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Outcome of the Pediatric Patients with Portal Cavernoma: The Retrospective Study for 10 Years Focusing on Recurrent Variceal Bleeding. Gastroenterol Res Pract 2016; 2016:7953870. [PMID: 26949386 PMCID: PMC4754495 DOI: 10.1155/2016/7953870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 12/06/2015] [Accepted: 01/05/2016] [Indexed: 02/07/2023] Open
Abstract
Background. Portal cavernoma (PC) is the most critical condition with risk or variceal hemorrhage in pediatric patients. We retrospectively investigated the patients with PC focusing on the predictors for recurrent variceal bleeding. Methods. Between July 2003 and June 2013, we retrospectively enrolled all consecutive patients admitted to our department with a diagnosis of PC without abdominal malignancy or liver cirrhosis. The primary endpoint of this observational study was recurrent variceal bleeding. Independent predictors of recurrent variceal bleeding were identified using the logistic regression model. Results. A total of 157 patients were enrolled in the study. During the follow-up period, 24 patients exhibited onset of recurrent variceal bleeding. Acute variceal bleeding was subjected to conservative symptomatic treatment and emergency endoscopic sclerotherapy. Surgical procedure selection was based on the severity of vascular dilation and collateral circulation. Multivariate logistic regression analysis demonstrated that the presence of ascites, collateral circulation, and portal venous pressure were independent prognostic factors of recurrent variceal bleeding for patients with portal cavernoma. Conclusions. The presence of ascites, collateral circulation, and portal venous pressure evaluation are important and could predict the postsurgical recurrent variceal bleeding in patients with portal cavernoma.
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Ribeiro JP, Matuguma SE, Cheng S, Herman P, Sakai P, D'Albuquerque LAC, Maluf-Filho F. Results of treatment of esophageal variceal hemorrhage with endoscopic injection of n-butyl-2-cyanoacrylate in patients with Child-Pugh class C cirrhosis. Endosc Int Open 2015; 3:E584-9. [PMID: 26716117 PMCID: PMC4683151 DOI: 10.1055/s-0034-1392600] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 06/16/2015] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND AND STUDY AIMS The results of endoscopic treatment with elastic band ligation for esophageal variceal bleeding in patients with Child-Pugh class C cirrhosis remain poor. In comparison with treatment with elastic band ligation, we have found lower rates of rebleeding and mortality with n-butyl-2-cyanoacrylate injections. Thus, the aim of the current study was to describe our unit's 10 years of experience with injection of n-butyl-2-cyanoacrylate to control esophageal variceal ruptures in patients with Child-Pugh class C cirrhosis. PATIENTS AND METHODS A single-center, retrospective study was conducted. Sixty-three patients with Child-Pugh class C cirrhosis had been admitted to the center with an acute episode of esophageal variceal bleeding. All were treated with injection of n-butyl-2-cyanoacrylate. The patients were assigned to 1 of 2 groups according to their Child-Pugh class C cirrhosis scores: group I (score range, 10 through 13 points) and group II (score, 14 or 15 points). The 3 variables studied were rates of initial failure to control bleeding, failure to prevent rebleeding (secondary prophylaxis), and mortality. Patients in the 2 groups (group I, n = 50; group II, n = 13) had similar characteristics. RESULTS Bleeding was successfully controlled in almost 75 % of the patients during the first 5 days after treatment, with no significant differences observed between groups I and II. There were no significant differences between the 2 groups with respect to mortality rate for the first 5 days after treatment. Thirty-four patients (54 %) were free of bleeding at 6 weeks after treatment, with a significant difference noted between the groups: group I, 64 %, versus group II, 15.4 % (P < 0.001). The overall mortality rate was 44.4 %, with a significant difference noted between the groups: group I, 34 %, versus group II, 84.6 % (P < 0.001). CONCLUSION Endoscopic injection of n-butyl-2-cyanoacrylate is a valid treatment option to control esophageal variceal bleeding in patients with a Child-Pugh class C cirrhosis score in the range of 10 through 13 points.
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Affiliation(s)
- Joao Paulo Ribeiro
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | | | - Spencer Cheng
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | - Paulo Herman
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | - Paulo Sakai
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil,Laboratory of Investigation of University of São Paulo – LIM37, São Paulo, Brazil
| | - Luiz Augusto Carneiro D'Albuquerque
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil,Laboratory of Investigation of University of São Paulo – LIM37, São Paulo, Brazil
| | - Fauze Maluf-Filho
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil,Laboratory of Investigation of University of São Paulo – LIM37, São Paulo, Brazil,Corresponding author Fauze Maluf-Filho, MD, PhD Av. Brigadeiro Luis Antonio, 4161CEP 01402-001São Paulo – SPBrazil+55-11-3884-7599
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Ribeiro JP, Matuguma SE, Cheng S, Herman P, Sakai P, D'Albuquerque LAC, Maluf-Filho F. Results of treatment of esophageal variceal hemorrhage with endoscopic injection of n-butyl-2-cyanoacrylate in patients with Child-Pugh class C cirrhosis. Endosc Int Open 2015. [PMID: 26716117 DOI: 10.1055/s-0034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS The results of endoscopic treatment with elastic band ligation for esophageal variceal bleeding in patients with Child-Pugh class C cirrhosis remain poor. In comparison with treatment with elastic band ligation, we have found lower rates of rebleeding and mortality with n-butyl-2-cyanoacrylate injections. Thus, the aim of the current study was to describe our unit's 10 years of experience with injection of n-butyl-2-cyanoacrylate to control esophageal variceal ruptures in patients with Child-Pugh class C cirrhosis. PATIENTS AND METHODS A single-center, retrospective study was conducted. Sixty-three patients with Child-Pugh class C cirrhosis had been admitted to the center with an acute episode of esophageal variceal bleeding. All were treated with injection of n-butyl-2-cyanoacrylate. The patients were assigned to 1 of 2 groups according to their Child-Pugh class C cirrhosis scores: group I (score range, 10 through 13 points) and group II (score, 14 or 15 points). The 3 variables studied were rates of initial failure to control bleeding, failure to prevent rebleeding (secondary prophylaxis), and mortality. Patients in the 2 groups (group I, n = 50; group II, n = 13) had similar characteristics. RESULTS Bleeding was successfully controlled in almost 75 % of the patients during the first 5 days after treatment, with no significant differences observed between groups I and II. There were no significant differences between the 2 groups with respect to mortality rate for the first 5 days after treatment. Thirty-four patients (54 %) were free of bleeding at 6 weeks after treatment, with a significant difference noted between the groups: group I, 64 %, versus group II, 15.4 % (P < 0.001). The overall mortality rate was 44.4 %, with a significant difference noted between the groups: group I, 34 %, versus group II, 84.6 % (P < 0.001). CONCLUSION Endoscopic injection of n-butyl-2-cyanoacrylate is a valid treatment option to control esophageal variceal bleeding in patients with a Child-Pugh class C cirrhosis score in the range of 10 through 13 points.
