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Kirchner VA, Shankar S, Victor DW, Tanaka T, Goldaracena N, Troisi RI, Olthoff KM, Kim JM, Pomfret EA, Heaton N, Polak WG, Shukla A, Mohanka R, Balci D, Ghobrial M, Gupta S, Maluf D, Fung JJ, Eguchi S, Roberts J, Eghtesad B, Selzner M, Prasad R, Kasahara M, Egawa H, Lerut J, Broering D, Berenguer M, Cattral MS, Clavien PA, Chen CL, Shah SR, Zhu ZJ, Ascher N, Ikegami T, Bhangui P, Rammohan A, Emond JC, Rela M. Management of Established Small-for-size Syndrome in Post Living Donor Liver Transplantation: Medical, Radiological, and Surgical Interventions: Guidelines From the ILTS-iLDLT-LTSI Consensus Conference. Transplantation 2023; 107:2238-2246. [PMID: 37749813 DOI: 10.1097/tp.0000000000004771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
Small-for-size syndrome (SFSS) following living donor liver transplantation is a complication that can lead to devastating outcomes such as prolonged poor graft function and possibly graft loss. Because of the concern about the syndrome, some transplants of mismatched grafts may not be performed. Portal hyperperfusion of a small graft and hyperdynamic splanchnic circulation are recognized as main pathogenic factors for the syndrome. Management of established SFSS is guided by the severity of the presentation with the initial focus on pharmacological therapy to modulate portal flow and provide supportive care to the patient with the goal of facilitating graft regeneration and recovery. When medical management fails or condition progresses with impending dysfunction or even liver failure, interventional radiology (IR) and/or surgical interventions to reduce portal overperfusion should be considered. Although most patients have good outcomes with medical, IR, and/or surgical management that allow graft regeneration, the risk of graft loss increases dramatically in the setting of bilirubin >10 mg/dL and INR>1.6 on postoperative day 7 or isolated bilirubin >20 mg/dL on postoperative day 14. Retransplantation should be considered based on the overall clinical situation and the above postoperative laboratory parameters. The following recommendations focus on medical and IR/surgical management of SFSS as well as considerations and timing of retransplantation when other therapies fail.
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Affiliation(s)
- Varvara A Kirchner
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Sadhana Shankar
- The Liver Unit, King's College Hospital, London, United Kingdom
| | - David W Victor
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, TX
| | - Tomohiro Tanaka
- Department of Internal Medicine, Gastroenterology and Hepatology, University of Iowa, Iowa City, IA
| | - Nicolas Goldaracena
- Abdominal Organ Transplant and Hepatobiliary Surgery, University of Virginia Health System, Charlottesville, VA
| | - Roberto I Troisi
- Division of Hepato-Bilio-Pancreatic, Minimally Invasive and Robotic Surgery, Department of Public Health, Federico II University Hospital, Naples, Italy
| | - Kim M Olthoff
- Department of Surgery, Division of Transplant Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Elizabeth A Pomfret
- Division of Transplant Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Nigel Heaton
- The Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Wojtek G Polak
- The Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Akash Shukla
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Ravi Mohanka
- Institute of Liver Disease, HPB Surgery and Transplant, Global Hospital, Mumbai, Maharashtra, India
| | - Deniz Balci
- Department of General Surgery and Organ Transplantation Bahcesehir University School of Medicine, Istanbul, Turkey
| | - Mark Ghobrial
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, TX
| | - Subash Gupta
- Max Centre for Liver and Biliary Sciences, Max Saket Hospital, New Delhi, India
| | - Daniel Maluf
- Program in Transplantation, University of Maryland Medical Center, University of Maryland School of Medicine, Baltimore, MD
| | - John J Fung
- Department of Surgery, University of Chicago Medicine Transplant Institute, Chicago, IL
| | - Susumu Eguchi
- Department of Surgery, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - John Roberts
- Department of Surgery, University of California San Francisco Medical Center, San Francisco, CA
| | - Bijan Eghtesad
- Digestive Disease and Surgery Institute, Cleveland Clinic; Clinical Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Markus Selzner
- HPB and Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Raj Prasad
- Division of Transplantation, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Mureo Kasahara
- National Center for Child Health and Development, Tokyo, Japan
| | - Hiroto Egawa
- Department of Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Jan Lerut
- Institute for Experimental and Clinical Research-Université catholique de Louvain, Brussels, Belgium
| | - Dieter Broering
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Marina Berenguer
- Liver Unit, CIBERehd, Instituto de Investigación Sanitaria La Fe, Hospital Universitario y Politécnico La Fe-Universidad de Valencia, Valencia, Spain
| | - Mark S Cattral
- HPB and Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Chao-Long Chen
- Liver Transplant Center and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Samir R Shah
- Institute of Liver Disease, HPB Surgery and Transplant, Global Hospitals, Mumbai, India
| | - Zhi-Jun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University; and Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
| | - Nancy Ascher
- Department of Surgery, University of California San Francisco Medical Center, San Francisco, CA
| | - Toru Ikegami
- Divsion of Hepatobiliary Surgery and Pancreas Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, New Delhi, India
| | - Ashwin Rammohan
- The Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, India
| | - Jean C Emond
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY
| | - Mohamed Rela
- The Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, India
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Felli E, Nulan Y, Selicean S, Wang C, Gracia-Sancho J, Bosch J. Emerging Therapeutic Targets for Portal Hypertension. CURRENT HEPATOLOGY REPORTS 2023; 22:51-66. [PMID: 36908849 PMCID: PMC9988810 DOI: 10.1007/s11901-023-00598-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 02/13/2023]
Abstract
Purpose of Review Portal hypertension is responsible of the main complications of cirrhosis, which carries a high mortality. Recent treatments have improved prognosis, but this is still far from ideal. This paper reviews new potential therapeutic targets unveiled by advances of key pathophysiologic processes. Recent Findings Recent research highlighted the importance of suppressing etiologic factors and a safe lifestyle and outlined new mechanisms modulating portal pressure. These include intrahepatic abnormalities linked to inflammation, fibrogenesis, vascular occlusion, parenchymal extinction, and angiogenesis; impaired regeneration; increased hepatic vascular tone due to sinusoidal endothelial dysfunction with insufficient NO availability; and paracrine liver cell crosstalk. Moreover, pathways such as the gut-liver axis modulate splanchnic vasodilatation and systemic inflammation, exacerbate liver fibrosis, and are being targeted by therapy. We have summarized studies of new agents addressing these targets. Summary New agents, alone or in combination, allow acting in complementary mechanisms offering a more profound effect on portal hypertension while simultaneously limiting disease progression and favoring regression of fibrosis and of cirrhosis. Major changes in treatment paradigms are anticipated.
