Treatment of acute esophageal variceal bleeding in cirrhotic patients

Abstract

Esophageal variceal bleeding is the most dangerous complication in cirrhotic patients and is accompanied by high mortality. Treatment strategy involves early diagnosis, maintaining vital body functions and specific therapy aimed at the provision of local hemostasis and reduction of portal pressure. To this end, it is currently recommended to combine vasoactive drug (mainly, terlipressin or somatostatin) therapy with endoscopic methods of hemostasis (sclerotherapy or ligation). The use of Sengstaken-Blakemore tube is appropriate only in cases of refractory bleeding if the above methods cannot be used. An alternative to balloon tamponade may be the installation of self-expandable metal stents. Although transjugular intrahepatic portosystemic shunting is an extremely useful technique for the treatment of acute bleeding from esophageal varices, currently it is viewed as second-line therapy. Urgent surgical intervention is rarely performed and can be considered only in case of failure of conservative and/or endoscopic therapy and being unable to use a transjugular intrahepatic portosystemic shunt for technical or organizational reasons or due to anatomic problems. Among surgical operations described in the literature are various kinds of portocaval anastomoses and azygoportal disconnection procedure. To improve the results of treatment of cirrhotic patients with acute esophageal variceal bleeding it seems important to stratify them by risk groups, which will allow one to tailor therapeutic approaches to the expected results. For example, to initiate early use of more aggressive methods in patients with predictors of poor outcomes, and to protect individuals with a good prognosis from unnecessary invasive procedures. It is hoped that further research will refine this hypothesis.