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Affiliation(s)
- Joao Paulo Ribeiro
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | | | - Spencer Cheng
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | - Paulo Herman
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | - Paulo Sakai
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil ; Laboratory of Investigation of University of São Paulo - LIM37, São Paulo, Brazil
| | - Luiz Augusto Carneiro D'Albuquerque
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil ; Laboratory of Investigation of University of São Paulo - LIM37, São Paulo, Brazil
| | - Fauze Maluf-Filho
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil ; Laboratory of Investigation of University of São Paulo - LIM37, São Paulo, Brazil
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Kong DR, Wang JG, Sun B, Wang MQ, Chen C, Yu FF, Xu JM. β-2 Adrenergic receptor gene polymorphism and response to propranolol in cirrhosis. World J Gastroenterol 2015; 21:7191-7196. [PMID: 26109805 PMCID: PMC4476880 DOI: 10.3748/wjg.v21.i23.7191] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 01/26/2015] [Accepted: 02/11/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the association of β-2 adrenergic receptor (β2-AR) gene polymorphism with response of variceal pressure to propranolol in cirrhosis.
METHODS: Sixty-four non-related cirrhotic patients participated in this study and accepted variceal pressure measurement before and after propranolol administration. Polymorphism of the β2-AR gene was determined by directly sequencing of the polymerase chain reaction products from the DNA samples that were prepared from the patients.
RESULTS: The prevalence of Gly16-Glu/Gln27 and Arg16-Gln27 homozygotes, and compound heterozygotes was 29.7%, 10.9%, and 59.4%, respectively. Patients with cirrhosis with Gly16-Glu/Gln27 homozygotes had a greater decrease of variceal pressure after propranolol administration than those with Arg16-Gln27 homozygotes or with compound heterozygotes (22.4% ± 2.1%, 13.1% ± 2.7% and 12.5% ± 3.1%, respectively, P < 0.01).
CONCLUSION: The variceal pressure response to propranolol was associated with polymorphism of β2-AR gene. Patients with the Gly16-Glu/Gln27 homozygotes probably benefit from propranolol therapy.
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Karadsheh Z, Allison H. Primary prevention of variceal bleeding: pharmacological therapy versus endoscopic banding. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2014; 5:573-9. [PMID: 24350068 PMCID: PMC3842697 DOI: 10.4103/1947-2714.120791] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Variceal bleeding is one of the most feared complications in patients with liver cirrhosis. It continues to be a leading cause of death among patients with liver cirrhosis. Although its prognosis has improved over the last several decades, it still carries substantial mortality. Preventing variceal bleeding has been extensively studied and evaluated in several studies in the recent years and the comparison between the different modalities available to prevent variceal bleeding has been an area of discussion. Currently the two most widely used modalities to prevent variceal bleeding are pharmacologic (non-selective beta-blockers [NSBB]) and endoscopic (variceal band ligation [VBL]) which have replaced sclerotherapy in the recent years. In addition to NSBB and recent carvedilol, different other medications have been evaluated including isosorbide mononitrates, spironolactone and angiotensin blocking agents. Comparing the outcomes and adverse effects of these two modalities has been evaluated in different studies. Some studies have showed superiority of VBL until recently, when carvedilol has been included, however; overall mortality has been similar in most trials. Despite that, NSBB remain the first line treatment, as they are cheaper and relatively effective in preventing both esophageal and gastric bleeding. The following sections discuss the primary prevention of variceal bleeding with a focus on NSBB, carvedilol and VBL.
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Affiliation(s)
- Zeid Karadsheh
- Department of Medicine, Brockton Hospital, Brockton, USA
| | - Harmony Allison
- Division of Gastroenterology, Tufts Medical Center, Boston, MA, USA
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Yu FF, Wang JG, He BB, Wu AJ, Sun B, Zhuang XJ, Xu JM, Kong DR. A fiber-optic pressure sensor for measuring esophageal variceal pressure. Shijie Huaren Xiaohua Zazhi 2014; 22:221-226. [DOI: 10.11569/wcjd.v22.i2.221] [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
AIM: To test the feasibility and validity of a fiber-optic pressure sensor for measuring esophageal variceal pressure.
METHODS: A fiber-optic pressure sensor was used to measure the pressure of artificial variceal model (5 mm in diameter) with different intraluminal pressures (ranging from 6 to 42 cmH2O). Pressure measurements were performed by two independent operators, and the results were compared with actual intraluminal pressures. In clinical tests, the technique was used to measure variceal pressure in 25 patients with esophageal varices, and the correlation between variceal pressure and the risk factors for esophageal variceal bleeding was analyzed.
RESULTS: In vitro studies demonstrated a good correlation between the pressure measured with the fiber-optic pressure sensor and the actual intravariceal pressure (r ≥ 0.99 P < 0.01), and there were good correlations between the pressures measured by two operators (r ≥ 0.99). The determination of variceal pressure by this method was technically successful in all 25 patients. The variceal pressure measurements correlated with previous variceal bleeding history, the size of varices, the presence of red colour signs and the Child-Pugh classification (t = 4.42, P < 0.01).
CONCLUSION: Our preliminary results indicate that the fiber-optic pressure sensor is feasible and accurate in measurement of esophageal variceal pressure in vivo and in vitro, and warrants further investigation.
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Kong DR, Ma C, Wang M, Wang JG, Chen C, Zhang L, Hao JH, Li P, Xu JM. Effects of propranolol or propranolol plus isosorbide-5-mononitrate on variceal pressure in schistosomiasis. World J Gastroenterol 2013; 19:4228-4233. [PMID: 23864788 PMCID: PMC3710427 DOI: 10.3748/wjg.v19.i26.4228] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 03/29/2013] [Accepted: 06/06/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the effects of propranolol (PR) to that of PR plus isosorbide-5-mononitrate (ISMN) on variceal pressure in patients with schistosomiasis.
METHODS: Forty-eight patients with schistosomiasis who had no previous variceal bleeding were treated with PR alone or PR plus ISMN. Seven patients refused variceal pressure manometry (3 receiving PR and 4 receiving PR plus ISMN). One patient withdrew from the trial due to headache after taking ISMN. At the time of termination, twenty patients were randomly assigned to treatment with PR plus ISMN or PR alone. The dose of PR was adjusted until the resting heart rate had been reduced by 25% or was less than 55 bpm. In the PR plus ISMN group, after PR was titrated to the same target, the dose of ISMN was increased up to 20 mg orally twice a day. Variceal pressure was measured using a noninvasive endoscopic balloon technique at the end of the 6-mo treatment period.