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Affiliation(s)
- Eric Felli
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3012 Bern, Switzerland
- Department for BioMedical Research, Hepatology, University of Bern, 3012 Bern, Switzerland
| | - Yelidousi Nulan
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3012 Bern, Switzerland
- Department for BioMedical Research, Hepatology, University of Bern, 3012 Bern, Switzerland
| | - Sonia Selicean
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3012 Bern, Switzerland
- Department for BioMedical Research, Hepatology, University of Bern, 3012 Bern, Switzerland
| | - Cong Wang
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3012 Bern, Switzerland
- Department for BioMedical Research, Hepatology, University of Bern, 3012 Bern, Switzerland
| | - Jordi Gracia-Sancho
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3012 Bern, Switzerland
- Department for BioMedical Research, Hepatology, University of Bern, 3012 Bern, Switzerland
- Liver Vascular Biology Research Group, CIBEREHD, IDIBAPS Research Institute, 08036 Barcelona, Spain
| | - Jaume Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3012 Bern, Switzerland
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Novel therapeutics for portal hypertension and fibrosis in chronic liver disease. Pharmacol Ther 2020; 215:107626. [DOI: 10.1016/j.pharmthera.2020.107626] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 06/30/2020] [Indexed: 02/06/2023]
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Chuah YY, Hsu PI, Tsai WL, Yu HC, Tsay FW, Chen WC, Lin KH, Lee YY, Wang HM. Short-term vasoactive agent treatment driven by physicians' preference in acute esophageal variceal bleeding in a tertiary center. PeerJ 2019; 7:e7913. [PMID: 31720102 PMCID: PMC6842295 DOI: 10.7717/peerj.7913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 09/17/2019] [Indexed: 11/20/2022] Open
Abstract
Background Vasoactive drugs are frequently used in combination with endoscopic variceal ligation (EVL) in treatment of acute esophageal variceal bleeding (EVB). The aim of study was to assess physicians’ preference of vasoactive agents in acute EVB, their reasons of preference and efficacy and safety of these short course regimens. Methods Cirrhotic patients with suspected EVB were screened (n = 352). Eligible patients were assigned based on the physician’s preference to either somatostatin (group S) or terlipressin (group T) followed by EVL. In group S, intravenous bolus (250 µg) of somatostatin followed by 250 µg/hour was continued for three days. In group T, 2 mg bolus injection of terlipressin was followed by 1 mg infusion every 6 h for three days. Results A total of 150 patients were enrolled; 41 in group S and 109 in group T. Reasons for physician preference was convenience in administration (77.1%) for group T and good safety profile (73.2%) for group S. Very early rebleeding within 49–120 h occurred in one patient in groups S and T (p = 0.469). Four patients in group S and 14 patients in group T have variceal rebleeding episodes within 6–42 d (p = 0.781). Overall treatment-related adverse effects were compatible in groups S and T (p = 0.878), but the total cost of terlipressin and somatostatin differed i.e., USD 621.32 and USD 496.43 respectively. Conclusions Terlipressin is the preferred vasoactive agent by physicians in our institution for acute EVB. Convenience in administration and safety profile are main considerations of physicians. Safety and hemostatic effects did not differ significantly between short-course somatostatin or terlipressin, although terlipressin is more expensive.
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Affiliation(s)
- Yoen Young Chuah
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Department of Medicine, Ping Tung Christian Hospital, Ping Tung, Taiwan; Department of Nursing, Meiho University, Taiwan
| | - Ping-I Hsu
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Lun Tsai
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsien-Chung Yu
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Feng-Woei Tsay
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Chi Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Kung Hung Lin
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia.,Gut Research Group, Faculty of Medicine, The National University of Malaysia, Kuala Lumpur, Malaysia
| | - Huay-Min Wang
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
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5
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Abstract
Terlipressin, somatostatin, or octreotide are recommended as pharmacologic treatment of acute variceal hemorrhage. Nonselective β-blockers decrease the risk of variceal hemorrhage and hepatic decompensation, particularly in those 30% to 40% of patients with good hemodynamic response. Carvedilol, statins, and anticoagulants are promising agents in the management of portal hypertension. Recent advances in the pharmacologic treatment of portal hypertension have mainly focused on modifying an increased intrahepatic resistance through nitric oxide and/or modulation of vasoactive substances. Several novel pharmacologic agents for portal hypertension are being evaluated in humans.
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Affiliation(s)
- Chalermrat Bunchorntavakul
- Division of Gastroenterology and Hepatology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Rajavithi Road, Ratchathewi, Bangkok 10400, Thailand; Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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6
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Abstract
Acute variceal bleeding should be suspected in all patients with cirrhosis presenting with upper gastrointestinal bleeding. Vasoactive drugs and prophylactic antibiotics must be started as soon as possible, even before performing the diagnostic endoscopy. Once the patient is hemodynamically stable, upper gastrointestinal endoscopy should be performed in order to confirm the diagnosis and provide endoscopic therapy (preferably banding ligation). After this initial approach, the most appropriate therapy to prevent both early and late rebleeding must be instituted following a risk stratification strategy. The present chapter will focus on the initial management of patients with acute variceal bleeding, including general management and hemostatic therapies, as well as the available treatments in case of failure to control bleeding or development of rebleeding.
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Brunner F, Berzigotti A, Bosch J. Prevention and treatment of variceal haemorrhage in 2017. Liver Int 2017; 37 Suppl 1:104-115. [PMID: 28052623 DOI: 10.1111/liv.13277] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 10/19/2016] [Indexed: 12/14/2022]
Abstract
Variceal haemorrhage is a major complication of portal hypertension that still causes high mortality in patients with cirrhosis. Improved knowledge of the pathophysiology of portal hypertension has recently led to a more comprehensive approach to prevent all the complications of this condition. Thus, optimal treatment of portal hypertension requires a strategy that takes into account the clinical stage of the disease and all the major variables that affect the risk of progression to the next stage and death. In patients with compensated liver disease, the correction of factors influencing the progression of fibrosis, in particular aetiologic factors, is now feasible in many cases and should be achieved to prevent the development or progression of gastroesophageal varices and hepatic decompensation. Once gastroesophageal varices have developed, non-selective beta-blockers remain the cornerstone of therapy. Carvedilol provides a greater decrease in portal pressure and is currently indicated as a first-choice therapy for primary prophylaxis. The treatment of acute variceal haemorrhage includes a combination of vasoactive drugs, antibiotics and endoscopic variceal band ligation. In high-risk patients, the early use of transjugular intrahepatic portosystemic shunt (TIPS) lowers the risk of re-bleeding and improves survival. Transjugular intrahepatic portosystemic shunt is the choice for uncontrolled variceal bleeding; a self-expandable metal stent or balloon tamponade can be used as a bridging measure. The combination of non-selective beta-blockers and endoscopic variceal band ligation reduces the risk of recurrent variceal bleeding and improves survival. In these cases, statins seem to further improve survival. Transjugular intrahepatic portosystemic shunt is indicated in patients who rebleed during secondary prophylaxis.
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Affiliation(s)
- Felix Brunner
- Swiss Liver Center, Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annalisa Berzigotti
- Swiss Liver Center, Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jaime Bosch
- Swiss Liver Center, Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Hepatic Hemodynamic Laboratory, Hospital Clinic-IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
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8
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Mohkam K, Darnis B, Schmitt Z, Duperret S, Ducerf C, Mabrut JY. Successful modulation of portal inflow by somatostatin in a porcine model of small-for-size syndrome. Am J Surg 2016; 212:321-6. [DOI: 10.1016/j.amjsurg.2016.01.043] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 01/03/2016] [Accepted: 01/03/2016] [Indexed: 02/07/2023]
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9
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Garbuzenko DV. Current approaches to the management of patients with liver cirrhosis who have acute esophageal variceal bleeding. Curr Med Res Opin 2016; 32:467-75. [PMID: 26804426 DOI: 10.1185/03007995.2015.1124846] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Esophageal variceal bleeding is the most dangerous complication in patients with liver cirrhosis, and it is accompanied by high mortality. Their treatment can be complex, and requires a multidisciplinary approach. This review examines current approaches to the management of patients with liver cirrhosis who have acute esophageal variceal bleeding. METHODS PubMed, Google Scholar, and Cochrane Systematic Reviews were searched for articles published between 1987 and 2015. Relevant articles were identified using the following terms: 'esophageal variceal bleeding', 'portal hypertension' and 'complications of liver cirrhosis'. The reference lists of articles identified were also searched for other relevant publications. Inclusion criteria were restricted to the management of patients with liver cirrhosis who have acute esophageal variceal bleeding. RESULTS It is currently recommended to combine vasoactive drugs (preferable somatostatin or terlipressin) and endoscopic therapies (endoscopic band ligation as first choice, sclerotherapy if endoscopic band ligation not feasible) for the initial treatment of acute variceal bleeding. Antibiotic prophylaxis must be regarded as an integral part of the treatment. The use of a Sengstaken-Blakemore tube is appropriate only in cases of refractory bleeding if the above methods cannot be used. An alternative to balloon tamponade may be the installation of self-expandable metal stents. The transjugular intrahepatic portosystemic shunt is an extremely useful technique for the treatment of acute bleeding from esophageal varices. Although most current clinical guidelines classify it as second-line therapy, the Baveno VI workshop recommends early transjugular intrahepatic portosystemic shunt with expanded polytetrafluoroethylene-covered stents within 72 h (ideally <24 h) in patients with esophageal variceal bleeding at high risk of treatment failure (e.g. Child-Turcotte-Pugh class C < 14 points or Child-Turcotte-Pugh class B with active bleeding) after initial pharmacological and endoscopic therapy. Urgent surgical intervention is rarely performed and can be considered only in case of failure of conservative and/or endoscopic therapy and being unable to use a transjugular intrahepatic portosystemic shunt. Among surgical operations described in the literature are a variety of portocaval anastomosis and azygoportal disconnection procedures. CONCLUSIONS To improve the results of treatment for patients with liver cirrhosis who develop acute esophageal variceal bleeding, it is important to stratify patients into risk groups, which will allow one to tailor therapeutic approaches to the expected results.
