Treatment Of Variceal Bleeding Research Articles

Immediate Management of Variceal Hemorrhage: Pharmacologic Measures and Balloon Tamponade

Pharmacologic agents and balloon tamponade are used as immediate treatment for variceal bleeding. Drugs with proven therapeutic effects include somatostatin, glypressin, and the combination of vasopressin and nitroglycerin. Balloon tamponade with the Sengstaken or Linton tubes is highly effective for the temporary control of bleeding, but it is associated with a high risk of complication and should only be used in experienced centers under close monitoring.

In-flight esophageal variceal bleeding en route for liver transplantation: A case report and review of the literature

Esophageal variceal bleeding owing to portal hypertension is a potential threat in pediatric patients awaiting liver transplantation. We report a case of a three-year-old boy with severe congenital hepatic fibrosis, Caroli's disease, and portal hypertension who developed a life-threatening variceal hemorrhage for the first time in his life during commercial air transport to a liver transplantation center. Factors precipitating variceal bleeding are discussed, particularly those resulting from changes in altitude. It is recommended that prophylactic treatment for variceal bleeding be at least considered in children awaiting liver transplantation prior to prolonged air transportation. Because of differences in capabilities of treatment providers in various locales, and because there are as yet no conclusive data, the treatment of choice must be decided on an individual basis. Equipment for treating in-flight hemorrhage should be available.

Reduction of transmural oesophageal variceal pressure by metoclopramide

In nineteen patients with portal hypertension and oesophageal varices, transmural variceal blood pressure was determined endoscopically by direct puncture of the varices before and after intravenous administration of 20 mg metoclopramide or placebo. No change in pressure was observed after placebo (mean difference -1.3 +/- 24.5%, N.S.), however, metoclopramide reduced the pressure by 17.6 +/- 18.6% (p = 0.02). Our results suggest that metoclopramide may be beneficial for the prevention or treatment of variceal haemorrhage.

Treatment of variceal hemorrhage.

HomeRadiologyVol. 179, No. 1 PreviousNext LettersTreatment of variceal hemorrhage.H L Berman, L R DelGuercio, S G KatzH L Berman, L R DelGuercio, S G KatzH L BermanL R DelGuercioS G KatzPublished Online:Apr 1 1991https://doi.org/10.1148/radiology.179.1.2006295MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Article HistoryPublished in print: 1991 FiguresReferencesRelatedDetailsRecommended Articles RSNA Education Exhibits RSNA Case Collection Vol. 179, No. 1 Metrics Altmetric Score PDF download

Selective Variceal Decompression: Current Status

Since its introduction into clinical practice in 1967, selective variceal decompression by means of a distal splenorenal shunt (DSRS) has become one of the more commonly performed portal-systemic shunting procedures in the treatment of variceal hemorrhage throughout the world. In addition to selective decompression of gastroesophageal varices, the DSRS provides the advantages of preservation of portal perfusion of the liver and maintenance of intestinal venous hypertension. Many large, uncontrolled series and the majority of controlled randomized studies have demonstrated a lower incidence of encephalopathy after the DSRS than after nonselective shunt procedures. A secondary advantage of the DSRS is that the hepatic hilum is avoided, thus making subsequent liver transplantation a less formidable procedure. None of the studies have shown an advantage to this shunt with respect to longterm survival in patients with alcoholic cirrhosis. However, some of the large, uncontrolled series have shown that survival is significantly improved in patients with non-alcoholic cirrhosis compared to nonselective shunt procedures in the same population. Controlled trials comparing the DSRS to endoscopic sclerotherapy have shown that chronic endoscopic variceal sclerosis is an appropriate initial therapy for most patients as long as shunt surgery is readily available if sclerotherapy fails.

Bleeding esophageal varices associated with pancreatic arteriovenous malformation

Three cases of bleeding esophageal varices associated with arteriovenous malformation of the pancreas have been observed over the last 7 years. In 1 case, arteriovenous malformation (AVM) was the cause of the portal hypertension; thus, it was considered to be a "primary lesion." In the other cases, liver cirrhosis was the cause of the portal hypertension, and the AVM, which originally was a minor pathology, became significant as the portal hypertension progressed, thus making it a "secondary lesion." In the case of a "primary lesion," resection of the lesion is the preferred treatment for bleeding varices, but our case had multiple lesions, and excision was problematic. In the case of bleeding varices caused by liver cirrhosis, if liver function is normal, surgical treatment of both the varices and the AVM is recommended, while if the liver function is abnormal, repeated sclerotherapy is the best mode of therapy.