RESULTS: In 40 patients (20 in the PR group and 20 in the PR plus ISMN group), variceal pressure was measured before treatment and at the end of the 6-mo treatment period. PR or PR plus ISMN treatment caused a significant reduction in variceal pressure (PR group: from 24.15 ± 6.05 mmHg to 22.68 ± 5.70 mmHg, P = 0.001; PR plus ISMN group: from 25.69 ± 5.26 mmHg to 20.48 ± 5.43 mmHg; P < 0.001). The percentage decrease in variceal pressure was significant after PR plus ISMN compared with that after PR alone (15.93% ± 8.37% vs 6.05% ± 3.67%, P = 0.01). One patient in the PR plus ISMN group and two patients in the PR group had variceal bleeding during follow-up. There were no significant differences between the two groups regarding the incidence of variceal bleeding. In the PR plus ISMN group, three patients had headache and hypotension. The headache was mild and transient and promptly disappeared after continuation of the relevant drug in two patients. Only one patient withdrew from the trial due to severe and lasting headache after taking ISMN. No side effects occurred in the PR group.
CONCLUSION: PR plus ISMN therapy may be an alternative treatment for patients with schistosomiasis who have a high risk of bleeding.
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Kong DR, Zhang C, Zhang L, Wang JG, Xiong Z, Li P, Xu JM. Measurement of variceal pressure with a computerized endoscopic manometry: validation and effect of propranolol therapy in cirrhotic patients. PLoS One 2013; 8:e56332. [PMID: 23431369 PMCID: PMC3576342 DOI: 10.1371/journal.pone.0056332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 01/08/2013] [Indexed: 11/23/2022] Open
Abstract
Background and Purpose Recently, we invented a computerized endoscopic balloon manometry (CEBM) to measure variceal pressure (VP) in cirrhotic patient. The purpose of this study was to evaluate the reliability and feasibility of this method, and whether this technique provided further information to pharmacological therapy. Patients and Methods VP measurements were performed in 83 cirrhotic patients and compared with HVPG as well as endoscopic bleeding risk parameters. Furthermore, VP was assessed before and during propranolol therapy in 30 patients without previous bleeding. Results VP measurements were successful in 96% (83/86) of all patients. Of the 83 patients, the VP correlated closely with the HVPG (P<0.001). The presence of red colour signs and the size of varices were strongly associated with VP. Patients with previous bleeding had higher VP than those who had not yet experienced bleeding. In univariate analysis, the level of VP, the size of varices, and red color signs predicted a higher risk of bleeding. The multiple logistic regression model revealed that VP was the major risk factor for bleeding. In 30 patients receiving propranolol, VP significantly decreased from 21.1±3.5 mmHg before therapy to 18.1±3.3 mmHg after 3 months and to 16.3±4.0 mmHg after 6 months. Comparing the mean decrease in VP with that in hepatic venous pressure gradient (HVPG), the decrease in VP was more obvious than HVPG response to propranolol. Conclusions This study showed that CEBM is safe and practical to assess VP in cirrhotic patient. It has the potential to be used as a clinical method to assess the risk of variceal bleeding and the effects of pharmacological therapy. Trial registration Effect of vasoactive drugs on esophageal variceal hemodynamics in patients with portal hypertension. Chinese Clinical Trial Registry –TRC-08000252.
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Affiliation(s)
- De-Run Kong
- Department of Gastroenterology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People’s Republic of China
| | - Chao Zhang
- Department of Surgery, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People’s Republic of China
| | - Lei Zhang
- Department of Gastroenterology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People’s Republic of China
| | - Jing-Guang Wang
- Department of Gastroenterology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People’s Republic of China
| | - Zhuang Xiong
- Department of Radiology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People’s Republic of China
| | - Pan Li
- Department of Gastroenterology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People’s Republic of China
| | - Jian-Ming Xu
- Department of Gastroenterology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People’s Republic of China
- * E-mail:
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Almadani B, Sood N, Yearsley M, Lee WM. Life-threatening variceal hemorrhage in a woman with severe pulmonary arterial hypertension. Gastroenterol Hepatol (N Y) 2012; 8:404-407. [PMID: 22933879 PMCID: PMC3424478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Bashar Almadani
- Department of Internal Medicine, The Ohio State University Medical Center, Columbus, Ohio
| | - Namita Sood
- Department of Internal Medicine, The Ohio State University Medical Center, Columbus, Ohio
| | - Martha Yearsley
- Department of Pathology, The Ohio State University Medical Center, Columbus, Ohio
| | - William M. Lee
- Department of Internal Medicine, The Ohio State University Medical Center, Columbus, Ohio
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Evangelista-Neto J, Pereira FF, França ST, Amaral FJ, Brandt CT, Fonseca-Neto OCLD, Lacerda CM. Esplenectomia e ligadura da veia gástrica esquerda na esquistossomose mansônica: efeitos sobre pressão das varizes do esôfago e indicadores endoscópicos de risco de sangramento por varizes esofagogástricas. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2012; 25:41-8. [DOI: 10.1590/s0102-67202012000100010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
RACIONAL: Expressivo contingente de pacientes esquistossomóticos com a forma hepatoesplênica e hipertensão portal apresentam hemorragia causada pela ruptura de varizes esofagogástricas, principal causa de alta morbidade e mortalidade da doença. OBJETIVO: Investigar os efeitos da esplenectomia e ligadura da veia gástrica esquerda sobre fatores de risco de sangramento por varizes esofagogástricas em portadores de esquistossomose mansônica, forma hepatoesplênica, com antecedente de hemorragia digestiva alta. MÉTODO: Estudaram-se, de forma prospectiva, 34 pacientes, com idade entre 1 e 74 anos (média 44,14), sendo 18 (53%) mulheres. Analisaram-se: 1) pressão das varizes do esôfago, aferida pela técnica endoscópica do balão pneumático; 2) tamanho, local, cor e sinais de cor vermelha nas varizes do esôfago; 3) varizes gástricas e gastropatia da hipertensão portal. Realizaram-se avaliações no pré-operatório, no pós-operatório imediato e no sexto mês após a ligadura da veia gástrica esquerda. RESULTADOS: A pressão das varizes do esôfago diminuiu de 22,3+/-2,6 mmHg, antes da operação, para 16,0+/-3,0 mmHg no pós-operatório imediato (p<0,001), caindo para 13,3+/-2,6 mmHg no pós-operatório do sexto mês (p<0,001). A proporção de varizes de grosso calibre, varizes no esôfago superior, varizes de cor azul, varizes com sinais de cor vermelha e de gastropatia da hipertensão portal decresceu de forma significante apenas no sexto mês de pós-operatório. CONCLUSÃO: A ligadura da veia gástrica esquerda, em esquistossomóticos hepatoesplênicos, com antecedente de hemorragia digestiva alta, revelou-se eficaz em diminuir alguns dos principais fatores de risco de hemorragia por varizes esofagogástricas, indicando boa perspectiva no controle definitivo do sangramento.