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Hu PX, Zhang SH. Advances in treatment of acute esophagogastric variceal bleeding. Shijie Huaren Xiaohua Zazhi 2015; 23:5636-5641. [DOI: 10.11569/wcjd.v23.i35.5636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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
Acute esophagogastric variceal bleeding is one of life-threatening complications of portal hypertension and the leading cause of death in patients with cirrhosis. How to effectively control bleeding is an important clinical subject, and specific measures include drug therapy, endoscopic therapy, and radiological interventional therapy. This review summarizes the current advances in the treatment of acute esophagogastric variceal bleeding.
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Abstract
Primary prophylaxis is advisable for all patients with moderate-sized or large esophageal varices. After the first episode of bleeding, secondary prophylaxis should be initiated to prevent rebleeding. Multiple treatment modalities are available for each circumstance. Optimal regimens have not yet been established but are under investigation. At present, nonselective beta-blockers are the drugs of choice for primary prophylaxis. In patients with actively bleeding varices, octreotide or, in rare cases, a combination of vasopressin and nitroglycerin is used in conjunction with endoscopic band ligation of the varices. Either a beta-blocker, band ligation, or a combination of the two is appropriate for secondary prophylaxis. The combination is often the better choice for patients for whom primary prophylaxis with beta-blockers has failed. As in any treatment situation, the specific approach must be tailored to clinical circumstances. The patient's preferences and willingness or ability to comply with the therapy must be taken into account as well as the physician's expertise. Interventions for hepatic encephalopathy predominantly focus on reducing the amount of ammonia absorbed or endogenously generated in the body. They include correction of precipitating factors, bowel cleansing, and lactulose therapy. In difficult cases, a combination of lactulose and neomycin, metronidazole, or rifaximin is recommended. Because the prognosis for patients with hepatic encephalopathy is generally poor, orthotopic liver transplantation should be considered.
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Affiliation(s)
- Vijay H Shah
- Department of Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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12
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Wang C, Han J, Xiao L, Jin CE, Li DJ, Yang Z. Efficacy of vasopressin/terlipressin and somatostatin/octreotide for the prevention of early variceal rebleeding after the initial control of bleeding: a systematic review and meta-analysis. Hepatol Int 2014; 9:120-9. [PMID: 25788386 DOI: 10.1007/s12072-014-9594-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 11/10/2014] [Indexed: 01/10/2023]
Abstract
PURPOSE Our purpose was to conduct a meta-analysis to compare the effectiveness of vasopressin/terlipressin and somatostatin/octreotide on variceal re-bleeding within and after 5 days of initial control bleeding. METHODS A search was conducted of PubMed, the Cochrane database, and Google Scholar until June 31, 2014 using combinations of the search terms: esophageal varices, variceal re-bleeding, recurrent variceal hemorrhage, early re-bleeding, vasopressin, somatostatin, terlipressin, octreotide. Inclusion criteria were: (1) randomized controlled trials, (2) patients with esophageal or esophageal and gastric varices confirmed by endoscopy, (3) re-bleeding control was evaluated, (4) treatment with somatostatin/vasopressin. Outcome measures were the re-bleeding rates within 5 days (≤ 5 days) or after 5 days (>5 days) after initial treatment. RESULTS Six studies were included in the analysis. Five studies had complete data of re-bleeding rate within 5 days after initial treatment, and the combined odds ratio (OR) of 0.87 [95% confidence interval (CI) 0.51, 1.50] indicated that there was no difference in the re-bleeding rate between patients treated with vasopressin/terlipressin or somatostatin/octreotide. Two studies had complete data of the re-bleeding rate 5 days after initial treatment, and the combined OR of 1.12 (95% CI 0.64, 1.95) indicated there was no difference in the re-bleeding rate between patients who were treated with vasopressin/terlipressin or somatostatin/octreotide. CONCLUSION There is no difference between vasopressin/terlipressin and somatostatin/octreotide in prevention of re-bleeding after the initial treatment of bleeding esophageal varices.
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Affiliation(s)
- Chao Wang
- Department of General Surgery, Tongji Hospital, Tongji Medical College, Science and Technology of Huazhong University, No. 1095 Liberation Avenue, Wuhan, 430030, China,
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Satapathy SK, Sanyal AJ. Nonendoscopic management strategies for acute esophagogastric variceal bleeding. Gastroenterol Clin North Am 2014; 43:819-33. [PMID: 25440928 PMCID: PMC4255471 DOI: 10.1016/j.gtc.2014.08.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Acute variceal bleeding is a potentially life-threatening complication of portal hypertension. Management consists of emergent hemostasis, therapy directed at hemodynamic resuscitation, protection of the airway, and prevention and treatment of complications including prophylactic use of antibiotics. Endoscopic treatment remains the mainstay in the management of acute variceal bleeding in combination with pharmacotherapy aimed at reducing portal pressure. This article intends to highlight only the current nonendoscopic treatment approaches for control of acute variceal bleeding.
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Affiliation(s)
- Sanjaya K Satapathy
- Division of Surgery, Methodist University Hospital Transplant Institute, University of Tennessee Health Sciences Center, Memphis, TN 38104, USA
| | - Arun J Sanyal
- Division of Gastroenterology, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, MCV Box 980341, Richmond, VA 23298-0341, USA.
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15
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Abstract
Progress in the knowledge of the pathophysiology of portal hypertension has disclosed new targets for therapy, resulting in a larger spectrum of drugs with a potential role for clinical practice. This review focuses on pharmacologic treatments already available for reducing portal pressure and summarizes drugs currently under investigation in this field.
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Affiliation(s)
- Annalisa Berzigotti
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic-IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, c/Villarroel 170, Barcelona 08036, Spain
| | - Jaime Bosch
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic-IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, c/Villarroel 170, Barcelona 08036, Spain.
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Gastrointestinal Bleeding in Cirrhotic Patients with Portal Hypertension. ISRN HEPATOLOGY 2013; 2013:541836. [PMID: 27335828 PMCID: PMC4890899 DOI: 10.1155/2013/541836] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 06/29/2013] [Indexed: 02/06/2023]
Abstract
Gastrointestinal bleeding related to portal hypertension is a serious complication in patients with liver cirrhosis. Most patients bleed from esophageal or gastric varices, but bleeding from ectopic varices or portal hypertensive gastropathy is also possible. The management of acute bleeding has changed over the last years. Patients are managed with a combination of endoscopic and pharmacologic treatment. The endoscopic treatment of choice for esophageal variceal bleeding is variceal band ligation. Bleeding from gastric varices is treated by injection with cyanoacrylate. Treatment with vasoactive drugs as well as antibiotic treatment is started before or at the time point of endoscopy. The first-line treatment for primary prophylaxis of esophageal variceal bleeding is nonselective beta blockers. Pharmacologic therapy is recommended for most patients; band ligation is an alternative in patients with contraindications for or intolerability of beta blockers. Treatment options for secondary prophylaxis include variceal band ligation, beta blockers, a combination of nitrates and beta blockers, and combination of band ligation and pharmacologic treatment. A clear superiority of one treatment over the other has not been shown. Bleeding from portal hypertensive gastropathy or ectopic varices is less common. Treatment options include beta blocker therapy, injection therapy, and interventional radiology.
