.3 g/dL (P = .008), and hepatic venous pressure gradients > or = 18 mm Hg (P = .009) were independent risk factors for variceal rebleeding. CONCLUSIONS EVL alone is sufficient to prevent variceal rebleeding in cirrhotic and noncirrhotic patients with history of variceal bleeding. Addition of propranolol and ISMN to EVL does not reduce the incidence of variceal rebleeding but increases severe adverse effects. Risk factors for rebleeding include ascites, low serum albumin, and high hepatic venous pressure gradients.
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Affiliation(s)
- Ashish Kumar
- Department of Medical Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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80
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Garcia-Tsao G, Lim JK. Management and treatment of patients with cirrhosis and portal hypertension: recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program. Am J Gastroenterol 2009; 104:1802-29. [PMID: 19455106 DOI: 10.1038/ajg.2009.191] [Citation(s) in RCA: 170] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cirrhosis represents the end stage of any chronic liver disease. Hepatitis C and alcohol are currently the main causes of cirrhosis in the United States. Although initially cirrhosis is compensated, it eventually becomes decompensated, as defined by the presence of ascites, variceal hemorrhage, encephalopathy, and/or jaundice. These management recommendations are divided according to the status, compensated or decompensated, of the cirrhotic patient, with a separate section for the screening, diagnosis, and management of hepatocellular carcinoma (HCC), as this applies to patients with both compensated and decompensated cirrhosis. In the compensated patient, the main objective is to prevent variceal hemorrhage and any practice that could lead to decompensation. In the decompensated patient, acute variceal hemorrhage and spontaneous bacterial peritonitis are severe complications that require hospitalization. Hepatorenal syndrome is also a severe complication of cirrhosis but one that usually occurs in patients who are already in the hospital and, as it represents an extreme of the hemodynamic alterations that lead to ascites formation, it is placed under treatment of ascites. Recent advances in the pathophysiology of the complications of cirrhosis have allowed for a more rational management of cirrhosis and also for the stratification of patients into different risk groups that require different management. These recommendations are based on evidence in the literature, mainly from randomized clinical trials and meta-analyses of these trials. When few or no data exist from well-designed prospective trials, emphasis is given to results from large series and consensus conferences with involvement of recognized experts. A rational management of cirrhosis will result in improvements in quality of life, treatment adherence, and, ultimately, in outcomes.
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81
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Lo GH, Chen WC, Chan HH, Tsai WL, Hsu PI, Lin CK, Chen TA, Lai KH. A randomized, controlled trial of banding ligation plus drug therapy versus drug therapy alone in the prevention of esophageal variceal rebleeding. J Gastroenterol Hepatol 2009; 24:982-7. [PMID: 19638080 DOI: 10.1111/j.1440-1746.2009.05792.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND & AIMS Both medications with beta-blockers and isosorbide-5-mononitrate and endoscopic variceal ligation have been proven plausible in the prevention of variceal rebleeding. However, the relative efficacy and safety of the combined treatment for preventing rebleeding remains unresolved. METHODS Patients with history of esophageal variceal bleeding were enrolled. Emergency ligation was performed in patients with acute variceal bleeding. After hemodynamic stability, eligible patients were randomized to either the Medication group, using nadolol plus isorsorbide-5-mononitrate, or the Combined group, receiving banding ligation in addition to medications. Patients in the two groups with rebleeding from esophageal varices were treated with band ligation. The end points were rebleeding from varices or death. RESULTS After a median follow up of 23 months, recurrent upper gastrointestinal bleeding developed in 51% in the Medication group and 38% in the Combined group (P = 0.21). Recurrent bleeding from esophageal varices occurred in 26 patients (43%) in the Medication group and in 16 patients (26%) in the Combined group (P = 0.07). Recurrent bleeding from gastroesophageal varices occurred in 48% of Medication group and 28% of Combined group (P = 0.05). The frequency of adverse effects and mortality rates were similar between both groups (P = 0.28). CONCLUSIONS Combined ligation with medications was marginally more effective than medication alone in the prevention of gastroesophageal variceal rebleeding with similar adverse effects and mortality.
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Affiliation(s)
- Gin-Ho Lo
- Digestive Center, E-DA Hospital, Taipei, Taiwan.