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Lee TH. [Recent advances in diagnosis of portal hypertension]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2010; 56:135-43. [PMID: 20847604 DOI: 10.4166/kjg.2010.56.3.135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Complications of portal hypertension are major concerns in liver cirrhosis and significant morbidity and mortality mainly because of variceal bleeding, ascites, bacterial infections, hepatic encephalopathy, and hepatorenal syndrome. Various modalities in the diagnosis of portal hypertension are reviewed. The measurement of hepatic venous pressure gradient (HVPG) is a simple, invasive, reproducible method and regarded as the gold standard for the diagnosis and staging of portal hypertension. Other tests such as transient elastography, per-endoscopic variceal pressure measurement, endoscopic ultrasonography, and Doppler ultrasonography may be complementary and promising.
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Affiliation(s)
- Tae Hee Lee
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea.
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Farias AQ, Kassab F, da Rocha ECV, Dos Santos Bomfim V, Vezozzo DCP, Bittencourt PL, Carrilho FJ. Propranolol reduces variceal pressure and wall tension in schistosomiasis presinusoidal portal hypertension. J Gastroenterol Hepatol 2009; 24:1852-6. [PMID: 19686417 DOI: 10.1111/j.1440-1746.2009.05912.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND AIM Although prophylaxis with beta-blockers has been shown to decrease variceal pressure and wall tension in cirrhotic patients, this has not been demonstrated in non-cirrhotic portal hypertension caused by Schistosoma mansoni infection. METHODS Thirteen patients without history of previous gastrointestinal bleeding were included. All of them had high-risk esophageal varices at endoscopy. An endoscopic gauge and a high-frequency endoscopic ultrasonography miniprobe were used to assess transmural variceal pressure and wall tension before and after achieving beta-blockade with propranolol. RESULTS Baseline variceal pressure decreased from 13.3 +/- 3.5 to 8.2 +/- 2.0 mmHg (P < 0.0001) and wall tension from 500.2 +/- 279.8 to 274.0 +/- 108.3 mg.mm(-1). The overall effect of propranolol on decreasing variceal pressure and wall tension expressed in percentage change in relation to baseline values was 35.7 +/- 18.4% and 35.9 +/- 26.7%, respectively (P = 0.9993). CONCLUSION Propranolol significantly reduced variceal pressure and wall tension in schistosomiasis.
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Sgouros SN, Vasiliadis KV, Pereira SP. Systematic review: endoscopic and imaging-based techniques in the assessment of portal haemodynamics and the risk of variceal bleeding. Aliment Pharmacol Ther 2009; 30:965-76. [PMID: 19735231 DOI: 10.1111/j.1365-2036.2009.04135.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Invasive measurement of the hepatic venous pressure gradient (HVPG) is regarded as the gold standard for risk stratification and the evaluation of pharmaceutical agents in patients with portal hypertension. AIM To review the techniques for endoscopic and imaging-based assessment of portal haemodynamics, with particular emphasis on trials where the results were compared with HVPG or direct portal pressure measurement. METHODS Systematic search of the MEDLINE electronic database with keywords: portal hypertension, variceal bleeding, variceal pressure, endoscopic ultrasound, Doppler ultrasonography, magnetic resonance angiography, CT angiography, hepatic venous pressure gradient. RESULTS Computed tomography angiography and endoscopic ultrasound (EUS) have been both employed for the diagnosis of complications of portal hypertension and for the evaluation of the efficacy of endoscopic therapy. Colour Doppler ultrasonography and magnetic resonance angiography has given discrepant results. Endoscopic variceal pressure measurements either alone or combined with simultaneous EUS, correlate well with HVPG and risk of variceal bleeding and have a low interobserver variability. CONCLUSIONS Endoscopic and imaging-based measurements of portal haemodynamics provide an alternate means for the assessment of complications of portal hypertension. Further studies are required to validate their use in risk stratification and the evaluation of drug therapies in patients with portal hypertension.
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Affiliation(s)
- S N Sgouros
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, UK
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Okamoto E, Amano Y, Fukuhara H, Furuta K, Miyake T, Sato S, Ishihara S, Kinoshita Y. Does gastroesophageal reflux have an influence on bleeding from esophageal varices? J Gastroenterol 2009; 43:803-8. [PMID: 18958550 DOI: 10.1007/s00535-008-2232-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Accepted: 06/02/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND Mucosal breaks induced by gastroesophageal reflux of gastric contents were more frequently found on the right anterior wall of the lower esophagus. Bleeding from esophageal varices may be also derived from gastroesophageal reflux. The circumferential location of the ruptured esophageal varices was evaluated to elucidate the relationship between gastroesophageal reflux and variceal rupture. METHODS Between January 2004 and December 2006, 26 patients who had primary bleeding from esophageal varices and 74 patients without evidence of bleeding with positive red color signs on varices were enrolled in this study retrospectively. Locations of bleeding spots and nonbleeding red color signs of esophageal varices were retrospectively evaluated by endoscopic photographs, and the relationship between the location of red color signs and the risk of bleeding was evaluated. Other possible predictors for bleeding were also investigated by multivariate regression analysis. RESULTS Red color signs were frequently found in the right posterior wall of the lower esophagus. However, bleeding spots of esophageal varices were more frequently seen in the right anterior side (64.0%) than in others. The positive predictor for bleeding from esophageal varices was the presence of red color sign in the right anterior wall of the esophagus, and the administration of proton pomp inhibitor was the negative predictor. CONCLUSIONS Gastroesophageal acid reflex may be a risk factor of bleeding from esophageal varices. Attention should be paid to the circumferential location of red color signs in endoscopic screening of patients with esophageal varices to predict future bleeding.
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Affiliation(s)
- Eisuke Okamoto
- Department of Gastroenterology and Hepatology, Shimane University, School of Medicine, Izumo, Japan
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Sarin SK, Kumar A, Chawla YK, Baijal SS, Dhiman RK, Jafri W, Lesmana LA, Guha Mazumder D, Omata M, Qureshi H, Raza RM, Sahni P, Sakhuja P, Salih M, Santra A, Sharma BC, Sharma P, Shiha G, Sollano J. Noncirrhotic portal fibrosis/idiopathic portal hypertension: APASL recommendations for diagnosis and treatment. Hepatol Int 2007; 1:398-413. [PMID: 19669336 PMCID: PMC2716836 DOI: 10.1007/s12072-007-9010-9] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2007] [Accepted: 06/06/2007] [Indexed: 12/23/2022]
Abstract
The Asian Pacific Association for the Study of the Liver (APASL) Working Party on Portal Hypertension has developed consensus guidelines on the disease profile, diagnosis, and management of noncirrhotic portal fibrosis and idiopathic portal hypertension. The consensus statements, prepared and deliberated at length by the experts in this field, were presented at the annual meeting of the APASL at Kyoto in March 2007. This article includes the statements approved by the APASL along with brief backgrounds of various aspects of the disease.