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Narváez-Rivera RM, Cortez-Hernández CA, González-González JA, Tamayo-de la Cuesta JL, Zamarripa-Dorsey F, Torre-Delgadillo A, Rivera-Ramos JFJ, Vinageras-Barroso JI, Muneta-Kishigami JE, Blancas-Valencia JM, Antonio-Manrique M, Valdovinos-Andraca F, Brito-Lugo P, Hernández-Guerrero A, Bernal-Reyes R, Sobrino-Cossío S, Aceves-Tavares GR, Huerta-Guerrero HM, Moreno-Gómez N, Bosques-Padilla FJ. [Mexican consensus on portal hypertension]. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2013; 78:92-113. [PMID: 23664429 DOI: 10.1016/j.rgmx.2013.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Revised: 11/30/2012] [Accepted: 01/21/2013] [Indexed: 02/07/2023]
Abstract
The aim of the Mexican Consensus on Portal Hypertension was to develop documented guidelines to facilitate clinical practice when dealing with key events of the patient presenting with portal hypertension and variceal bleeding. The panel of experts was made up of Mexican gastroenterologists, hepatologists, and endoscopists, all distinguished professionals. The document analyzes themes of interest in the following modules: preprimary and primary prophylaxis, acute variceal hemorrhage, and secondary prophylaxis. The management of variceal bleeding has improved considerably in recent years. Current information indicates that the general management of the cirrhotic patient presenting with variceal bleeding should be carried out by a multidisciplinary team, with such an approach playing a major role in the final outcome. The combination of drug and endoscopic therapies is recommended for initial management; vasoactive drugs should be started as soon as variceal bleeding is suspected and maintained for 5 days. After the patient is stabilized, urgent diagnostic endoscopy should be carried out by a qualified endoscopist, who then performs the corresponding endoscopic variceal treatment. Antibiotic prophylaxis should be regarded as an integral part of treatment, started upon hospital admittance and continued for 5 days. If there is treatment failure, rescue therapies should be carried out immediately, taking into account that interventional radiology therapies are very effective in controlling refractory variceal bleeding. These guidelines have been developed for the purpose of achieving greater clinical efficacy and are based on the best evidence of portal hypertension that is presently available.
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Affiliation(s)
- R M Narváez-Rivera
- Servicio de Gastroenterología, Departamento de Medicina Interna, Hospital Universitario «Dr. José Eleuterio González», Monterrey, N.L., México
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Zhang C, Xu JM, Kong DR, Min XK, Chen R. Immediate effects of different schedules of somatostatin on portal pressure in patients with liver cirrhosis. J Clin Pharm Ther 2013; 38:206-11. [PMID: 23437909 DOI: 10.1111/jcpt.12007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Somatostatin (SST) is used for the treatment of acute variceal bleeding based on its ability to decrease portal pressure and collateral blood flow. To date, no studies have focused on the immediate-early effects (between 1 and 30 min) of SST. The aim of this study was to compare the efficacy of different schedules of SST therapy with placebo on portal pressure in patients with portal hypertension treated with portal-azygous disconnection and to test whether an increase in bolus or infusion dose can improve the clinical efficacy of SST therapy. METHODS Patients were treated with four different schedules: (a) standard dose (n = 11): one 250 μg bolus + a continuous infusion of 250 μg/h; (b) medium dose (n = 10): 500 μg bolus + a continuous infusion of 250 μg/h; (c) high dose (n = 10): 250 μg bolus + a continuous infusion of 500 μg/h; (d) control (n = 10): an injection of placebo (saline) followed by a placebo infusion. Following SST or placebo administration, portal pressure, central venous pressure (CVP), systemic blood pressure and heart rate (HR) were measured at 1, 3, 5, 7, 10 and 30 min. RESULTS AND DISCUSSION The three schedules of SST induced a marked, rapid and highly significant decrease in portal pressure. The decline in portal pressure was moderate at 1 min (P < 0·040), achieved a peak effect at 5 min (P < 0·009) and remained decreased at 30 min. The effect of SST on portal pressure was significantly greater than placebo from 1 min after administration. There were no significant differences in portal pressure decrease between the three schedules of SST. The three schedules of SST and the placebo schedule did not induce significant changes in HR, systemic blood pressure and CVP. WHAT IS NEW AND CONCLUSION This study shows that SST is effective in decreasing portal pressure within 30 min of administration in patients with liver cirrhosis. The clinical schedule used in this study was reasonable and safe.
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Affiliation(s)
- C Zhang
- Department of Surgery, Anhui Geriatric Institute, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
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19
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Improvement in the prognosis of cirrhotic patients admitted to an intensive care unit, a retrospective study. Eur J Gastroenterol Hepatol 2012; 24:897-904. [PMID: 22569082 DOI: 10.1097/meg.0b013e3283544816] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To examine how the outcomes of cirrhotic patients admitted to an ICU have changed over time. METHODS A retrospective study in a medical ICU during two separate 3-year periods [period 1 (P1): 1995-1998 and period 2 (P2): 2005-2008]. RESULTS A total of 56 cirrhotic patients were admitted during P1 and 138 during P2, accounting for 2.3 and 4.5% of the total ICU admissions (P<0.01). Patients' characteristics were markedly different between the two periods: previous functional status improved (Knaus scale, A/B/C/D: P1 - 7.1%/53.6%/35.7%/3.6% vs. P2 - 28.2%/47.8%/22.5%/1.5%, P<0.01), the number of comorbidities decreased (Charlson: 1.79±2.22 vs. 1.02±1.40, P=0.02), the severity of cirrhosis increased [Child-Pugh: 8 (7-13) vs. 11 (8-13), P=0.04; Model for End-Stage Liver Disease: 16 (12-28) vs. 22 (15-31), P=0.02], and acute organ dysfunctions increased (Sequential Organ Failure Assessment: 7.3±5.6 vs. 11.3±5.5, P<0.01). The crude in-ICU mortality was similar during the two periods (39.3 vs. 41.3%, P=0.92). However, after adjustment for severity, in-ICU mortality was markedly decreased during P2 (odds ratio: 0.36 [0.15; 0.88], P=0.02). CONCLUSION Cirrhotic patients admitted to the ICU have an improved outcome despite increased severity of liver disease. This improvement is associated with a higher selection according to their previous functional status and comorbidities.
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20
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Addley J, Tham TC, Cash WJ. Use of portal pressure studies in the management of variceal haemorrhage. World J Gastrointest Endosc 2012; 4:281-9. [PMID: 22816007 PMCID: PMC3399005 DOI: 10.4253/wjge.v4.i7.281] [Citation(s) in RCA: 16] [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] [Received: 01/09/2012] [Revised: 06/01/2012] [Accepted: 07/01/2012] [Indexed: 02/05/2023] Open
Abstract
Portal hypertension occurs as a complication of liver cirrhosis and complications such as variceal bleeding lead to significant demands on resources. Endoscopy is the gold standard method for screening cirrhotic patients however universal endoscopic screening may mean a lot of unnecessary procedures as the presence of oesophageal varices is variable hence a large time and cost burden on endoscopy units to carry out both screening and subsequent follow up of variceal bleeds. A less invasive method to identify those at high risk of bleeding would allow earlier prophylactic measures to be applied. Hepatic venous pressure gradient (HVPG) is an acceptable indirect measurement of portal hypertension and predictor of the complications of portal hypertension in adult cirrhotics. Varices develop at a HVPG of 10-12 mmHg with the appearance of other complications with HPVG > 12 mmHg. Variceal bleeding does not occur in pressures under 12 mmHg. HPVG > 20 mmHg measured early after admission is a significant prognostic indicator of failure to control bleeding varices, indeed early transjugular intrahepatic portosystemic shunt (TIPS) in such circumstances reduces mortality significantly. HVPG can be used to identify responders to medical therapy. Patients who do not achieve the suggested reduction targets in HVPG have a high risk of rebleeding despite endoscopic ligation and may not derive significant overall mortality benefit from endoscopic intervention alone, ultimately requiring TIPS or liver transplantation. Early HVPG measurements following a variceal bleed can help to identify those at risk of treatment failure who may benefit from early intervention with TIPS. Therefore, we suggest using HVPG measurement as the investigation of choice in those with confirmed cirrhosis in place of endoscopy for intitial variceal screening and, where indicated, a trial of B-blockade, either intravenously during the initial pressure study with assessment of response or oral therapy with repeat HVPG six weeks later. In those with elevated pressures, primary medical prophylaxis could be commenced with subsequent close monitoring of HVPG thus negating the need for endoscopy at this point. All patients presenting with variceal haemorrhage should undergo HVPG measurement and those with a gradient greater than 20 mmHg should be considered for early TIPS. By introducing portal pressure studies into a management algorithm for variceal bleeding, the number of endoscopies required for further intervention and follow up can be reduced leading to significant savings in terms of cost and demand on resources.
