Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding
Universidad de Las Palmas de Gran Canaria, Las Palmas, Canary Islands, SpainHepatology (Impact Factor: 11.06). 11/2004; 40(4):793-801. DOI: 10.1002/hep.20386
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.
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- "Two small randomized controlled trials have now been performed, which demonstrated that early application of TIPS in patients with a high predicted risk of rebleeding reduces early rebleeding and mortality. However, the number of patients enrolled in these studies is small, and given the limited access to TIPS outside specialist centers, provision of this therapy to all high-risk patients would be logistically difficult  . Given the limitations of TIPS and BT, there appears to be an unmet need for a therapy in patients with refractory bleeding from esophageal varices which can be easily and effectively applied even outside specialist centers and which can prevent early rebleeding in high-risk patients regardless of underlying liver function. "
ABSTRACT: Refractory esophageal hemorrhage and early rebleeding following endoscopic therapy remain challenging conditions to treat and are associated with a high mortality. Techniques such as balloon tamponade (BT) and transjugular intrahepatic portosystemic shunt (TIPS) are highly effective at controlling refractory bleeding but can be associated with a high rate of complications and in the case of TIPS may not be immediately available outside specialist centers. Recently, removable self-expanding metal stents (SEMS) have entered clinical practice for the management of esophageal variceal bleeding. SEMS control bleeding by tamponading varices in the distal esophagus and can remain in situ for a number of days thus preventing early rebleeding. The use of SEMS does not require the transfer of the patient to a specialist center and unlike TIPS is not associated with deterioration in liver function. The use of SEMS has been described in small series of patients with refractory bleeding. These series report high rates of hemostasis with low complication rates suggesting that SEMS may have an important role in the management of refractory bleeding either as an alternative to BT or where TIPS is contraindicated. SEMS may also have a role in treating complications of therapy for bleeding esophageal varices such as post banding ulceration and BT induced esophageal tears. The aim of this review is summarize the published data on the efficacy of SEMS and suggest future studies that may clarify its role in the management of esophageal variceal hemorrhage.
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- "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. "
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 β -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 β -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 β -blockers.
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- "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 . "
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.
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