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Ding SH, Liu J, Wang JP. Efficacy of β-adrenergic blocker plus 5-isosorbide mononitrate and endoscopic band ligation for prophylaxis of esophageal variceal rebleeding: A meta-analysis. World J Gastroenterol 2009; 15:2151-5. [PMID: 19418589 PMCID: PMC2678587 DOI: 10.3748/wjg.15.2151] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To systematically assess the efficacy and safety of β-adrenergic blocker plus 5-isosorbide mononitrate (BB + ISMN) and endoscopic band ligation (EBL) on prophylaxis of esophageal variceal rebleeding.
METHODS: Randomized controlled trials (RCTs) comparing the efficacy and safety of BB + ISMN and EBL on prophylaxis of esophageal variceal rebleeding were gathered from Medline, Embase, Cochrane Controlled Trial Registry and China Biological Medicine database between January 1980 and August 2007. Data from five trials were extracted and pooled. The analyses of the available data using the Revman 4.2 software were based on the intention-to-treat principle.
RESULTS: Four RCTs met the inclusion criteria. In comparison with BB + ISMN with EBL in prophylaxis of esophageal variceal rebleeding, there was no significant difference in the rate of rebleeding [relative risk (RR), 0.79; 95% CI: 0.62-1.00; P = 0.05], bleeding-related mortality (RR, 0.76; 95% CI: 0.31-1.42; P = 0.40), overall mortality (RR, 0.81; 95% CI: 0.61-1.08; P = 0.15) and complications (RR, 1.26; 95% CI: 0.93-1.70; P = 0.13).
CONCLUSION: In the prevention of esophageal variceal rebleeding, BB + ISMN are as effective as EBL. There are few complications with the two treatment modalities. Both BB + ISMN and EBL would be considered as the first-line therapy in the prevention of esophageal variceal rebleeding.
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83
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Cerebral embolism following N-butyl-2-cyanoacrylate injection for esophageal postbanding ulcer bleed: a case report. Hepatol Int 2009; 3:504-8. [PMID: 19669253 DOI: 10.1007/s12072-009-9130-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Accepted: 04/13/2009] [Indexed: 12/12/2022]
Abstract
Systemic embolization is a rare but serious complication of variceal injection with cyanoacrylate. We report a case of cerebral embolism a few hours after an injection of Histoacryl into a bleeding esophageal post-banding ulcer. Echocardiogram revealed patent foramen ovale.
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84
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Villanueva C, Aracil C, Colomo A, Lopez-Balaguer JM, Piqueras M, Gonzalez B, Torras X, Guarner C, Balanzo J. Clinical trial: a randomized controlled study on prevention of variceal rebleeding comparing nadolol + ligation vs. hepatic venous pressure gradient-guided pharmacological therapy. Aliment Pharmacol Ther 2009; 29:397-408. [PMID: 19006538 DOI: 10.1111/j.1365-2036.2008.03880.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hepatic venous pressure gradient (HVPG) monitoring of therapy to prevent variceal rebleeding provides strong prognostic information. Treatment of nonresponders to beta-blockers +/- nitrates has not been clarified. AIM To assess the value of HVPG-guided therapy using nadolol + prazosin in nonresponders to nadolol + isosorbide-5-mononitrate (ISMN) compared with a control group treated with nadolol + ligation. METHODS Cirrhotic patients with variceal bleeding were randomized to HVPG-guided therapy (n = 30) or nadolol + ligation (n = 29). A Baseline haemodynamic study was performed and repeated within 1 month. In the guided-therapy group, nonresponders to nadolol + ISMN received nadolol and carefully titrated prazosin and had a third haemodynamic study. RESULTS Nadolol + prazosin decreased HVPG in nonresponders to nadolol + ISMN (P < 0.001). Finally, 74% of patients were responders in the guided-therapy group vs. 32% in the nadolol + ligation group (P < 0.01). The probability of rebleeding was lower in responders than in nonresponders in the guided therapy group (P < 0.01), but not in the nadolol + ligation group (P = 0.41). In all, 57% of nonresponders rebled in the guided-therapy group and 20% in the nadolol + ligation group (P = 0.05). The incidence of complications was similar. CONCLUSIONS In patients treated to prevent variceal rebleeding, the association of nadolol and prazosin effectively rescued nonresponders to nadolol and ISMN, improving the haemodynamic response observed in controls receiving nadolol and endoscopic variceal ligation. Our results also suggest that ligation may rescue nonresponders.
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Affiliation(s)
- C Villanueva
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Autonomous University, Barcelona, Spain.