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Affiliation(s)
- Jennifer Addley
- Jennifer Addley, William Jonathan Cash, The Liver Unit, Royal Victoria Hospital, Belfast BT7 1NN, United Kingdom
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21
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Chandok N, Kamath PS, Blei A, Bosch J, Carey W, Grace N, Kowdley KV, Benner K, Groszmann RJ. Randomised clinical trial: the safety and efficacy of long-acting octreotide in patients with portal hypertension. Aliment Pharmacol Ther 2012; 35:904-12. [PMID: 22380529 DOI: 10.1111/j.1365-2036.2012.05050.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Revised: 01/23/2012] [Accepted: 02/08/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND It remains unclear whether a long-acting preparation of octreotide (Sandostatin LAR) can be safely used for portal hypertension in patients with compensated cirrhosis. AIM To determine the safety and efficacy of LAR among patients with Child Pugh Class A or B cirrhosis and small oesophageal varices. METHODS A randomised, double-blind, placebo-controlled study was conducted in 39 patients with cirrhosis and small oesophageal varices. Safety was based on frequency and severity of adverse events. Efficacy was determined by hepatic vein pressure gradient (HVPG) measured at baseline and day 84 following administration of LAR 10 mg (n = 15), 30 mg (n = 10) or saline (n = 14). Fasting and postprandial portal blood flow (PBF), superior mesenteric artery pulsatility index (SMA-PI), glucagon and octreotide levels were measured. An intention-to-treat analysis was performed. RESULTS Four patients in the LAR 30 group (40%) withdrew from the study due to serious adverse events. No patient in the LAR 10 or control group had serious adverse events. There was no statistically significant decrease between HVPG at day 84 and baseline with LAR 30 mg (11.8 ± 2.3 mmHg vs. 14.1 ± 3.2), LAR 10 mg (15.3 ± 4.8 mmHg vs. 15.1 ± 3.8), or saline (13.3 ± 3.8 mmHg vs. 15.1 ± 4.3) (P = 0.26). Neither PBF, SMA-PI nor plasma glucagon levels were significantly decreased from baseline (P = 0.56). CONCLUSIONS The absence of significant haemodynamic benefit, as well as the high frequency of severe adverse events associated with use of LAR, do not support the use of this agent in the treatment of portal hypertension.
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Affiliation(s)
- N Chandok
- Division of Gastroenterology and Hepatology, Mayo Clinic and Foundation, Rochester, MN 55905, USA
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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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Octreotide bolus injection and azygos blood flow in patients with cirrhosis: is the effect really predictable? J Clin Gastroenterol 2010; 44:e206-9. [PMID: 19996986 DOI: 10.1097/mcg.0b013e3181c4f111] [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: 01/05/2023]
Abstract
BACKGROUND Octreotide (OCT) improves the management of variceal bleeding, but the pattern of administration is not clearly defined. Available data show a transient decrease in portal pressure and azygos blood flow (AzBF) after OCT bolus injection with desensitization at readministration. AIM To explore the sustained hemodynamic effects of OCT and changes associated with readministration at 60 minutes on AzBF in patients with portal hypertension. PATIENTS AND METHODS AzBF was measured invasively (thermodilution technique) in 12 patients at baseline and at 10 minutes intervals after OCT 50-μg IV bolus for a total of 60 minutes. Readministration of OCT was followed by AzBF measurement for another 15 minutes. Patients [age 51.4 y (30 to 69)] had cirrhosis (alcoholic in 9 patients; Pugh's score 8.8±0.3), portal hypertension (HVPG 19±1 mm Hg), and elevated AzBF (658±138 mL/min). RESULTS The bolus of OCT was followed at 10 minutes by a 34% decline in AzBF as compared with baseline value. This AzBF reduction was sustained over the 60-minute study period (-36%±1.4%) with the values that remained decreased as compared with baseline (P<0.01). Mean arterial pressure remained stable. At 60 minutes, the repeat OCT bolus induced a further significant (P<0.01) decline in AzBF, although the response was blunted (-18%±1.2%). CONCLUSION The AzBF showed a sustained decrease of value after a bolus injection of 50-μg OCT. A further hemodynamic response is detectable at OCT readministration after 60 minutes. The pattern of hemodynamic response to OCT may not be uniform among cirrhotics.
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Augustin S, González A, Genescà J. Acute esophageal variceal bleeding: Current strategies and new perspectives. World J Hepatol 2010; 2:261-74. [PMID: 21161008 PMCID: PMC2998973 DOI: 10.4254/wjh.v2.i7.261] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Revised: 06/14/2010] [Accepted: 06/21/2010] [Indexed: 02/06/2023] Open
Abstract
Management of acute variceal bleeding has greatly improved over recent years. Available data indicates that general management of the bleeding cirrhotic patient by an experienced multidisciplinary team plays a major role in the final outcome of this complication. It is currently recommended to combine pharmacological and endoscopic therapies for the initial treatment of the acute bleeding. Vasoactive drugs (preferable somatostatin or terlipressin) should be started as soon as a variceal bleeding is suspected (ideally during transfer to hospital) and maintained afterwards for 2-5 d. After stabilizing the patient with cautious fluid and blood support, an emergency diagnostic endoscopy should be done and, as soon as a skilled endoscopist is available, an endoscopic variceal treatment (ligation as first choice, sclerotherapy if endoscopic variceal ligation not feasible) should be performed. Antibiotic prophylaxis must be regarded as an integral part of the treatment of acute variceal bleeding and should be started at admission and maintained for at least 7 d. In case of failure to control the acute bleeding, rescue therapies should be immediately started. Shunt therapies (especially transjugular intrahepatic portosystemic shunt) are very effective at controlling treatment failures after an acute variceal bleeding. Therapeutic developments and increasing knowledge in the prognosis of this complication may allow optimization of the management strategy by adapting the different treatments to the expected risk of complications for each patient in the near future. Theoretically, this approach would allow the initiation of early aggressive treatments in high-risk patients and spare low-risk individuals unnecessary procedures. Current research efforts will hopefully clarify this hypothesis and help to further improve the outcomes of the severe complication of cirrhosis.
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Affiliation(s)
- Salvador Augustin
- Salvador Augustin, Antonio González, Joan Genescà, Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona 08035, Spain
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Abstract
Acute esophageal variceal hemorrhage (AEVH) is a severe complication of portal hypertension. Its management has rapidly evolved in recent years. Traditional methods included vasoconstrictor and balloon tamponade. Vasoconstrictors were shown to control approximately 80% of the bleeding episodes and are generally used as a first-line therapy. Following the use of vasoconstrictors, endoscopic therapy is often used to arrest the bleeding varices and prevent early rebleeding. A meta-analysis showed that the combination of vasoconstrictor and endoscopic therapy is superior to endoscopic therapy alone for controlling AEVH. Balloon tamponade may be used to achieve temporary control of the hemorrhage in case of severe bleeding. A transjugular intrahepatic portosystemic stent shunt may be needed in patients with refractory acute variceal hemorrhage. Surgical intervention is now widely contraindicated during acute variceal hemorrhage, except for patients with good liver reserve. Conversely, apart from the control of acute variceal hemorrhage, prophylactic antibiotics were shown to be helpful in the prevention of bacterial infection and to prevent early variceal rebleeding. With the introduction of new treatment modalities and the measures taken to manage patients with AEVH, the mortality due to AEVH has significantly decreased in recent years.
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Affiliation(s)
- Gin-Ho Lo
- Department of Medical Education, Digestive Center, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.
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26
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Smith MM. Emergency: Variceal hemorrhage from esophageal varices associated with alcoholic liver disease. Am J Nurs 2010; 110:32-9; quiz 40-1. [PMID: 20107398 DOI: 10.1097/01.naj.0000368049.57482.00] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Esophageal varices occur in about half of all people with alcoholic cirrhosis. About one-third of these will experience variceal hemorrhage, a life-threatening event. This article describes alcoholic cirrhosis and its complications, discusses the etiology of esophageal varices and the risk factors for hemorrhage, and addresses emergent treatment. Further treatment options, including endoscopic variceal ligation, endoscopic injection sclerotherapy, balloon tamponade, and transjugular intrahepatic portosystemic shunt placement, are also discussed.
