15 - Portal Hypertensive Bleeding

Abstract

Variceal bleeding is one of the most severe complications of liver cirrhosis. When cirrhosis is diagnosed, varices are present in approximately 30% to 40% of compensated patients and in 60% of those who present with ascites. Once varices have been diagnosed, the overall incidence of variceal bleeding is 25% within two years. Variceal size is the most useful predictor for variceal bleeding; other predictors being the severity of liver dysfunction (Child-Pugh classification) and the presence of red wale marks on the variceal wall. When a patient presents with acute variceal bleeding, appropriate management with initial general measures such as resuscitation (airway, breathing, and circulation), a restrictive transfusion policy, antibiotic prophylaxis, pharmacological therapy with vasoconstrictors, and endoscopic therapy with endoscopic band ligation is mandatory. After bleeding has been controlled, combination therapy with nonselective β-blockers (NSBBs) and endoscopic band ligation should be used to prevent rebleeding. In patients at high risk of treatment failure identified early after admission, the placement of a preemptive TIPS (transjugular intrahepatic portosystemic shunt) improves control of bleeding, prevents rebleeding, reduces mortality, and should be the treatment of choice if no contraindications are present. When initial endoscopic therapy fails, rescue therapies such as Sengstaken-Blakemore tubes and fully covered self-expandable esophageal metal stents may be required as a bridge toward the definitive treatment with TIPS. Regarding gastric variceal bleeding, data is limited. In acute cardiofundal variceal bleeding, vasoactive agents, together with cyanoacrylate (CYA) injection, seem to be the treatment of choice. Further CA injections and/or NSBB may be used to prevent rebleeding. TIPS, or balloon-occluded retrograde transvenous obliteration when TIPS is contraindicated, may be used as a rescue therapy.