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Affiliation(s)
- Shiv Kumar Sarin
- Department of Gastroenterology, G B Pant Hospital, University of Delhi, Room 201, Academic Block, New Delhi, 110 002, India,
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Sharma P, Kumar A, Mehta V, Sharma BC, Sarin SK. Systemic and pulmonary hemodynamics in patients with non-cirrhotic portal fibrosis (NCPF) is similar to compensated cirrhosis. Hepatol Int 2007; 1:275-80. [PMID: 19669349 PMCID: PMC2720720 DOI: 10.1007/s12072-007-5006-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Non-cirrhotic portal fibrosis (NCPF) is an important cause of portal hypertension (PHT) and variceal bleeding, especially in the developing countries. While the hepatic parenchyma and liver functions are normal, the patho-anatomic defect in these patients is pre- and peri-sinusoidal in nature. AIM To study the systemic and pulmonary hemodynamic alterations in patients with NCPF and compare them with compensated cirrhotic patients. PATIENTS AND METHODS Patients with NCPF (n = 20, mean age 29.3 +/- 9.8 year) and matched Child's A cirrhotic patients (n = 17, age 34.1 +/- 9.8 year) who had bled in the past, underwent hemodynamic measurements using a balloon tipped catheter. RESULTS In NCPF patients, the hepatic venous pressure gradient (HVPG) was significantly lower than in the cirrhotic patients (4.9 +/- 1.5 mmHg vs. 15.7 +/- 4.5 mmHg; P < 0.01). NCPF patients had hyperdynamic circulation and peripheral vasodilatation comparable to cirrhotic patients; cardiac output (8.0 +/- 1.2 l/min vs. 8.4 +/- 1.9 l/min; P = 0.4), cardiac index (5.4 +/- 0.8 l/min/m(2) vs. 5.5 +/- 1.9 l/min/m(2); P = 0.86), mean arterial pressure (88.2 +/- 14.1 mmHg vs. 89.9 +/- 17.3 mmHg; P = 0.73), systemic vascular resistance (852.8 +/- 204.3 dynes . s/cm(5) vs. 854.1 +/- 189.9 dynes . s/cm(5); P = 0.98) and pulmonary vascular resistance (41.6 +/- 18.1 dynes . s/cm(5) vs. 41.3 +/- 17.9 dynes . s/cm(5); P = 0.95) were comparable in the two groups. CONCLUSIONS NCPF associated portal hypertension leads to a hyperdynamic state with high cardiac index and low systemic and pulmonary vascular resistance comparable to compensated cirrhosis. These novel observations suggest a primary role of portal hypertension in the development of hyperdynamic state.
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Affiliation(s)
- Praveen Sharma
- Department of Gastroenterology, G B Pant Hospital, Affiliated to University of Delhi, Room 201, Academic Block, New Delhi, 110 002 India
| | - Ashish Kumar
- Department of Gastroenterology, G B Pant Hospital, Affiliated to University of Delhi, Room 201, Academic Block, New Delhi, 110 002 India
| | - Vimal Mehta
- Department of Cardiology, G. B. Pant Hospital, New Delhi, India
| | - Barjesh Chander Sharma
- Department of Gastroenterology, G B Pant Hospital, Affiliated to University of Delhi, Room 201, Academic Block, New Delhi, 110 002 India
| | - Shiv Kumar Sarin
- Department of Gastroenterology, G B Pant Hospital, Affiliated to University of Delhi, Room 201, Academic Block, New Delhi, 110 002 India
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Abstract
Portal hypertension is characterized by an increase in portal pressure (>10 mm Hg) and could be a result of cirrhosis of the liver or noncirrhotic diseases. Noncirrhotic portal hypertension (NCPH), as it generally is termed, is a heterogeneous group of diseases that is due to intrahepatic or extrahepatic etiologies. In general, the lesions in NCPH are vascular in nature and can be classified based on the site of resistance to blood flow. Noncirrhotic portal fibrosis and extrahepatic portal vein obstruction are two diseases that are common in developing countries; they most often present only with features of portal hypertension and not of parenchymal dysfunction. These are described in detail.
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Affiliation(s)
- Shiv Kumar Sarin
- Department of Gastroenterology, G B Pant Hospital, Room 201, Academic Block, New Delhi 110 002, India.
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19
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Liu TT, Wong WJ, Hou MC, Lin HC, Chang FY, Lee SD. Hemorheology in patients with liver cirrhosis: special emphasis on its relation to severity of esophageal variceal bleeding. J Gastroenterol Hepatol 2006; 21:908-13. [PMID: 16704544 DOI: 10.1111/j.1440-1746.2006.04266.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Patients with decreased blood viscosity are supposed to have a higher risk of bleeding and increased severity of bleeding (severity of bleeding proportional to transmural pressure x area of variceal tear/blood viscosity). However, the hemorheological factors have never been assessed in patients with esophageal variceal bleeding. Therefore, the purpose of the present study was to examine the hemorheological factors in liver cirrhotic patients with special emphasis on the outcome of variceal bleeding. METHODS Forty-two liver cirrhosis patients with variceal bleeding and another 44 matched patients without bleeding were enrolled. The hemorheological and hemostatic factors of their peripheral blood were examined. The clinical course was under careful surveillance. RESULTS Patients with poor hepatic reserve (Child B + C vs A) had lower whole blood viscosity (4.34 +/- 0.56 mPa.s vs 5.06 +/- 1.35 mPa.s, P < 0.05), lower hematocrit levels (32.86 +/- 5.97% vs 36.62 +/- 5.44%, P < 0.05), lower platelet counts (79.7 +/- 47.6 x 10(3)/mL vs 108.0 +/- 71.2 x 10(3)/mL, P < 0.05) and prolonged prothrombin time (2.88 +/- 2.33 s vs 1.27 +/- 1.37 s, P < 0.05). Patients with bleeding (vs non-bleeding group) had lower hematocrit levels (31.44 +/- 5.75% vs 36.57 +/- 5.19%, P < 0.01) and lower fibrinogen levels (226.7 +/- 92.7 mg/dL vs 286.4 +/- 111.8 mg/dL, P < 0.05). Patients with bleeding with shock had worse liver cirrhosis (Child A/B/C = 0/5/4 vs 11/18/4, P < 0.05), lower whole blood viscosity (4.01 +/- 0.17 mPa.s vs 4.57 +/- 0.76 mPa.s, P < 0.05), reduced erythrocyte aggregability (2.94 +/- 0.41 vs 3.54 +/- 0.61, P < 0.001), and lower platelet counts (56.22 +/- 17.05 x 10(3)/mL vs 88.87 +/- 38.12 x 10(3)/mL, P < 0.001). The Child-Pugh grade and erythrocyte aggregability were two independent factors associated with bleeding shock. CONCLUSIONS Whole blood viscosity, hematocrit levels and platelet counts were lower in patients with advanced liver cirrhosis. Advanced liver cirrhosis and reduced erythrocyte aggregability were independent factors for hypovolemic shock in cirrhotic patients with esophageal variceal bleeding. However, the causal relationship between hemorheology and bleeding needs to be clarified in further studies.
