Variceal Bleeding

Opinion statement Primary prophylaxis: Patients with cirrhosis who have esophageal varices but who have never had a bleeding episode may be treated medically or endoscopically. Without treatment, approximately 30% of cirrhotic patients with varices bleed and this risk is reduced by approximately 50% with therapy. Medical therapy includes nonselective beta blockers with or without nitrates. Compliance and side effects limit efficacy. Primary prophylaxis with endoscopic sclerotherapy is not warranted because of evidence suggesting that complications outweigh benefits. Studies of endoscopic therapy with ligation (endoscopic banding) demonstrate that in select patients (those with large varices), endoscopic banding may reduce the risk of first bleeding episode when compared with propranolol. Patients with large varices may benefit from a combination of banding with nonselective beta blockers. Secondary prophylaxis: After an initial variceal bleed, the risk of a second bleed is high and therapy is warranted to reduce the risk of rebleeding. The options are similar to those for primary prophylaxis, and in addition to medical and endoscopic therapy, transjugular intrahepatic portosystemic shunts (TIPS) and surgical shunts are therapeutic options. The combination of endoscopic therapy with medical therapy is the initial approach to prevent variceal rebleeding. Endoscopic banding is preferred to sclerotherapy because banding is associated with lower bleeding rates and fewer complications. TIPS is useful in cases refractory to endoscopic therapy or in uncontrolled variceal hemorrhage. Surgical shunts are typically reserved for patients in whom TIPS cannot be performed for technical reasons or for well-compensated cirrhotic patients. Acute variceal bleeding: Acute bleeding from esophageal varices requires an endoscopic evaluation and therapeutic intervention. Technically, endoscopic banding may not be possible because of limited visualization from bleeding and sclerotherapy is used because it is easier to perform in this setting. A continuous intravenous drip of octreotide should be initiated if variceal bleeding is suspected. If variceal bleeding cannot be controlled, then a Minnesota tube or Sengstaken-Blakemore tube should be placed by someone with experience. TIPS is effective rescue therapy for controlling acute variceal hemorrhage in circumstances when other methods fail.     

Intraabdominal Variceal Bleeding

A patient with known liver cirrhosis, but no previous variceal bleeding, presented with sudden abdominal pain and distention, hypotension, and bloody ascitic fluid. At exploration, he was found to be bleeding from varices in the gastrohepatic omentum and perisplenic area. Pathology of the liver showed cirrhosis and metastatic undifferentiated carcinoma.     

Variceal Band Ligation in the Prevention of Variceal Bleeding: A Multicenter Trial

Background/Aim:

Variceal bleeding is a life-threatening complication of portal hypertension with a high probability of recurrence. Treatment to prevent first bleeding or rebleeding is mandatory. The study has been aimed at investigating the effectiveness of endoscopic band ligation in preventing upper gastrointestinal bleeding in patients with portal hypertension and to establish the clinical outcome of patients.

Patients and Methods:

We analyzed in a multicenter trial, the efficacy and side effects of endoscopic band ligation for the primary and secondary prophylaxis of esophageal variceal bleeding. We assigned 603 patients with portal hypertension who were hospitalized to receive treatment with endoscopic ligation. Sessions of ligation were repeated every two to three weeks until the varices were eradicated. The primary end point was recurrent bleeding.

Results:

The median follow-up period was 32 months. A total of 126 patients had recurrent bleeding. All episodes were related to portal hypertension and 79 to recurrent variceal bleeding. There were major complications in 51 patients (30 had bleeding esophageal ulcers). Seventy-eight patients died, 26 deaths were related to variceal bleeding and 1 to bleeding esophageal ulcers.

Conclusions:

A great improvement in the prevention of variceal bleeding has emerged over the last years. However, further therapeutic options that combine higher efficacy, better tolerance and fewer side effects are needed.     

Treatment of Acute Variceal Bleeding

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Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Variceal Bleeding in Portal Hypertension (Comparison of Emergency and Elective Interventions)

Nonsurgical reduction of portal hypertension bytransjugular intrahepatic portosystemic shunt (TIPS) iswidely used for prevention of variceal rebleeding(elective TIPS). Information is limited about the value of emergency TIPS for acute varicealbleeding unresponsive to endoscopic and drug therapy.The aim of the present study was therefore to determinewhether the effects and complications differ between emergency and elective TIPS in patients withcirrhosis of the liver. TIPS was performed in 11patients with acute variceal bleeding unresponsive toendoscopic treatment and 22 patients in stable condition after an episode of variceal bleeding. Clinicalexamination, blood sampling, Doppler sonography of TIPSflow, and upper gastrointestinal endoscopy wereperformed at days 1, 7, and 30 and at three-month intervals after TIPS. Mean follow-up was 549(1-987) days. Bleeding was controlled by emergency TIPSin 10/11 patients. Probability of survival was notdifferent after emergency and elective TIPS (0.73 vs 0.84 at one year). Early rebleeding (2weeks) occurred more often after emergency TIPS (3/11 vs0/22 patients; P = 0.03), but there was no significantdifference in late rebleeding. Occlusion of TIPS was more frequent after emergency TIPS.Occurrence of TIPS stenoses was identical in both groups(4/11 vs 8/22). De novo or deterioration of preexistinghepatic encephalopathy was similar (18% vs 24%; NS). Itis concluded that TIPS is effective for control of acutevariceal bleeding unresponsive to endoscopic and drugtreatment. Early rebleeding and stent occlusion occurredmore often after emergency TIPS. Late rebleeding, complications, andlong-term survival did not differ from electiveTIPS.     