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Abstract
Chronic liver failure is an important cause of morbidity and mortality and is the long-term consequence of many chronic liver diseases. In addition to determining the specific cause of the chronic liver disease, which may be amenable to targeted therapy, it is important to treat the sequelae of chronic liver failure effectively to improve quality of life, to prolong survival, and to provide a bridge to liver transplantation. Once a patient who has chronic liver failure develops hepatic decompensation, liver transplantation is the definitive treatment for those who qualify. Management of chronic liver failure is the focus of this article.
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Affiliation(s)
- Gaurav Arora
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Room M211, Stanford, CA 94305-5187, USA
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Garcia-Pagan JC, De Gottardi A, Bosch J. Review article: the modern management of portal hypertension--primary and secondary prophylaxis of variceal bleeding in cirrhotic patients. Aliment Pharmacol Ther 2008; 28:178-86. [PMID: 18462268 DOI: 10.1111/j.1365-2036.2008.03729.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Variceal bleeding is a life-threatening complication of liver cirrhosis with a high probability of recurrence. Treatment to prevent first bleeding or rebleeding is mandatory. AIM To provide an overview of the current knowledge on the best evidence-based therapeutic options to prevent first or recurrent bleeding from oesophageal varices in patients with cirrhosis. METHODS For the preparation of this narrative review, we sought to analyse randomized controlled trials that examined the efficacy and side effects of pharmacological or endoscopic therapy for the primary and secondary prophylaxis of oesophageal variceal bleeding. RESULTS Endoscopic band ligation (EBL) and nonselective beta-blockers are both effective in preventing first bleeding. Until more long-term data are available, nonselective beta-blockers should be the first treatment option because of less severe side effects. EBL is an alternative when beta-blockers are contraindicated or not tolerated. Patient preference may also be considered. For prevention of rebleeding, nonselective beta-blockers (preferably in association with isosorbide-5-mononitrate) or EBL are both effective and good alternative treatments. A combination of both treatments may be the best alternative. CONCLUSIONS A great improvement in the prevention of variceal bleeding has emerged over the last years. However, further therapeutic options that combine higher efficacy, better tolerance and fewer side effects are needed.
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Affiliation(s)
- J C Garcia-Pagan
- Liver Unit, Hepatic Hemodynamic Laboratory, Hospital Clinic, IDIBAPS and Ciberehd, Barcelona, Spain.
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87
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Sharma S, Gurakar A, Jabbour N. Avoiding pitfalls: what an endoscopist should know in liver transplantation--part 1. Dig Dis Sci 2008; 53:1757-73. [PMID: 17990105 DOI: 10.1007/s10620-007-0079-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2007] [Accepted: 10/14/2007] [Indexed: 02/07/2023]
Abstract
Cirrhosis is associated with global homodynamic changes, but the majority of the complications are usually manifested through the gastrointestinal tract. Therefore, Gastrointestinal Endoscopy has become an important tool in the multidisciplinary approach in the management of these patients. With the ever growing number of cirrhotic patients requiring pre-transplant endoscopic management, it is imperative that the community endoscopists are well aware of the pathologies that can be potentially noted on Gastrointestinal Endoscopy. Their timely management is also considered to have the utmost importance in being able to stabilize the patient until their transfer to a Liver Transplant Center. The aim of this manuscript is to give a comprehensive update and review of various endoscopic findings that a non-transplant endoscopist will encounter in the pre-transplant setting.
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Affiliation(s)
- Sharad Sharma
- Baptist Medical Center, Nazih Zuhdi Transplant Institute, 3300 North West Expressway, Oklahoma City, OK 73112, USA.
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88
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Bosch J, Berzigotti A, Garcia-Pagan JC, Abraldes JG. The management of portal hypertension: rational basis, available treatments and future options. J Hepatol 2008; 48 Suppl 1:S68-92. [PMID: 18304681 DOI: 10.1016/j.jhep.2008.01.021] [Citation(s) in RCA: 185] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Variceal bleeding is the last step in a chain of events initiated by an increase in portal pressure, followed by the development and progressive dilation of varices until these finally rupture and bleed. This sequence of events might be prevented - and reversed - by achieving a sufficient decrease in portal pressure. A different approach is the use of local endoscopic treatments at the varices. This article reviews the rationale for the management of patients with cirrhosis and portal hypertension, the current recommendations for the prevention and treatment of variceal bleeding, and outlines the unsolved issues and the perspectives for the future opened by new research developments.
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Affiliation(s)
- Jaime Bosch
- Hepatic Hemodynamic Laboratory, Liver Unit, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), University of Barcelona, Hospital Clínic, C.Villarroel 170, 08036 Barcelona, Spain.
