Management Of Variceal Bleeding Research Articles

Management of variceal hemorrhage in the potential liver transplant candidate

The increased utilization of liver transplantation raises new issues regarding the management of bleeding esophageal varices in patients who are or may become transplant candidates. Since December 1982, 53 patients were referred from a university hospital to distant liver transplant centers for transplantation. Transplants were performed in 37 patients; at last follow-up, 6 died before transplantation, 7 were awaiting transplantation, and 3 were declined. Of the 53 patients referred for transplantation, 22 (42 percent) had a history of variceal hemorrhage. Sclerotherapy was required in nine patients and portosystemic shunt in four patients. Variceal hemorrhage contributed to the deaths of three of the six patients who died before transplantation could be performed. Endoscopic sclerotherapy has become the mainstay of invasive therapy in most patients with bleeding esophageal varices. If sclerotherapy is unsuccessful in the arrest or control of variceal hemorrhage, the decision must be made whether to proceed with urgent liver transplantation or portosystemic shunt. Factors which influence this choice include the ability to stabilize an acutely bleeding patient, the hepatic reserve and general clinical stature of a patient, and the availability of a liver transplant center.

Management of bleeding varices in the elderly.

In 207 consecutive patients the outcome of bleeding varices was compared in those aged under 65 (n = 146) and those aged over 65 (n = 61). All patients were seen during seven years and were treated by active initial and maintenance sclerotherapy. Alcoholic cirrhosis was commoner in younger patients (68 (47%) v 12 (20%] and cryptogenic cirrhosis commoner in older patients (21 (34%) v 19 (13%]. Mortality due to the first bleed was dependent on the severity of liver disease and was unrelated to age. Survival corrected for age (life table analysis) was 65% at one year and 60% at two years for both groups of patients. It is concluded that patients should not be denied active treatment for bleeding varices on the basis of age alone. In order to obtain optimum results early endoscopy and sclerotherapy is essential.

Endoscopic sclerotherapy with portal-systemic shunt rescue

This paper reports the preliminary results of a prospective randomized trial comparing endoscopic variceal sclerosis and distal splenorenal shunt (DSRS) in the management of patients with cirrhosis and variceal bleeding. Seventy-one patients have been entered; 36 have received sclerosis and 35 DSRS. Randomization of the study population was stratified on Child's A/B (56%) and Child's C (44%). Sixty-one per cent had alcoholic and 39% nonalcoholic cirrhosis. No patients have been lost to follow-up, which currently stands at a median of 26 months. Rebleeding occurred significantly (p < 0.05) more frequently in patients in the sclerosis group (19 of 36: 53%) compared to DSRS (1 of 35: 3%), but only 11 of 36 (31%) were not controlled by further sclerosis and failed that therapy. Patients in whom sclerosis failed underwent surgery. Survival was significantly (p < 0.01) improved in the sclerosis group (+ surgery in 31%), with an 84% 2-year survival compared to a 59% 2-year survival in the DSRS group. Portal perfusion was significantly (p < 0.05) better maintained in the sclerosis (95%) compared to the DSRS (53%) group. Galactose elimination capacity improved significantly (p < 0.05) in 21 patients successfully managed by sclerosis at 1 year and was significantly (p < 0.01) better maintained in the sclerosis compared to DSRS group. The authors conclude that endoscopic sclerosis: (1) has a higher rebleeding rate than DSRS, with one third of patients failing therapy from rebleeding; (2) allows significant improvement in liver function when successful; and (3) gives significantly improved survival in the management of variceal bleeding when backed up by surgical therapy for patients with uncontrolled rebleeding. The authors report the results of a randomized comparison of emergency portacaval anastomosis (PCA) (32 patients) with endoscopic sclerotherapy (EST) (32 patients). Short-term survival was similar in the two groups, respectively (44% vs. 50%). The amount of blood transfusions required and the length of the hospital admissions were significantly less in the EST group (p < 0.001). Recurrences of variceal hemorrhage, the number of transfusions required to treat them and the duration of hospital readmissions were all greater in the EST group (p < 0.001). Almost half of the EST patients who were discharged from the hospital alive subsequently rebled and required surgical treatment. The authors conclude that EST is as effective as PCA in the acute treatment of bleeding, but that when EST fails, PCA may be effective management.