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Affiliation(s)
- Melissa M Smith
- Division of Nursing at Aultman College of Nursing and Health Sciences in Canton, OH, USA.
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Fortune BE, Jackson J, Leonard J, Trotter JF. Vapreotide: a somatostatin analog for the treatment of acute variceal bleeding. Expert Opin Pharmacother 2009; 10:2337-42. [PMID: 19708854 DOI: 10.1517/14656560903207019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Portal hypertension is a clinically important consequence of cirrhosis that can lead to morbidities such as variceal bleeding, hepatic encephalopathy and ascites. All of these outcomes carry high mortality rates. There have been several drugs created to assist with endoscopic therapy for the treatment of acute variceal bleeding. Recently, vapreotide has been studied in patients to evaluate its efficacy as treatment for acute variceal hemorrhage. Although no comparisons have been made between vapreotide and other somatostatin analogues, this drug has been shown to have efficacy in the control of acute variceal bleeding as well as reducing the risk of recurrent bleeding and death, especially when started prior to endoscopy. OBJECTIVE This paper reviews the literature regarding the basic science and clinical efficacy of vapreotide in acute variceal bleeding. METHODS We used a PubMed/Medline search in order to review the literature regarding the drug, vapreotide. RESULTS/CONCLUSIONS Vapreotide appears to have benefit in the control of acute variceal bleeding. It is easy to administer and has few side effects, which are minor. These findings endorse the need for future trials to evaluate vapreotide and its use in acute variceal hemorrhage, a morbidity among patients with cirrhosis.
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Affiliation(s)
- Brett E Fortune
- University of Colorado-Denver, Division of Gastroenterology and Hepatology, Academic Office 1, B158, 12631 E 17th Avenue Room 7614, PO Box 6511, Aurora, CO 80045, USA
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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: 208] [Impact Index Per Article: 13.0] [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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Abstract
Portal hypertension, a major hallmark of cirrhosis, is defined as a portal pressure gradient exceeding 5 mm Hg. In portal hypertension, porto-systemic collaterals decompress the portal circulation and give rise to varices. Successful management of portal hypertension and its complications requires knowledge of the underlying pathophysiology, the pertinent anatomy, and the natural history of the collateral circulation, particularly the gastroesophageal varices.
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Affiliation(s)
- Nagib Toubia
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University School of Medicine, MCV, Box 980341, Richmond, VA 23298-0341, USA
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30
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Abstract
Variceal bleeding is a life-threatening complication of portal hypertension. The recommended treatment includes the early administration of a vasoactive drug. Vapreotide is a somatostatin analogue with a different receptor affinity to octreotide. It decreases portal pressure and blood flow of collateral circulation in rats with cirrhosis. The pivotal study of early administration of vapreotide in patients with cirrhosis and variceal bleeding has shown a significant improvement in bleeding control and, in the subset of patients with significant bleeding, a significant reduction in mortality. In addition, a meta-analysis of four randomized studies has shown a significant improvement in bleeding control. Vapreotide administrated via the intravenous route is simple to use, with practically no contraindications and few, usually minor, side effects.
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Affiliation(s)
- Paul Calès
- Université d'Angers, IFR 132, Laboratoire HIFIH (UPRES 3959) Angers, F-49035 France.
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31
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Dell'Era A, de Franchis R, Iannuzzi F. Acute variceal bleeding: pharmacological treatment and primary/secondary prophylaxis. Best Pract Res Clin Gastroenterol 2008; 22:279-94. [PMID: 18346684 DOI: 10.1016/j.bpg.2007.11.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Variceal bleeding is one of the most severe complications of portal hypertension related to liver cirrhosis. Primary prophylaxis is considered mandatory in patients with cirrhosis and high-risk oesophageal varices, and once varices have bled, every effort should be made to arrest the haemorrhage and prevent further bleeding episodes. In acute variceal bleeding, vasoactive drugs that lower portal pressure should be started even before endoscopy, and should be maintained for up to 5 days. The choice of vasoactive drug should be made according to local resources. Terlipressin, somatostatin and octreotide can be used; vasopressin plus transdermal nitroglycerin may be used if no other drug is available. In variceal bleeding, antibiotic therapy is also mandatory. In primary and secondary prophylaxis, beta-blockers are the mainstay of therapy. In secondary prophylaxis (but not in primary prophylaxis) these drugs can be combined with organic nitrates.
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Affiliation(s)
- A Dell'Era
- Department of Medical Sciences, University of Milano, and Gastroenterology 3 Unit, IRCCS Ospedale Maggiore Policlinico, Mangiagalli and Regina Elena Foundation, Via Pace 9, 20122 Milano, Italy
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32
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Mejias M, Garcia-Pras E, Tiani C, Bosch J, Fernandez M. The somatostatin analogue octreotide inhibits angiogenesis in the earliest, but not in advanced, stages of portal hypertension in rats. J Cell Mol Med 2008; 12:1690-9. [PMID: 18194463 PMCID: PMC3918085 DOI: 10.1111/j.1582-4934.2008.00218.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Angiogenesis is an important determinant of the pathophysiology of portal hypertension contributing to the formation of portosystemic collateral vessels and the hyperdynamic splanchnic circulation associated to this syndrome. Somatostatin and its analogues, like octreotide, have been shown to be powerful inhibitors of experimental angiogenesis. Aim: To determine whether octreotide has angioinhibitory effects in portal hypertensive rats. Methods: Partial portal vein-ligated (PPVL) rats were treated with octreotide or vehicle during 4 or 7 days. Splanchnic neovascularization and VEGF expression were determined by histological analysis and western blotting. Expression of the somatostatin receptor subtype 2 (SSTR2), which mediates the anti-angiogenic effects of octreotide, was also analyzed. Formation of portosystemic collaterals (radioactive microspheres) and hemodynamic parameters were also measured. Results: Octreotide treatment during 4 days markedly and significantly decreased splanchnic neovascularization, VEGF expression by 63% and portal pressure by 15%, whereas portosystemic collateralization and splanchnic blood flow were not modified. After 1 week of octreotide injection, portal pressure was reduced by 20%, but inhibition of angiogenesis escaped from octreotide therapy, a phenomenon that could be related to the finding that expression of SSTR2 receptor decreased progressively (up to 78% reduction) during the evolution of portal hypertension. Conclusion: This study provides the first experimental evidence showing that octreotide may be an effective anti-angiogenic therapy early after induction of portal hypertension, but not in advanced stages most likely due to SSTR2 down-regulation during the progression of portal hypertension in rats. These findings shed light on new mechanisms of action of octreotide in portal hypertension.
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Affiliation(s)
- Marc Mejias
- Hepatic Hemodynamic Laboratory, Liver Unit, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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33
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34
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Vlachogiannakos J, Kougioumtzian A, Triantos C, Viazis N, Sgouros S, Manolakopoulos S, Saveriadis A, Markoglou C, Economopoulos T, Karamanolis DG. Clinical trial: The effect of somatostatin vs. octreotide in preventing post-endoscopic increase in hepatic venous pressure gradient in cirrhotics with bleeding varices. Aliment Pharmacol Ther 2007; 26:1479-87. [PMID: 17919272 DOI: 10.1111/j.1365-2036.2007.03539.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hepatic venous pressure gradient (HVPG) increases significantly after endoscopic therapy in patients with bleeding oesophageal varices, which may precipitate further haemorrhage. Whether vasoactive drugs can suppress these changes remains unknown. AIM To investigate the efficacy of somatostatin when compared with octreotide in preventing the post-endoscopic increase in HVPG during acute bleeding and whether the changes affect outcome. METHODS Thirty-three cirrhotics with bleeding varices were randomized to receive somatostatin (n = 17) or octreotide (n = 16) under double-blind conditions, soon after their admission. HVPG measurements were performed before and immediately after endoscopic treatment. RESULTS In the somatostatin group, postendotherapy HVPG values did not change significantly when compared with pre-treatment values (18.9 vs. 17.2, P = 0.092). Conversely, in the octreotide group, HVPG increased significantly after endoscopy (18.2 vs. 20.8, P = 0.003). The probability of 6-week survival without treatment failure was significantly higher in the somatostatin group (P = 0.024). Post-endoscopic HVPG value was independently associated with 6-week failure. CONCLUSIONS Somatostatin, but not octreotide, effectively prevents the post-endoscopic increase in HVPG, which may be associated with low probability of treatment failure.