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89
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Bureau C, Vinel JP. Management of failures of first line treatments. Dig Liver Dis 2008; 40:343-7. [PMID: 18378199 DOI: 10.1016/j.dld.2008.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2007] [Accepted: 02/15/2008] [Indexed: 12/11/2022]
Abstract
Up to 70% of the patients treated to prevent rebleeding will experience a bleeding episode within 2 years. The response should be adapted to the delay after the index bleed, the source and the severity of the haemorrhage, the underlying liver disease and the initial treatment to prevent rebleeding. Bleeding can be caused by endoscopic techniques themselves, which should incitate to complete obliteration rather than to switch to another therapy. Failure of drug therapy can be secondary to ineffectiveness, to a lack of compliance, or to an insufficient dosage. The two latter conditions may be corrected. Whenever a patient rebleeds in spite of optimal treatment, liver transplantation should be considered. When such a procedure is contra-indicated and in patients on the waiting list, a Transjugular intra-hepatic porto-systemic shunt (TIPS) should be performed.
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Affiliation(s)
- C Bureau
- Service d'Hépato-Gastroentérologie, CHU Purpan, et INSERM U858, Toulouse, France
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90
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Berzigotti A, García-Pagán JC. Prevention of recurrent variceal bleeding. Dig Liver Dis 2008; 40:337-42. [PMID: 18291735 DOI: 10.1016/j.dld.2007.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Accepted: 12/04/2007] [Indexed: 12/11/2022]
Abstract
Patients surviving a first episode of variceal bleeding have a risk of over 60% of experiencing recurrent haemorrhages within 1 year from the index episode. Because of this, all patients surviving a variceal bleeding should receive active treatments for the prevention of rebleeding. beta-Blockers+/-isosorbide-5-mononitrate and band ligation are effective in preventing recurrent bleeding and both can be used. Combination of beta-blockers+/-isosorbide-5-mononitrate and band ligation may be the best treatment to prevent rebleeding but more studies are needed to confirm this issue. In patients with recurrent variceal bleeding despite appropriate medical and endoscopic treatment, transjugular intrahepatic porto-systemic shunt is highly effective in controlling bleeding. The efficacy is not significantly different from that of shunt surgery (distal splenorenal shunt or 8mm H-graft shunt), especially since the introduction of polytetrafluoroethylene-covered stents. Therefore, in this situation, transjugular intrahepatic porto-systemic shunt using polytetrafluoroethylene stents should be the treatment of choice.
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Affiliation(s)
- A Berzigotti
- Hepatic Hemodynamic Laboratory, Liver Unit, IMD, Hospital Clinic, IDIBAPS and Ciberehd, University of Barcelona, C. Villarroel 170, 08036 Barcelona, Spain
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91
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Garcia-Tsao G, Bosch J, Groszmann RJ. Portal hypertension and variceal bleeding--unresolved issues. Summary of an American Association for the study of liver diseases and European Association for the study of the liver single-topic conference. Hepatology 2008; 47:1764-72. [PMID: 18435460 DOI: 10.1002/hep.22273] [Citation(s) in RCA: 191] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520, USA.
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92
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Klebl FH, Schölmerich J. Future expectations in the prophylaxis of intestinal bleeding. Best Pract Res Clin Gastroenterol 2008; 22:373-87. [PMID: 18346690 DOI: 10.1016/j.bpg.2007.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Prophylaxis of gastrointestinal bleeding is attempted in widely varying situations. In NSAID-induced peptic ulcer, the advantage of selective cyclooxygenase 2 inhibitors with regard to gastrointestinal damage has yet to be translated into an advantage in overall morbidity. Strategies for primary and secondary prevention of variceal bleeding have been established. Therapy tailored to hepatic venous pressure gradient has the potential to achieve clinical relevance. Several methods have been developed to prevent postpolypectomy bleeding, but their optimal risk-tailored application has yet to be demonstrated. Although octreotide treatment seems to be beneficial in reducing the blood loss from angiodysplasias, controlled studies to determine its optimal use are awaited. Stress-ulcer prophylaxis is commonly applied in critically ill patients. Although data indicate that H2-receptor antagonists and omeprazole are effective in preventing clinically significant bleeding, evidence for an advantage with respect to length of hospital or intensive-care-unit stay, as well as mortality, is still lacking. Since there is misuse of acid-suppressing drugs on regular wards, in-house guidelines may offer the potential for saving costs and reducing inappropriate prescription.
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Affiliation(s)
- F H Klebl
- Department of Internal Medicine I, University of Regensburg, D-93042 Regensburg, Germany.
