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Management of Varices and Variceal Hemorrhage in Cirrhosis
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Transcript
Risk Stratification for Patients with Portal Hypertension
Prevention of Varices and a First Variceal Hemorrhage
- In patients without varices, treatment with nonselective β-blockers is not recommended because they do not prevent the development of varices and are associated with side effects.
- In patients with small varices with high risk of hemorrhage (varices with red wale marks or varices with Child class B or C), nonselective β-blockers are recommended.
- In patients with medium or large varices, either nonselective β-blockers or endoscopic variceal ligation can be used.
Treatment of Acute Variceal Hemorrhage
Patients who have Child class A or B or who have an HVPG < 20 mmHg should receive standard therapy
- combination of vasoconstrictor (terlipressin, somatostatin, or octreotide, administered from the time of admission and maintained for 2 to 5 days) and endoscopic therapy (preferably endoscopic variceal ligation, performed at diagnostic endoscopy <12 hours after admission), together with short-term prophylactic antibiotics (either norfloxacin or ceftriaxone).
- Placement of a TIPS is currently considered a salvage therapy for the 10 to 20% of patients in whom standard medical therapy fails.
- Endoscopic variceal obturation is the best endoscopic technique to control acute hemorrhage and the TIPS is more effective than variceal obturation in preventing recurrent hemorrhage.
Prevention of Recurrent Variceal Hemorrhage
- Combination endoscopic variceal ligation plus nonselective β-blockers are warranted because of the high risk of recurrence.
- In patients who are not candidates for endoscopic variceal ligation, the strategy would be to maximize portal-pressure reduction by combining nonselective β -blockers plus nitrates.
- Patients who have rebleeding despite combined treatment with endoscopic variceal ligation and drugs should undergo TIPS or surgical shunt; the two shunts are equally effective.
REVIEW ARTICLE
Natural History and Epidemiology
Management of Varices and Variceal Hemorrhage in Cirrhosis
- Gastroesophageal varices are present in almost half of patients with cirrhosis at the time of diagnosis, with the highest rate among patients with Child-Turcotte-Pugh class B or C disease.
- Development and growth of gastroesophageal varices each occur at a rate of 7% per year.
- The 1-year rate of recurrent variceal hemorrhage is approximately 60%.
- The 6-week mortality with each episode of variceal hemorrhage is approximately 15 to 20%.
N Engl J Med March 4, 2010;362:823-32.
Purpose of Therapy
Sclerotherapy
Band ligation
- Prevention of Varices and a First Variceal Hemorrhage
- Treatment of Acute Variceal Hemorrhage
- Prevention of Recurrent Variceal Hemorrhage
Endoscopic Therapy
Cirrhosis
Portal Hypertension
Esophageal Varices
Surgical Therapy
Distal splenorenal shunt
Pharmacologic Therapy
Esophagogastroduodenoscopy
- to evaluate the presence of varices, red wale marks, and variceal size
Stent
Transjugular Intrahepatic
Portosystemic Shunt (TIPS)
HVPG (hepatic venous pressure gradient)
- Portal hypertension is clinically significant when HVPG >10 mmHg, this pressure is the strongest predictor of the development of varices, clinical decompensation, and HCC.
- In patients with variceal hemorrhage, HVPG >20 mmHg (measured within 24 hours after admission) is the best predictor of a poor outcome.