Injection sclerotherapy for the long‐term management of variceal bleeding

AbstractInjection sclerotherapy for the long‐term management of variceal bleeding is discussed with particular reference to our experience at King's College Hospital. The important questions of which techniques to use, which sclerosing agent to inject, the timing of the first and subsequent treatments, and the periods between follow‐up endoscopic examinations are reviewed. The efficacy of sclerotherapy both with respect to rebleeding and survival are assessed on the basis of 2 completed controlled trials and a third study from which preliminary data are available. A possible role for the prophylatic use of sclerotherapy in selected high‐risk patients is discussed. The complications associated with sclerotherpy are detailed and attention is drawn to the very low mortality rate of the procedure.

Management of variceal hemorrhage.

Management of variceal hemorrhage.

Selective and nonselective shunts for variceal bleeding: A prospective study of 103 patients

Based on the experience reported herein, the following conclusions have been made: (1) Although nonoperative means, including sclerotherapy, have an important role in the management of bleeding varices, they are not definitive means of treating recurrent variceal hemorrhage. (2) Because of the maintenance of hepatopetal flow and splanchnic venous hypertension, a selective shunt is associated with a lower incidence of encephalopathy and provides a better quality of life than does a nonselective shunt. Thus, an elective distal splenorenal shunt is the elective operation of choice for recurrent variceal hemorrhage. (3) Nonselective shunts can be performed with similar expectation of patient survival as selective shunts, but because of increased encephalopathy, should be reserved for emergency operations, in cases of unsuitable venous anatomy, and in those patients with intractable ascites. (4) A well-conceived elective shunt procedure can be performed with low operative mortality and long-term patency, results in significant survival, and is still considered the “gold standard” for treatment of variceal bleeding.

Strategies in the management of bleeding varices.

Australian and New Zealand Journal of MedicineVolume 12, Issue 4 p. 320-324 Strategies in the Management of Bleeding Varices B. Jones, B. Jones Gastroenterology Unit and University of Melbourne Department of Surgery, Austin Hospital, Heidelberg, Victoria *Gastroenterologya Fellow.Search for more papers by this authorM. Douglast, M. Douglast Gastroenterology Unit and University of Melbourne Department of Surgery, Austin Hospital, Heidelberg, VictoriaSearch for more papers by this authorR. Smallwood, Corresponding Author R. Smallwood Gastroenterology Unit and University of Melbourne Department of Surgery, Austin Hospital, Heidelberg, Victoria ‡Director of Gastroenterology.Dr. Richard Smallwood, Gastroenterology Unit, Austin Hospital, Heidelberg, Victoria 3084Search for more papers by this author B. Jones, B. Jones Gastroenterology Unit and University of Melbourne Department of Surgery, Austin Hospital, Heidelberg, Victoria *Gastroenterologya Fellow.Search for more papers by this authorM. Douglast, M. Douglast Gastroenterology Unit and University of Melbourne Department of Surgery, Austin Hospital, Heidelberg, VictoriaSearch for more papers by this authorR. Smallwood, Corresponding Author R. Smallwood Gastroenterology Unit and University of Melbourne Department of Surgery, Austin Hospital, Heidelberg, Victoria ‡Director of Gastroenterology.Dr. Richard Smallwood, Gastroenterology Unit, Austin Hospital, Heidelberg, Victoria 3084Search for more papers by this author First published: August 1982 https://doi.org/10.1111/j.1445-5994.1982.tb03820.x †First Assistant, Department of Surgery. AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume12, Issue4August 1982Pages 320-324 RelatedInformation