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Affiliation(s)
- J Vlachogiannakos
- 2nd Department of Gastroenterology, Evangelismos Hospital, Athens, Greece.
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35
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Abstract
Bleeding from gastroesophageal varices is a frequent and often deadly complication of cirrhosis. Although mortality from an episode of variceal bleeding has decreased in the last 2 decades it is still around 20%. This paper reviews the most recent advancements in the general management and hemostatic treatments of acute variceal bleeding.
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A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding. J Hepatol 2006; 45:560-7. [PMID: 16904224 DOI: 10.1016/j.jhep.2006.05.016] [Citation(s) in RCA: 124] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2005] [Revised: 05/30/2006] [Accepted: 05/31/2006] [Indexed: 02/07/2023]
Abstract
BACKGROUND/AIMS The currently recommended treatment for acute variceal bleeding is the association of vasoactive drugs and endoscopic therapy. However, which emergency endoscopic treatment combines better with drugs has not been clarified. This study compares the efficacy and safety of variceal ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin. METHODS Patients admitted with acute gastrointestinal bleeding and with suspected cirrhosis received somatostatin infusion (for 5 days). Endoscopy was performed within 6h and those with esophageal variceal bleeding were randomized to receive either sclerotherapy (N=89) or ligation (N=90). RESULTS Therapeutic failure occurred in 21 patients treated with sclerotherapy (24%) and in nine treated with ligation (10%) (RR=2.4, 95% CI=1.1-4.9). Failure to control bleeding occurred in 15% vs 4%, respectively (P=0.02). Treatment group, shock and HVPG >16 mmHg were independent predictors of failure. Side-effects occurred in 28% of patients receiving sclerotherapy vs 14% with ligation (RR=1.9, 95% CI=1.1-3.5), being serious in 13% vs 4% (P=0.04). Six-week survival probability without therapeutic failure was better with ligation (P=0.01). CONCLUSIONS The use of variceal ligation instead of sclerotherapy as emergency endoscopic therapy added to somatostatin for the treatment of acute variceal bleeding significantly improves the efficacy and safety.
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Abstract
Portal hypertension is a progressively debilitating complication of cirrhosis and a principal cause of mortality in patients who have hepatic decompensation. During the last few decades, significant clinical advances in the prevention of initial variceal hemorrhage, the management of acute variceal hemorrhage, and the prevention of recurrent variceal hemorrhage have reduced the morbidity and mortality of this lethal complication of cirrhosis. This article discusses the pharmacologic treatment of portal hypertension, including preprimary prophylaxis, prevention of a first variceal hemorrhage, treatment of acute variceal hemorrhage, and secondary prophylaxis of a variceal hemorrhage.
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Affiliation(s)
- Melissa A Minor
- Department of Medicine, Division of Gastroenterology and Hepatology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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38
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Affiliation(s)
- Preeti A Reshamwala
- Liver Diseases Branch, National Institutes of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 20892-1800, USA
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39
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Chen WC, Lo GH, Tsai WL, Hsu PI, Lin CK, Lai KH. Emergency endoscopic variceal ligation versus somatostatin for acute esophageal variceal bleeding. J Chin Med Assoc 2006; 69:60-7. [PMID: 16570572 DOI: 10.1016/s1726-4901(09)70115-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Endoscopic variceal ligation and somatostatin are widely used for treating acute esophageal variceal bleeding. This study compared the efficacy, safety, and survival of both therapies. METHODS Acute esophageal variceal bleeding patients were randomized to undergo emergency ligation or receive a bolus of 250 microg somatostatin plus infusion at 250 microg/hour for 48 hours and undergo ligation subsequently. RESULTS Three (4.8%) of 62 patients in the ligation group and 20 (31.7%) of 63 patients in the somatostatin group encountered treatment failure (p = 0.0001). Transfusion requirements were 4.7 +/- 3.2 units in the ligation group and 6.9 +/- 7.3 units in the somatostatin group (p = 0.03). Hospital stay was 7.7 +/- 4.0 days in the ligation group and 10.2 +/- 9.9 days in the somatostatin group (p = 0.07). Adverse effects occurred in the ligation group (20 episodes) and the somatostatin group (27 episodes) (p = 0.2). The 42-day mortality rates were 5 patients (8.1%) in the ligation group and 3 patients (4.8%) in the somatostatin group (p = 0.5). CONCLUSION Emergency ligation was superior to somatostatin in treating acute esophageal variceal bleeding, with fewer requirements of transfusion and a tendency toward shorter hospital stay. The adverse effects and 42-day mortality rates were similar between both treatments.
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Affiliation(s)
- Wen-Chi Chen
- Division of Gastroenterology, Department of Medicine, Kaohsiung Veterans General Hospital, Taiwan, ROC
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40
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Abstract
Portal hypertension (PHT) is responsible for the more severe and often lethal complications of cirrhosis such as bleeding oesophageal varices, ascites, renal dysfunction and hepatic encephalopathy. Because of the combined impact of these complications, PHT remains the most important cause of morbidity and mortality in patients with cirrhosis. Over the years, it has become clear that a decrease in portal pressure is not only protective against the risk of variceal (re)bleeding but is also associated with a lower long-term risk of developing complications and an improved long-term survival. A milestone in therapy was the introduction of non-selective beta-blockers for the prevention of bleeding and rebleeding of gastro-esophageal varices. However, in practice, less than half the patients under beta-blockade are protected from these risks, supporting the overall demand for innovation and expansion of our therapeutic armamentarium. Recent advances in the knowledge of the pathophysiology of cirrhotic PHT have directed future therapy towards the increased intrahepatic vascular resistance, which, in part, is determined by an increased hepatic vascular tone. This increased vasculogenic component provides the rationale for the potential use of therapies aimed at increasing intrahepatic vasorelaxing capacity via gene therapy, liver-selective nitric oxide donors and statines on the one hand, and at antagonizing excessive intrahepatic vasoconstrictor force through the use of endothelin antagonists, angiotensin blockers, alpha(1) adrenergic antagonists or combined alpha(1)- and non-selective beta-blockers or somatostatin analogues on the other. The focus of this review is to give an update on the pathophysiology of PHT in order to elucidate these potential novel strategies subsequently.
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Affiliation(s)
- Wim Laleman
- Department of Hepatology, University Hospital Gasthuisberg, Leuven, Belgium
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41
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Zhu CQ, Dong SX, Mao YM, Zeng MD, Jiang YB, Xu JM, Tian DA, Liu JY, Xu SP, Sun Y, Luo HS, Wang BY. A multicentred clinical comparative study on curative effect and safety of acetic octreotide in treatment of esophageal varices bleeding. Shijie Huaren Xiaohua Zazhi 2005; 13:2570-2573. [DOI: 10.11569/wcjd.v13.i21.2570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [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 evaluate curative effect and safety of acetic octreotide in the treatment of esophageal varices blee-ding (EVB) in comparison with octreotide (Sandostatin).
METHODS: EVB patients were randomly and double-blinded assigned into acetic octreotide group (n = 70) and Sandostatin group (n = 66). Both kinds of drugs were dissolved in normal saline and then given to the patients at the rate of 50 mg/h for 48 h. The amount of bleeding and vital signs of all the patients were observed and comparatively analyzed.
RESULTS: The frequencies and amount of hemateme-sis, the excreted frequencies and amount of black feces were significantly different before and after treatment with both kinds of drugs (P <0.05), but there was no marked difference between the two groups (P >0.05). The vital signs such as heart rate, systolic and diastolic blood pressure as well as symptoms of nausea, swirling, heart-throb, sweatiness, and thirst were notably improved after treatment (P <0.05), but there was still no obvious difference between the two groups (P >0.05). Adverse drug reaction was also different between the two groups 1.43% (1.43% vs 1.52%, P >0.05). The total effective rates in acetic octreotide and Sandostatin group were 97.14% and 92.42%, respectively (P >0.05).
CONCLUSION: Acetic octreotide is safe and effective in the treatment of EVB, and its effect is not significan-tly different from Sandostatin's.