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93
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Villanueva C, Colomo A, Aracil C, Guarner C. Current endoscopic therapy of variceal bleeding. Best Pract Res Clin Gastroenterol 2008; 22:261-78. [PMID: 18346683 DOI: 10.1016/j.bpg.2007.11.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Variceal ligation has proved more effective and safer than sclerotherapy and is currently the endoscopic treatment of choice for oesophageal varices. In acute bleeding, vasoactive drugs should be started before endoscopy and maintained for 2-5 days. The efficacy of drugs is improved when associated with emergency endoscopic therapy. Antibiotic prophylaxis should also be used. To prevent rebleeding, both endoscopic ligation and the combination of beta-blockers and nitrates may be used. Adding beta-blockers improves the efficacy of ligation. Haemodynamic responders to beta-blockers+/-nitrates (those with a decrease in portal pressure gradient HVPG to <12 mmHg or by >20% of baseline) have a marked reduction in the risk of haemorrhage and will not need further treatment. Beta-blockers significantly reduce the risk of a first haemorrhage in patients with large varices, and they improve survival. As compared to beta-blockers, endoscopic ligation reduces the risk of first bleeding without affecting mortality, and should be used in patients with contraindications or intolerance to beta-blockers.
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Affiliation(s)
- Càndid Villanueva
- Servei de Patologia Digestiva, Hospital de la Santa Creu i Sant Pau, Avgda Sant Antoni M. Claret, 167, 08025 Barcelona, Spain.
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94
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D'Amico G, Luca A. TIPS is a cost effective alternative to surgical shunt as a rescue therapy for prevention of recurrent bleeding from esophageal varices. J Hepatol 2008; 48:387-90. [PMID: 18199520 DOI: 10.1016/j.jhep.2007.12.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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95
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96
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Scaife C. Liver. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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97
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Thalheimer U, Bosch J, Burroughs AK. How to prevent varices from bleeding: shades of grey--the case for nonselective beta blockers. Gastroenterology 2007; 133:2029-36. [PMID: 18054573 DOI: 10.1053/j.gastro.2007.10.028] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2007] [Accepted: 09/27/2007] [Indexed: 12/11/2022]
Affiliation(s)
- Ulrich Thalheimer
- Liver Transplantation and Hepatobiliary Unit, Royal Free Hospital, London, United Kingdom
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98
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Prevention of recurrent esophageal variceal hemorrhage: review and current recommendations. J Clin Gastroenterol 2007; 41 Suppl 3:S318-22. [PMID: 17975483 DOI: 10.1097/mcg.0b013e318157f0a7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Variceal rebleeding is a very frequent and severe complication in cirrhotic patients; therefore, its prevention should be mandatory. Lately several studies demonstrated that the rate of rebleeding was decreased by 40% and overall survival is improved by 20% with beta-blockers. However, this treatment presents some problems, such as the number of nonresponders and contraindications for its use. Recent trials found that the combination of beta-blockers with mononitrate of isosorbide to be superior to beta-blockade alone. Furthermore, endoscopic band ligation also shown to decrease the frequency of rebleeding, complications, and death compared with sclerotherapy and should be the preferred endoscopic treatment. In addition, the comparison between combined pharmacologic treatment with endoscopic treatment present similar rebleeding and mortality rates. More recently, the addition of nadolol to endoscopic band ligation increased the efficacy of endoscopy alone in the prevention of variceal rebleeding. These studies suggest that banding plus drugs could be the treatment of choice for the prophylaxis of rebleeding. When these treatments fail, the recommendation is to use transjugular intrahepatic portosystemic shunt (TIPS) or surgical shunts. Both treatments are effective in preventing rebleeding; however, they are associated with a greater risk of encephalopathy. The comparison of portacaval shunts with TIPS demonstrated that TIPS patients presented higher rebleeding, treatment failure, and transplantation. Another randomized controlled trial comparing distal splenorenal shunt with TIPS shows that variceal rebleeding was similar in both groups without differences in encephalopathy and mortality. The only difference observed was the higher rate of reintervention observed in the TIPS group to maintain his patency.
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99
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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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Affiliation(s)
- Erwin Biecker
- Department of Internal Medicine I, University Hospital of Bonn, University of Bonn, Sigmund-Freud-Str. 25, Bonn, Germany.
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100
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Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007; 46:922-38. [PMID: 17879356 DOI: 10.1002/hep.21907] [Citation(s) in RCA: 1152] [Impact Index Per Article: 67.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University School of Medicine and VACT Healthcare System, New Haven, CT, USA
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