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Affiliation(s)
- Tsu-Te Liu
- Division of Gastroenterology, Department of Medicine, Taipei-Veterans General Hospital and the National Yang Ming University School of Medicine, Taipei, Taiwan
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Cui CJ, Jin YR, Piao XX, Pei FY. Correlative factors of esophageal varices in patients with hepatocirrhosis: an analysis of 501 cases. Shijie Huaren Xiaohua Zazhi 2005; 13:2269-2272. [DOI: 10.11569/wcjd.v13.i18.2269] [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
AIM: To investigate the incidence rate and the risk factors of esophageal varices (EV) in patients with hepatocirrhosis.
METHODS: The clinical data of 501 patients with hepatocirrhosis were retrospectively studied.
RESULTS: The incidence rate of EV in patients with hepatocirrhosis were significantly different between the groups of different sex (male 84.3% vs female 72.0%, P < 0.05), different diameters of the portal vein (≥14 mm 85.9% vs <14 mm 72.5%, P < 0.05), and different grades of Child-Pugh. It was significantly different between the patients with and without sotting (84.9% vs 77.3%, P < 0.05) and ascites (83.9% vs 73.7%, P < 0.05). The serum albumin and cholinesterase in EV patients with hepatocirrhosis were significantly lower than those in non-EV patients. The EV incidence rate was correlated with the sex and diameters of portal vein (OR = 0.491, P = 0.016, OR = 2.203, P = 0.001).
CONCLUSION: The incidence of EV in patients with hepatocirrhosis is related to sex, the diameters of the portal vein, ascites, sotting, degree of hypohepatia, and dysbolism of serum albumin and cholinesterase. Sex and the diameters of the portal vein are more risky factors.
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Abstract
The development of portal hypertension plays a major role in the pathogenesis of many of the complications of chronic liver disease. In developed countries, most patients with portal hypertension have cirrhosis, and, in this condition, portal pressure is elevated as a result of both an increase in hepatic resistance to portal perfusion and increased mesenteric blood flow. Bleeding from oesophageal varices is a major cause of mortality in patients with significant portal hypertension. This review concentrates on the recognition, prevention and acute management of this life threatening complication of cirrhosis.
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Affiliation(s)
- J S Lubel
- Department of Gastroenterology, Austin Health, Melbourne, Victoria, Australia
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22
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Puckett JL, Liu J, Bhalla V, Kravetz D, Krinsky ML, Hassanein T, Mittal RK. Ultrasound system to measure esophageal varix pressure: an in vitro validation study. Am J Physiol Gastrointest Liver Physiol 2005; 288:G914-9. [PMID: 15626729 DOI: 10.1152/ajpgi.00373.2004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We report our experience with an ultrasound system to measure esophageal varix pressure in an in vitro model. The ultrasound system consists of a 12.5 MHz frequency intraluminal ultrasound probe, a water infusion catheter, and a manometry catheter, all contained within a nondistensible latex bag. Esophagi and external jugular veins were harvested from five pigs. The vein and ultrasound system were placed inside the esophagus. One end of the vein was connected to a water reservoir to modulate its pressure; the other end was connected in two different ways to simulate hydrodynamic and hydrostatic flow conditions. The bag was inflated with water until vein occlusion was discernible on the ultrasound images. The influences of vein pressure, vein cross-sectional area and esophageal elasticity on the ultrasound measurement of vein pressure were assessed. A total of 108 trials were performed at nine different vein pressures. Complete vein occlusion occurred when the bag pressure was slightly greater (1.4 +/- 0.7 mmHg) than the vein pressure. For a vein pressure of 25 mmHg, the average occlusion and opening pressures were 27 +/- 0.2 and 25.7 +/- 0.3 mmHg, respectively (P < .05) suggesting that the vein opening pressure on the ultrasound images is more accurate than the vein closing pressure. In conclusion, the ultrasound technique can accurately measure intravariceal pressure in vitro. The bag pressure at the point of vein reopening is the best determinant of the vein pressure.
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Affiliation(s)
- James L Puckett
- Division of Gastroenterology 111D, Veterans Affairs Medical Center, University of California, San Diego, 3350 La Jolla Village Drive, San Diego, California 92161, USA
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23
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Abstract
Portal hypertension is defined by an elevation in blood pressure in the portal system. Different causes are known and include a pre-, intra-, or posthepatic block. Portal hypertension is also classified according to the sinusoidal system. Portal pressure becomes elevated by either an increase in blood flow (Q), an increase in resistance (R), or both. Regulation of the vascular tone in the splanchnic system includes intrinsic and extrinsic aspects. A variety of metabolic end-products (e.g. adenosine), endothelium-derived substances (e.g. nitric oxide), and certain neurotransmitters (e.g. acetylcholine) are known to relax the tone and thus produce vasodilation. Important vasoconstrictor influences on splanchnic arterioles include circulating agents (e.g. angiotensin), endothelium-derived substances (e.g. endothelin), and again neurotransmitters (norepinephrine). Besides vascular tone, structural changes (thrombosis, fibrosis, shear stress, and cell regeneration) add to overall hepatic resistance. Further consequences of portal hypertension include an increase in blood flow which leads to a hyperdynamic state with fluid retention, leading to secondary involvement of other organs, such as cirrhotic cardiomyopathy, hepatopulmonary syndrome and hepatorenal syndrome. Finally, portal hypertension will end up in the formation of collateral vessels. Varices can involve the whole gastrointestinal tract and are a frequent source of bleeding.
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Affiliation(s)
- Gerhard Treiber
- Department of Gastroenterology, Hepatology, and Infectious Diseases, University Hospital Magdeburg, Magdeburg, Germany.
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24
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Miller LS, Dai Q, Thomas A, Chung CY, Park J, Irizarry S, Nguyen T, Thangada V, Miller ES, Kim JK. A new ultrasound-guided esophageal variceal pressure-measuring device. Am J Gastroenterol 2004; 99:1267-73. [PMID: 15233664 DOI: 10.1111/j.1572-0241.2004.30177.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To develop a noninvasive method and device to determine intravariceal pressure and variceal wall tension by measuring the variables of the Laplace equation and test this device in a model of esophageal varices. METHODS Two variceal pressure measurement devices were constructed. The first device consists of an Olympus 20 MHz ultrasound transducer placed next to a latex balloon catheter attached to a pressure transducer. The second device was constructed by placing the same ultrasound transducer inside a latex condom balloon attached to a pressure transducer. These pressure measurement devices were tested blindly in varix models with different intravariceal pressures, by inflating the balloon to flatten the varix models. Each variceal pressure was measured 10 times by two separate investigators blinded to the actual pressures. The mean intravariceal pressures were calculated. The variceal models were made of a latex balloon filled with water and coffeemate. RESULTS The correlation coefficient between the actual and measured varix pressures for both devices was 0.99. The percent error ranged from 0 to 10%. The correlation coefficient between the investigators making the blinded measurements for both devices was 0.98. CONCLUSION Two pressure-measuring devices were developed to determine intravariceal pressure in a model varix system. These devices demonstrate a low percent error and a high correlation to the actual variceal pressures with low intra- and interobserver variability. These devices have the potential to measure all the variables of the Laplace equation for wall tension. We plan to test these devices in human subjects.