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42
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Abstract
Portal hypertension is an almost unavoidable complication of cirrhosis, and it is responsible for the more lethal complications of this syndrome. Appearance of these complications represents the major cause of death and liver transplantation in patients who have cirrhosis. This article highlights treatment modalities in use for managing portal hypertension and those that may be available in the future.
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Affiliation(s)
- Juan G Abraldes
- Hepatic Hemodynamic Laboratory, Liver Unit, ICMDM, Hospital Clinic, IDIBAPS, University of Barcelona, Villaroel 170 08036, Barcelona, Spain
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43
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Affiliation(s)
- Andres Cardenas
- Liver Unit, Institut de Malalties Digestives, Hospital Clinic, IDIBAPS, University of Barcelona, Villaroel 170, 08036 Barcelona, Spain
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44
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Villanueva C, Planella M, Aracil C, López-Balaguer JM, González B, Miñana J, Balanzó J. Hemodynamic effects of terlipressin and high somatostatin dose during acute variceal bleeding in nonresponders to the usual somatostatin dose. Am J Gastroenterol 2005; 100:624-30. [PMID: 15743361 DOI: 10.1111/j.1572-0241.2004.40665.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES High dose of somatostatin infusion achieves a greater reduction of hepatic venous pressure gradient (HVPG) than the usual dose, and terlipressin decreases HVPG through mechanisms other than somatostatin. Our aim was to assess the hemodynamic effects of terlipressin and high somatostatin dose during acute variceal bleeding in nonresponders to the usual somatostatin dose. METHODS Hemodynamic studies were performed in 80 patients with cirrhosis and variceal bleeding during the first 3 days of admission. After baseline measurements, somatostatin was administered (250 microg/h with an initial bolus of 250 microg). Patients were considered responders when the HVPG decreased by >10% from baseline (n = 31). Nonresponders were randomized under double-blind conditions to a control group (n = 7), or to receive terlipressin (2 mg IV bolus, n = 22), or high dose of somatostatin (500 microg/h, n = 20). Final measurements were obtained 30 min later. RESULTS Terlipressin caused a decrease in HVPG (from 22.2 +/- 5 to 19.1 +/- 5.2, p < 0.01) and heart rate (p < 0.01), while mean arterial pressure increased (p < 0.01). High somatostatin dose also reduced HVPG (from 21.8 +/- 3.4 to 19.6 +/- 3.1, p < 0.01), although this decrease was more pronounced with terlipressin (15%+/- 9%vs 10%+/- 6% from baseline, p= 0.05). Both terlipressin and high somatostatin dose achieved a significantly higher rate of response than that in the control group. A decrease in HVPG >20% was observed in 36% of cases with terlipressin versus 5% with high somatostatin dose (p= 0.02). CONCLUSIONS In nonresponders to usual somatostatin dose, both terlipressin and high-dose of somatostatin infusion significantly decreased HVPG and increased the rate of hemodynamic responders. Such effects were greater with terlipressin. Both treatments may be an alternative when standard somatostatin fails.
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Affiliation(s)
- Càndid Villanueva
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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45
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Baik SK, Jeong PH, Ji SW, Yoo BS, Kim HS, Lee DK, Kwon SO, Kim YJ, Park JW, Chang SJ, Lee SS. Acute hemodynamic effects of octreotide and terlipressin in patients with cirrhosis: a randomized comparison. Am J Gastroenterol 2005; 100:631-5. [PMID: 15743362 DOI: 10.1111/j.1572-0241.2005.41381.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Octreotide and terlipressin are widely used in acute variceal hemorrhage to reduce the bleeding rate. They purportedly act by mesenteric arterial vasoconstriction, thus reducing portal venous flow (PVF) and portal pressure. Little is known about the immediate-early hemodynamic effects of these drugs. AIM To compare the acute hemodynamic effects of octreotide and terlipressin in patients with cirrhosis. PATIENTS Forty-two cirrhotic patients with a history of variceal bleeding were randomized to receive either octreotide 100 microg intravenous bolus followed by a continuous infusion at 250 microg/h (n = 21), or terlipressin 2 mg intravenous bolus (n = 21). METHODS Mean arterial pressure (MAP), heart rate (HR), hepatic venous pressure gradient (HVPG), and PVF, assessed by duplex Doppler ultrasonography, were measured before and at 1, 5, 10, 15, 20, and 25 min after the start of drug administration. RESULTS Octreotide markedly decreased HVPG (-44.5 +/- 17.8%) and PVF (-30.6 +/- 13.6%) compared to the baseline at 1 min (p < 0.05). Thereafter, both variables rapidly returned toward the baseline, and by 5 min, no significant differences in HVPG (-7.1 +/- 28.9%) and PVF (10.2 +/- 26.2%) were noted. A similar transient effect on MAP and HR was observed. Terlipressin significantly decreased HVPG (-18.3 +/- 11.9%) and PVF (-32.6 +/- 10.5%) at 1 min (p < 0.05) and sustained these effects at all time points. The effects on arterial pressure and HR were also sustained. CONCLUSIONS Octreotide only transiently reduced portal pressure and flow, whereas the effects of terlipressin were sustained. These results suggest that terlipressin may have more sustained hemodynamic effects in patients with bleeding varices.
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Affiliation(s)
- Soon Koo Baik
- Department of Internal Medicine,Yonsei University Wonju College of Medicine, Wonju, South Korea
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46
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Abstract
The complications of portal hypertension are totally prevented if hepatic venous pressure gradient is decreased below 12 mm Hg. Besides, if this target is not achieved, a 20% decrease in portal pressure from baseline levels offers an almost total protection from variceal bleeding. This sets the rationale for drug therapy to reduce portal pressure in portal hypertension. Pharmacological therapy to decrease portal pressure includes vasoconstrictors to decrease portal blood inflow, vasodilators to decrease hepatic resistance, and combination therapy. Oral agents, such as beta-adrenergic blockers and organic nitrates, are used for long-term prevention of variceal bleeding, while parenteral agents, such as somatostatin (and analogues) and terlipressin, are used for the treatment of acute variceal bleeding.
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Affiliation(s)
- Jaime Bosch
- Hepatic Hemodynamics Laboratory, Liver Unit, IMD, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain.
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47
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Bosch J, Dell'era A. [Vasoactive drugs for the treatment of bleeding esophageal varices]. ACTA ACUST UNITED AC 2004; 28 Spec No 2:B186-9. [PMID: 15150511 DOI: 10.1016/s0399-8320(04)95254-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Jaime Bosch
- Liver Unit, IMD, Hospital Clinic et IDIBAPS, Université de Barcelone, Casanova, 143, 08036 Barcelone
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48
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Abstract
Ruptured gastroesophageal varices are the most severe and frequent cause of gastrointestinal bleeding in cirrhotic patients, leading to death in 5% to 8% of patients during the first 48 hours. In recent times, the 6-week mortality rate has fallen to 20% due to the development of effective treatment strategies. Initial treatment is aimed at achieving hemostasis and preventing bleeding-related complications such as renal failure, infection, and hepatic decompensation. Blood volume replacement is initiated as soon as possible and antibiotic prophylaxis is instituted from admission. Hemostatic treatment for variceal bleeding includes vasoactive drugs to decrease portal pressure, endoscopic procedures, and portosystemic shunts-either a surgical or transjugular intrahepatic portosystemic shunt (TIPS). Treatment of coagulopathy has only been recently assessed in clinical studies, but results to date are promising. This article reviews the current clinical data on management strategies for variceal bleeding and presents the risks and benefits for each type of treatment. Specific sections on gastric varices and portal hypertensive gastropathy are included.
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Affiliation(s)
- Jaime Bosch
- Liver Unit, Hospital Clinic, University of Barcelona, Spain
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49
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Abraldes JG, García-Pagán JC, Bosch J. Componente funcional de la hipertensión portal. GASTROENTEROLOGIA Y HEPATOLOGIA 2004; 27:377-87. [PMID: 15207139 DOI: 10.1016/s0210-5705(03)70480-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- J G Abraldes
- Hepatic Hemodynamic Laboratory, VA Healthcare System, West Haven, USA.
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50
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Affiliation(s)
- Jaime Bosch
- Hepatic Hemodynamic Laboratory, Liver Unit, IMD, Hospital Clinic, IDIBAPS, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain.
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