Increased portal pressure during variceal bleeding may have an influence on the treatment failure rate, as well as on short- and long-term survival. However, the usefulness of hepatic hemodynamic measurement during the acute episode has not been prospectively validated, and no information exists about the outcome of hemodynamically defined high-risk patients treated with early portal decompression. Hepatic venous pressure gradient (HVPG) measurement was made within the first 24 hours after admission of 116 consecutive patients with cirrhosis with acute variceal bleeding treated with a single session of sclerotherapy injection during urgent endoscopy. Sixty-four patients had an HVPG less than 20 mm Hg (low-risk [LR] group), and 52 patients had an HVPG greater than or equal to 20 mm Hg (high-risk [HR] group). HR patients were randomly allocated into those receiving transjugular intrahepatic portosystemic shunt (TIPS; HR-TIPS group, n = 26) within the first 24 hours after admission and those not receiving TIPS (HR-non-TIPS group). The HR-non-TIPS group had more treatment failures (50% vs. 12%, P =.0001), transfusional requirements (3.7 +/- 2.7 vs. 2.2 +/- 2.3, P =.002), need for intensive care (16% vs. 3%, P <.05), and worse actuarial probability of survival than the LR group. Early TIPS placement reduced treatment failure (12%, P =.003), in-hospital and 1-year mortality (11% and 31%, respectively; P <.05). In conclusion, increased portal pressure estimated by early HVPG measurement is a main determinant of treatment failure and survival in variceal bleeding, and early TIPS placement reduces treatment failure and mortality in high risk patients defined by hemodynamic criteria.
"The high mortality associated with the use of TIPS as a rescue treatment raises the question of whether patients with poor prognostic indicators might benefit from a more aggressive therapeutic approach. Two randomized, controlled trials have shown that an early placement of such a shunt (within up to 72 hours after admission) was associated with a reduction in failure to control bleeding, lower incidence of rebleeding, and a decreased mortality rate among high-risk patients (Child-Pugh C or an HVPG of >20 mmHg) [48, 49]. In addition, the TIPS group did not have an increased incidence of hepatic encephalopathy. "
[Show abstract][Hide abstract] ABSTRACT: Variceal hemorrhage is a common and devastating complication of portal hypertension and is a leading cause of death in patients with cirrhosis. The management of gastroesophageal varices has evolved over the last decade resulting in improved mortality and morbidity rates. Regarding the primary prevention of variceal hemorrhaging, nonselective
-blockers should be the first-line therapy in all patients with medium to large varices and in patients with small varices associated with high-risk features such as red wale marks and/or advanced cirrhosis. EVL should be offered in cases of intolerance or side effects to
-blockers, or for patients at high-risk for variceal bleeding who have medium or large varices with red wale marks or advanced liver cirrhosis. In acute bleeding, vasoactive agents should be initiated along with antibiotics followed by EVL or endoscopic sclerotherapy (if EVL is technically difficult) within the first 12 hours of presentation. Where available, terlipressin is the preferred agent because of its safety profile and it represents the only drug with a proven efficacy in improving survival. All patients surviving an episode of bleeding should undergo further prophylaxis to prevent rebleeding with EVL and nonselective
"Two studies showed that early placement of TIPS reduces the risk of failure to control bleeding and rebleeding in patients at high risk of recurrence
[75,76]. In the more recent study, high-risk patients were defined as Child-Pugh class B patients with persistent bleeding at the time of EGD or Child-Pugh class C patients
[Show abstract][Hide abstract] ABSTRACT: Intensivists are regularly confronted with the question of gastrointestinal bleeding. To date, the latest international recommendations regarding prevention and treatment for gastrointestinal bleeding lack a specific approach to the critically ill patients. We present recommendations for management by the intensivist of gastrointestinal bleeding in adults and children, developed with the GRADE system by an experts group of the French-Language Society of Intensive Care (Societe de Reanimation de Langue Francaise (SRLF), with the participation of the French Language Group of Paediatric Intensive Care and Emergencies (GFRUP), the French Society of Emergency Medicine (SFMU), the French Society of Gastroenterology (SNFGE), and the French Society of Digestive Endoscopy (SFED). The recommendations cover five fields of application: management of gastrointestinal bleeding before endoscopic diagnosis, treatment of upper gastrointestinal bleeding unrelated to portal hypertension, treatment of upper gastrointestinal bleeding related to portal hypertension, management of presumed lower gastrointestinal bleeding, and prevention of upper gastrointestinal bleeding in intensive care.
Annals of Intensive Care 11/2012; 2(1):46. DOI:10.1186/2110-5820-2-46 · 3.31 Impact Factor
"Patients with an HVPG > 20 mmHg measured within 24 hours of variceal bleeding have been identified as being at a higher risk for early rebleeding or failure to control bleeding (83% versus 29%) and a higher 1-year mortality (64% versus 20%) compared to those with lower pressure [16, 17]. Large varices, age over 60 years' old, renal failure, and severe initial bleeding as defined by a hemoglobin <8 g/dL at admission, are the risk factors for early rebleeding . "
[Show abstract][Hide abstract] ABSTRACT: Esophageal varices are the major complication of portal hypertension. It is detected in about 50% of cirrhosis patients, and approximately 5-15% of cirrhosis patients show newly formed varices or worsening of varices each year. The major therapeutic strategy of esophageal varices consists of primary prevention, treatment for bleeding varices, and secondary prevention, which are provided by pharmacological, endoscopic, interventional and surgical treatments. Optimal management of esophageal varices requires a clear understanding of the pathophysiology and natural history. In this paper, we outline the current knowledge and future prospect in the pathophysiology of esophageal varices and portal hypertension.
Càndid Villanueva, Agustín Albillos, Joan Genescà, Juan G Abraldes, Jose L Calleja, Carles Aracil, Rafael Bañares, Rosa Morillas, María Poca, Beatriz Peñas, Salvador Augustin, Joan C Garcia-Pagan, Oana Pavel, Jaume Bosch
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