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Affiliation(s)
- Larry S Miller
- Department of Gastroenterology, Temple University Hospital, Philadelphia, Pennsylvania 19140, USA
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25
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N/A. N/A. Shijie Huaren Xiaohua Zazhi 2004; 12:1191-1195. [DOI: 10.11569/wcjd.v12.i5.1191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Zhang XH, Zhang YF, Ning FQ, Yang SJ. Ultrasonographic prediction of esophageal varices in patients with liver cirrhosis. Shijie Huaren Xiaohua Zazhi 2004; 12:911-913. [DOI: 10.11569/wcjd.v12.i4.911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the value of ultrasonographic prediction of the esophageal varices in patients with liver cirrhosis.
METHODS: All 207 cases were examined by ultrasonography and endoscopy, and classified according to the Child-Pugh score. The valuable ultrasonographic variables were selected to form regression formulae to predict the esophageal varices degrees in patients with liver cirrhosis.
RESULTS: The esophageal varices degree was correlated with Child-Pugh classification (r = 0.39, P<0.01). In class Child-Pugh C, about 93.3% of patients had over medium degree of esophageal varices. The Logistic formula (P(B) = 1/[1+e-(-19.554+9.295AS-2.757PUV-4.278GBBL+1.288PVD)] might predict Child-Pugh B, and the diagnostic accuracy was 92.7%. The Logistic formula (P(A) = 1/[1+e-(-0.405+1.686PUV)] might predict Child-Pugh A, and the diagnostic accuracy was 68.0%.
CONCLUSION: A majority of patients in class Child-Pugh C has over moderate esophageal varices, therefore all patients in this class should be examined by endoscopy. But patients in classes Child-Pugh B and A should be examined by ultrasonography first, and for high risk patients, endoscopy should be carried out.
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27
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Raines DL, Dupont AW, Arguedas MR. Cost-effectiveness of hepatic venous pressure gradient measurements for prophylaxis of variceal re-bleeding. Aliment Pharmacol Ther 2004; 19:571-81. [PMID: 14987326 DOI: 10.1111/j.1365-2036.2004.01875.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Measurement of the hepatic venous pressure gradient may identify a sub-optimal response to drug prophylaxis in patients with a history of variceal bleeding. However, the cost-effectiveness of routine hepatic venous pressure gradient measurements to guide secondary prophylaxis has not been examined. METHODS A Markov model was constructed using specialized software (DATA 3.5, Williamstown, MA, USA). Three strategies involved secondary prophylaxis without haemodynamic monitoring using beta-blockers alone, beta-blockers plus isosorbide mononitrate or endoscopic variceal ligation alone. Four strategies involved secondary prophylaxis with beta-blockers plus isosorbide mononitrate or beta-blockers alone, accompanied by one or two hepatic venous pressure gradient measurements to identify haemodynamic non-responders, who underwent endoscopic variceal ligation as an alternative. The total expected costs, variceal bleeding episodes and total deaths were calculated for each strategy over 3 years. RESULTS The two most effective strategies were combination therapy alone and combination therapy with two hepatic venous pressure gradient measurements. The incremental cost-effectiveness ratio of the latter strategy was 136,700 dollars per year of life saved compared with combination therapy alone. The ratio improved as the time horizon was extended or the rates of variceal re-bleeding were increased. CONCLUSIONS The cost-effectiveness of haemodynamic monitoring to guide secondary prophylaxis of recurrent variceal bleeding is highly dependent on local hepatic venous pressure gradient measurement costs, life expectancy and re-bleeding rates.
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Affiliation(s)
- D L Raines
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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28
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Eroglu Y, Emerick KM, Whitingon PF, Alonso EM. Octreotide therapy for control of acute gastrointestinal bleeding in children. J Pediatr Gastroenterol Nutr 2004; 38:41-7. [PMID: 14676593 DOI: 10.1097/00005176-200401000-00011] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To evaluate the outcomes of octreotide use in children with gastrointestinal bleeding with or without portal hypertension. METHODS The medical charts of children who received continuous octreotide infusion for the indication of gastrointestinal bleeding from January 1995 to December 2000 were retrospectively reviewed. RESULTS Twenty-one children with portal hypertension received octreotide infusions (1-2 microg/kg/h) during 35 gastrointestinal bleeding episodes. The duration of infusion ranged from 19 hours to 7 days. Bleeding ceased in 71% of children. Post-treatment rebleeding occurred in 52%, and the mortality was 19%. Response to octreotide, rebleeding, and mortality did not differ significantly between patients with or without intrinsic liver disease. Twelve children with gastrointestinal bleeding unrelated to portal hypertension received octreotide during 14 episodes. The duration of octreotide ranged from 3 hours to 36 days. Fifty percent of children had resolution of bleeding during the infusion. Post-treatment rebleeding occurred in 29%, and the mortality was 50%. No major adverse events were observed in either group. CONCLUSIONS A high rate of bleeding control was achieved with octreotide during acute gastrointestinal bleeding in children with portal hypertension. However, controlled studies are needed for more definitive description of its clinical effects. The role of octreotide is less clear in gastrointestinal bleeding unrelated to portal hypertension.
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Affiliation(s)
- Y Eroglu
- Department of Gastroenterology, Hepatology and Nutrition, Children's Memorial Hospital, Northwestern University Medical School, Chicago, IL 60614, USA
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29
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Abstract
Non-cirrhotic portal hypertension (NCPH) comprises of diseases having an increase in portal pressure (PP) due to intraheptic or prehepatic lesions, in the absence of cirrhosis. The lesions are generally vascular, either in the portal vein, its branches or in the perisinusoidal area. Because the wedged hepatic venous pressure (WHVP) is near normal, measurement of intravariceal or intrasplenic pressure is needed to assess portal pressure. The majority of the diseases included in the category of NCPH are well characterized disease entities where portal hypertension (PHT) is a late manifestation and hence, these are not discussed. Two diseases which present only with features of PHT and are common in developing countries are NCPF and extra-hepatic portal vein obstruction (EHPVO). Non-cirrhotic portal fibrosis is a syndrome of obscure etiology, characterized by 'Obliterative portovenopathy' leading to PHT, massive splenomegaly, repeated well tolerated episodes of variceal bleeding and anemia in young adults from low socio-economic strata of life. The hepatic parenchymal functions are nearly normal. Jaundice, ascites and hepatic encephalopathy are rare. Management of variceal bleeding remains the main concern as nearly 85% of patients with NCPF present with variceal bleeding. Endoscopic variceal ligation or sclerotherapy are equally effective in about 90-95% of the patients. Gastric varices are seen in about 25% patients and a bleed from them can be managed with cyanoacrylate glue injection or surgery. Other indications for surgery include failure of endoscopic therapy to control acute bleed and symptomatic hypersplenism. The prognosis of patients with NCPF is good and 5-years survival rates in patients in whom variceal bleeding can be controlled is about > 95%.