Liver Transplantation for Uncontrollable Variceal Bleeding

Objectives: A small number of liver transplant candidates experience variceal bleeding that cannot be controlled by standard medical therapy. The objective of this study was to analyze the role of urgent liver transplantation for this subset of patients with acute, refractory, portal hypertensive bleeding. Methods: Retrospective review of data from 416 patients undergoing 449 liver transplantations between March, 1988 and February, 1993 revealed seven patients (1.7%) with endstage liver disease who underwent transplantation for uncontrollable variceal bleeding. All patients failed therapy with intravenous pitressin, endoscopic sclerotherapy, balloon tamponade, and/or transjugular intrahepatic portosystemic shunt and continued to bleed. Patients ranged in age from 6 months to 56 years. All patients were Child's class C. Two patients were listed for transplantation with the United Network for Organ Sharing as status 3, and five patients were listed as status 4. Results: All patients underwent successful liver transplantation with immediate control of bleeding. One patient expired on the 26th postoperative day from multiple organ failure, and another patient expired with recurrent hep-atocellular carcinoma on the 110th postoperative day. No patients experienced late rebleeding from varices after transplantation. Conclusions: Urgent liver transplantation is effective and feasible for the small subset of patients with uncontrollable variceal bleeding and endstage liver disease. Prompt and complete evaluation of the potential recipient and availability of a donor organ are critical to the success of this approach.     

Old Drugs for New Indications in Cardiovascular Medicine

Inflammation participates in the initiation and progression of atherosclerotic cardiovascular disease, and it is a critical inciting factor leading to acute ischemic events. Evidence has shown that certain anti-inflammatory medications used to treat non-atherosclerotic inflammatory diseases reduce cardiovascular events. This article reviews evidence that commonly used anti-inflammatory therapies (colchicine, allopurinol, methotrexate), reduce cardiovascular events. We discuss potential mechanisms of action, efficacy, and safety of these therapies and propose a clinical trials design to investigate their efficacy.     

Pharmacological Prevention of Recurrent Variceal Bleeding

Bleeding varices are a major complication of portal hypertension and cause of death in patients with cirrhosis. The main goals of therapy for variceal bleeding are (1) prevention of the initial bleeding episode; (2) control of acute hemorrhage, and (3) prevention of recurrent variceal bleeding. The risk of rebleeding after initial control of variceal hemorrhage may be as high as 80%. Therefore, prevention of rebleeding should be considered as soon as initial control of bleeding.     

内镜下套扎法在食管静脉曲张出血中的临床应用

内镜下硬化疗法为一消除曲张食管静脉，治疗其急性出血的有效方法，但因有许多严重并发症如胸痛发热菌血症，胸膜浸润，食管穿孔及食管狭窄等，故并非理想疗法。而近来兴起的内镜下食管静脉套扎（EVL）不仅可以消除曲张的食管静脉，而且可以防止硬化疗法的上述副作用。本文56例肝硬化食管静脉曲张破裂出血患者进行了EVL治疗，其中36例患者随访观察18个月，4例进行了急诊EVL治疗。结果显示急诊止血率为75％，显效率69．4％，有效率为88．8％，每人年平均出血次数由结扎前的1．35次减少为0．18次，其疗效至少和硬化疗法相同。该法制作简单，容易，安全，并发症少，应该在临床上推广应用。     

Case Series Regarding Parastomal Variceal Bleeding: Presentation and Management

Parastomal variceal bleeding (PVB) is a serious complication occurring in up to 27% of patients with an ostomy and concurrent cirrhosis and portal hypertension. The management of PVB is difficult and there are no clear guidelines on this matter. Transjugular intrahepatic portosystemic shunt (TIPS), sclerotherapy, and /or coil embolization are all therapies that have been shown to successfully manage PVB. We present a case series with five different patients who had a PVB at our institution. The aim of this case series is to report our experience on the management of this infrequently reported but serious condition. We also conducted a systemic literature review focusing on the treatment modalities of 163 patients with parastomal variceal bleeds. In our series, patient 1 had embolization and sclerotherapy without control of bleed and expired on the day of intervention due to hemorrhagic shock. Patient 2 had TIPS in conjunction with embolization and sclerotherapy and had no instance of rebleed 441 days after therapy. Patient 3 did not undergo any intervention due to high risk for morbidity and mortality, the bleed self-resolved and there was no further rebleed, this same patient died of sepsis 73 days later. Patient 4 had embolization and sclerotherapy and had no instance of rebleed 290 days after therapy. Patient 5 had TIPS procedure and was discharged five days post procedure without rebleed, patient has since been lost to follow-up.     

食管胃静脉曲张破裂出血的内镜治疗进展

食管胃静脉曲张破裂出血（EVB）是肝硬化门静脉高压的严重并发症。〈50％的EVB为自限性出血,近30％的肝硬化死亡归因于活动性EVB。迄今,内镜治疗方法如内镜注射硬化疗法（EIS）、内镜曲张静脉结扎（EVL）等已广泛应用于临床．极大地提高了EVB患者的生存率。本文就EVB的内镜治疗进展作一综述。