Liver transplantation in the management of bleeding oesophageal varices

Surgical shunt versus TIPS for treatment of variceal hemorrhage in the current era of liver and multivisceral transplantation

Over the last 3 decades, management of acute variceal bleeding and measures to prevent recurrent episodes has evolved due to the introduction of new therapeutic modalities including innovative surgical and minimally invasive shunt procedures. Such an evolution has been compounded by the parallel progress that has been achieved in organ transplantation. This article focuses primarily on the commonly used surgical and radiologic shunt procedures. Liver and multivisceral transplantation are also briefly discussed as important parts of the algorithmic management of these complex patients, particularly those with hepatic decompensation and portomesenteric venous thrombosis.

Management of bleeding in the cirrhotic patient

Important advances have been made in the management of variceal bleeding. Despite these advances, bleeding in the patient with cirrhosis remains one of the most demanding clinical challenges that a gastroenterologist or gastrointestinal surgeon may face. The aim is to identify the source of bleeding, control active bleeding and prevent rebleeding. This requires a multidisciplinary team, and the optimal management algorithm depends on the clinical circumstance of the patient and the local availability of endoscopic, radiological and surgical expertise. Injection sclerotherapy is effective in stopping acute variceal bleeding, but has the drawback of a high incidence of complications. Endoscopic variceal ligation is just as effective, and is associated with fewer complications. An overtube allows repeated introductions of the endoscope to be more tolerable for the patient and protects the airway against aspiration of blood; its use should be encouraged in patients with massive bleeding. Newer ligators can deliver multiple bands without removal of the scope but the high cost of these disposable devices limits their widespread use. Bleeding from gastric varices is even more challenging; the treatment of choice is injection with cyanoacrylate glue. To prevent rebleeding, beta-blockers are recommended for all patients with large varices (including those which have never bled). Injection sclerotherapy or band ligation, conducted at weekly intervals after the initial control of bleeding, is equally effective at obliterating varices and decreasing the risk of further hemorrhage; band ligation results in fewer complications. Other newer treatment modalities for variceal bleeding, such as somatostatin analogs, transjugular intrahepatic portasystemic shunt and liver transplantation, offer more optimal approaches to control bleeding and prevent rebleeding, but may be prohibitively expensive. Even for the most affluent communities, affordability, cost-effectiveness, and resource rationing are important considerations in management of patients with cirrhosis complicated by gastrointestinal bleeding.

Current status of transjugular intrahepatic portosystemic shunts

The use of the transjugular intrahepatic portosystemic shunt (TIPS) has emerged as an important nonoperative modality for variceal bleeding, intractable ascites, and for selected cases of hepatic venous obstruction. We believe that TIPS should be viewed as a 'bridge' to liver transplantation and should be carried out only in experienced centres. The adverse haemodynamic changes on the cardiopulmonary system after TIPS should be borne in mind. Prospective trials to evaluate the role of TIPS versus sclerotherapy in variceal bleeding will be watched with interest. There is, however, an urgent need to improve long-term results of TIPS as stent thrombosis and stenosis occur frequently. We advocate routine surveillance to detect these problems at an early stage.

Management of upper gastrointestinal bleeding in the patient with chronic liver disease

This article reviews the management of severe upper gastrointestinal bleeding in the patient with chronic liver diseases. The initial assessment, diagnostic work-up, and treatment options for variceal and nonvariceal bleeding are discussed. The role of diagnostic and therapeutic endoscopy for esophagogastric varices is reviewed with special emphasis on new endoscopic techniques including variceal band ligation and cyanoacrylate injection. Various pharmacologic, surgical, and radiologic treatment options for variceal bleeding also are discussed. In addition, nonvariceal causes of severe upper gastrointestinal bleeding are reviewed including peptic ulcer diseases, Mallory-Weiss tear, portal hypertensive gastropathy, and gastric antral vascular ectasia.

Management of variceal haemorrhage

Fig 2 gives an algorithm for the treatment of bleeding oesophageal varices. Initial resuscitation of the patient is of paramount importance, ideally followed by early interventional endoscopy. Recent advances in available endoscopic techniques enable the endoscopist to suit the therapeutic approach to the clinical situation. Injection sclerotherapy remains the initial treatment of choice in bleeding patients. Endoscopic banding ligation is an alternative, best used in patients who have spontaneously stopped bleeding or as a complementary treatment a few days after the initial session of injection sclerotherapy. The tissue adhesives and thrombin can be used to treat bleeding gastric varices. [table: see text] Should the endoscopic expertise not be available, drug treatment (with somatostatin or octreotide) or balloon tamponade are the treatments of choice. Transjugular intrahepatic portal-systemic stent shunt is a new effective technique, not yet widely available, which has a documented complication rate that has yet to be fully defined. It is a good alternative to surgery as a "rescue" procedure for patients who continue to bleed despite two sessions of endoscopic intervention.