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Affiliation(s)
- S K Sarin
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India.
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30
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Miller ES, Kim JK, Gandehok J, Hara M, Dai Q, Malik A, Miller A, Miller L. A new device for measuring esophageal variceal pressure. Gastrointest Endosc 2002; 56:284-91. [PMID: 12145614 DOI: 10.1016/s0016-5107(02)70195-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Esophageal varices are a frequent source of bleeding in patients with cirrhosis. Elevated intravariceal pressure is associated with variceal bleeding. There is no simple, easy-to-use device for noninvasive measurement of intravariceal pressure. The purposes of this study were to develop a noninvasive method for measuring intravariceal pressure, and to develop a model of esophageal varices that can be used to test this pressure measurement device. METHODS A variceal pressure measurement device was constructed by placing a 20 MHz US transducer in a latex balloon catheter sheath and attaching the catheter to a pressure transducer. The pressure measurement device was passed though the accessory channel of a large-channel endoscope and tested in blinded fashion by using tip deflection to compress each of 4 variceal models with the device. The pressure within each model was measured 10 times by 2 separate investigators blinded to the actual pressures. The mean (SD) pressure was calculated for each model. The variceal models were made of nitrocellulose dialysis tubing filled with water. Each "varix" had the same diameter but a different intraluminal pressure (5.5, 10, 15, 21.5 mm Hg). OBSERVATIONS The correlation coefficient between the actual and measured "varix" pressures for the first investigator (L.S.M.) was r = 0.96: 99% CI [0.93, 0.98]. For the varix models with pressures of 21.5, 15, 10, and 5.5 the percent errors were, respectively, 9.5, 3.9, 5.1, and 0.7. The correlation coefficient between the actual and measured varix pressures for the second investigator (Q.D.) was r = 0.97: 99% CI [0.94, 0.98]. For the varix models with pressures of 21.5, 15, 10, and 5.5 the percent errors were, respectively, 10.3, 3.4, 9.8, and 1.1. The correlation coefficient between the 2 investigators (L.S.M., Q.D.) for the varix model pressures was r = 0.97: 99% CI [0.95, 0.99]. CONCLUSION The variceal pressure measuring device developed for this study measured intravariceal pressure in a model varix with a low percent error and high correlation to the actual pressures. Intraobserver and interobserver variability was low.
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Affiliation(s)
- Elan S Miller
- Temple University Hospital, Philadelphia, Pennsylvania 19140, USA
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31
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Abstract
Non-cirrhotic portal hypertension (NCPH) comprises diseases having an increase in portal pressure (PP) due to intraheptic or prehepatic lesions, in the absence of cirrhosis. The lesions are generally vascular, either in the portal vein, its branches or in the perisinusoidal area. Because the wedged hepatic venous pressure is near normal, measurement of intravariceal or intrasplenic pressure is needed to assess PP. The majority of diseases included in the category of NCPH are well-characterized disease entities where portal hypertension (PHT) is a late manifestation and, hence, these are not discussed. Two diseases that present only with features of PHT and are common in developing countries are non-cirrhotic portal fibrosis (NCPF) and extrahepatic portal vein obstruction (EHPVO). Non-cirrhotic portal fibrosis is a syndrome of obscure etiology, characterized by 'obliterative portovenopathy' leading to PHT, massive splenomegaly and well-tolerated episodes of variceal bleeding in young adults from low socioeconomic backgrounds, having near normal hepatic functions. In some parts of the world, NCPF is called idiopathic portal hypertension (IPH) or 'hepatoportal sclerosis'. Because 85-95% of patients with NCPF and EHPVO present with variceal bleeding, treatment involves management with endoscopic sclerotherapy (EST) or variceal ligation (EVL). These therapies are effective in approximately 90-95% of patients. Gastric varices are another common cause of upper gastrointestinal bleeding in these patients and these can be managed with cyanoacrylate glue injection or surgery. Other indications for surgery include failure of EST/EVL, and symptomatic hypersplenism. The prognosis of patients with NCPF is good and 5 years survival in patients in whom variceal bleeding can be controlled has been reported to be approximately 95-100%.
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Affiliation(s)
- S K Sarin
- Department of Gastroenterology, GB Pant Hospital, New Delhi, India.
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Abstract
Noncirrhotic portal hypertension represents a heterogeneous group of conditions that have distinct clinical and hemodynamic features that often help distinguish them from cirrhosis. [figure: see text] The sites of portal flow resistance may not be precisely localized to one area of the hepatic lobule and may extend beyond the site where the pathogenetic process began. Even in patients with portal hypertension caused by an increased flow, there may be subsequent development of increased resistance. The prognosis is variable; outcomes are better in patients with presinusoidal portal hypertension. A good understanding of the presentation of the various noncirrhotic conditions that cause portal hypertension will help determine the cause, the site of resistance, and the therapeutic plan. Ascites is not a feature of presinusoidal portal hypertension, whereas it may be the predominant feature in postsinusoidal portal hypertension.
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Affiliation(s)
- E Molina
- Center for Liver Diseases, University of Miami School of Medicine, Miami, Florida, USA
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Vlachogiannakos J, Goulis J, Patch D, Burroughs AK. Review article: primary prophylaxis for portal hypertensive bleeding in cirrhosis. Aliment Pharmacol Ther 2000; 14:851-60. [PMID: 10886040 DOI: 10.1046/j.1365-2036.2000.00778.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Variceal bleeding is a consequence of portal hypertension, which in turn is the major complication of hepatic cirrhosis. Given the high rate of mortality of the first bleeding episode, primary prophylaxis to prevent bleeding from varices and portal hypertensive gastropathy is the current optimal therapeutic approach. The difficulty in identification of patients with varices who will bleed, before they do so, can justify a strategy of treating all patients with varices prophylactically. We evaluated the various therapies that have been assessed in randomized controlled trials for prevention of first bleeding, using meta-analysis where applicable. The current first choice treatment is non-selective beta-blockers; it is cheap, easy to administer, and is effective in preventing the first variceal haemorrhage and bleeding from gastric mucosa. Combination drug therapy of beta-blockers and nitrates looks promising, but needs further evaluation in randomized controlled trials. The conflicting results of the randomized studies of endoscopic banding ligation and the small number of patients and clinical events, as well as the cost, do not warrant any change in current practice. However, endoscopic banding ligation may be a reasonable alternative for patients who cannot tolerate, or have contraindications to beta-blockers or no haemodynamic response to the drug therapy, but this must be proved in randomized trials.
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Affiliation(s)
- J Vlachogiannakos
- Liver Transplantation and Hepatobiliary Medicine, Royal Free Hospital, London, UK
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