CONTROLLED TRIAL OF TERLIPRESSIN ('GLYPRESSIN') VERSUS VASOPRESSIN IN THE EARLY TREATMENT OF OESOPHAGEAL VARICES

In a randomised controlled trial the effect of intermittent bolus injection of triglycyl lysine vasopressin (terlipressin, 'Glypressin') (2 mg 6-hourly), an analogue of vasopressin, was compared with that of a constant peripheral intravenous infusion of vasopressin (0.4 units/min) in the initial management of bleeding oesophageal varices in nineteen patients. Failure of vasopressin therapy was defined as continued bleeding of sufficient severity to necessitate the passage of a Sengstaken tube. Bleeding was controlled in 70% of patients treated with glypressin but in only 9% of patients given vasopressin. The glypressin group required significantly less blood after randomisation than the vasopressin group. Because of its efficacy, lack of side-effects, and ease of administration, glypressin appears to be valuable in the management of bleeding varices.

Endoscopic variceal sclerosis: a one-year experience

Our first year's experience with endoscopic variceal sclerosis (EVS) performed with a cuffed balloon fiberoptic endoscope is presented. Seventy-five patients have been treated with EVS without requiring the use of general anesthesia. All but one patient had endoscopically documented variceal hemorrhage and underwent EVS while bleeding or shortly thereafter. Ninety-two per cent of the patients were discharged from the hospital after initial treatment with the current overall survival rate being 89.3%. Complications resulting in a prolonged hospitalization were infrequent, but two deaths occurred in which EVS complications may have been a contributing factor. Based on these results, EVS is recommended for managing variceal hemorrhage and is a reasonable alternative for shunt surgery in the management of variceal bleeding.

Management of variceal hemorrhage: results of a standardized protocol using vasopressin and transhepatic embolization.

We reviewed the courses of 40 patients with variceal bleeding treated with a standardized protocol, including intravenous (IV) vasopressin (Pitressin) and transhepatic embolization. Twelve of the 32 patients with acute episodes of massive variceal bleeding responded to the administration of IV vasopressin alone. Of the 20 patients who did not respond to vasopressin therapy, emergency transhepatic portography with embolization produced cessation of bleeding in ten (50%). The remaining ten patients who failed to respond to either IV vasopressin therapy or transhepatic embolization died, regardless of whether they were treated with aggressive medical therapy or emergency portosystemic shunt. Transhepatic embolization in both the emergent and elective situation demonstrated a thrombotic complication rate of 20%, which limited or precluded eventual therapy with elective portosystemic shunt. Because of this relatively high incidence of occult portal thromboses after transhepatic embolization, transhepatic portography should be obtained routinely prior to elective portosystemic shunts in those patients who have a history of transhepatic embolization.

Comparison of barium swallow and left gastric angiography in the diagnosis of esophageal varices, with special reference to the management of variceal bleeding

Seventy-five patients with portal hypertension and esophageal varices were studied by means of barium swallow and selective left gastric angiography. The relative merits and limitations of these techniques in demonstrating the presence, extent, and severity of the varices are discussed, with reference to the selection of patients for prophylactic transection of the esophagus to prevent bleeding from the varices.

Significance of hematochylia in Laennec's cirrhosis.

SINCE LYMPH normally contains practically no red cells, the finding of gross hematochylia in patients with cirrhosis is of great interest. 1 The obvious explanation for such contamination of the thoracic duct lymph is leakage of blood from distended liver sinusoids into the spaces of Disse. However, certain of our observations in both man 2 and animals 3 with portal hypertension are inconsistent with this hypothesis. Our previous experience 4,5 with the experimental development of hematochylia in animals with aortocaval fistulae had prompted us to study this phenomenon in patients with cirrhosis as originally reported by Dumont and Mulholland. 1 Additionally, we were interested in their suggestion regarding the therapeutic value of thoracic duct drainage in the management of bleeding varices and refractory ascites. Clinical Studies The thoracic duct was cannulated in 19 patients with a diagnosis of cirrhosis of the liver. Of these 13 had been admitted with upper

Criteria of surgical management of variceal hemorrhage in cirrhosis of the liver

Criteria of surgical management of variceal hemorrhage in cirrhosis of the liver

Colonic replacement of distal esophagus and proximal stomach in the management of bleeding varices in children.

Colonic replacement of distal esophagus and proximal stomach in the management of bleeding varices in children.