Direct catheterization of the mesenteric vein: combined surgical and radiologic approach to the treatment of variceal hemorrhage.

Minilaparotomy and direct catheterization of the mesenteric vein for variceal embolization was attempted in 15 patients in whom medical and endoscopic treatment of variceal hemorrhage had failed. Hemorrhage was controlled immediately after the procedure in 11 patients. The 30-day survival rate was 60% (n = 9). The cause of death in six patients was variceal bleeding (n = 2), liver failure (n = 3), and respiratory failure (n = 1). The 6-month survival rate was 33% (n = 5), and the 1-year survival rate was 27% (n = 4). Bleeding recurred in 67% of surviving patients; however, fatal variceal bleeding occurred in only 22% (n = 2). Direct mesenteric vein catheterization allows simplified entry into the portal vein for embolization of bleeding esophageal or gastric varices. Early experience suggests that the results are similar to those of percutaneous transhepatic embolization, without the complications and technical demands of a transhepatic approach.

A controlled study of glypressin versus vasopressin in the control of bleeding from oesophageal varices

To evaluate the therapeutic effect of glypressin (triglycyl-lysine-vasopressin, C52H74N16O15S2.2C2H4O2.5H2O) in the treatment of oesophageal variceal bleeding, a randomized controlled trial of glypressin and vasopressin was conducted in 54 cirrhotic patients with oesophageal varices bleeding. Bleeding ceased within 24 h in 50% (13/26) of patients treated with glypressin and in 53.6% (15/28) of patients given vasopressin. Re-bleeding within 7 days occurred in 30.8% (4/13) of the glypressin group and in 20.0% (3/15) of the vasopressin group. There was no statistically significant difference in the therapeutic effect between glypressin and vasopressin. In the glypressin group, bleeding was more easily stopped in non-hepatocellular carcinoma (HCC) cirrhotic patients of Pugh's criteria A or B than in patients of Pugh's criterion C or HCC. We conclude that glypressin and vasopressin have similar therapeutic effect. In considering the application convenience, glypressin is an alternative to vasopressin in the treatment of bleeding varices in patients of good liver function reserve.

Partial Portal Decompression: Two Approaches to the Management of Portal Hypertension

To test the hypothesis that partial portal decompression in the treatment of variceal hemorrhage will diminish subsequent encephalopathy, 50 consecutive patients were studied after construction of a small–stoma (10 to 12 mm) side–to–side portacaval shunt, with the goal of a postoperative portacaval pressure gradient of 10 mm Hg. During follow–up averaging 26 months, six patients (12 percent) died. Four patients (8 percent) had episodes of rebleeding, only one from varices. All patients had patent shunts at subsequent angiography or ultrasonography. Despite consistent (100 percent) postoperative reversal or stagnation of portal flow on duplex scan, encephalopathy on clinical and psychometric grounds was observed in only three patients (6 percent). This study suggests that small–stoma portacaval shunt can be performed with reliably low rates of rebleeding and encephalopathy. That encephalopathy was rare despite loss of hepatic portal perfusion incriminates other factors besides portal flow in the genesis of postshunt hepatic failure.

Surgical rescue for failures of cirrhotic sclerotherapy

Bleeding from gastroesophageal varices remains the most devastating complication of the portal hypertensive syndrome. Endoscopic sclerotherapy has emerged as the best initial treatment for bleeding varices because surgery is obviated and survival may be improved. However, sclerotherapy will fail and surgical rescue will be required in at least a third of patients. There are two viable surgical rescue procedures: shunt surgery and liver transplantation. This paper summarizes the available data and concludes that there is a role for both procedures.

Options for elective treatment of portal hypertension in cirrhotic patients in the transplantation era

We review herein our experience in the management of bleeding esophageal varices in cirrhotic patients and consider our findings in light of the dramatic changes in the treatment of cirrhosis resulting from the more widespread use of orthotopic liver transplantation (OLT). It does not seem realistic, at present, to propose OLT as the only effective treatment of variceal bleeding for a variety of reasons, and there remains a large group of patients who are noncompliant or unsuitable for liver transplantation. We propose that initial bleeding be controlled by endoscopic sclerotherapy, thereby allowing careful evaluation to be made electively. Grade A patients appear to be managed best by a reduced-size portacaval shunt (RPS) with prospects of good survival and few complications. Grade B patients can be managed by either sclerotherapy, RPS, or OLT, depending upon individual circumstances. Grade C patients are best managed by liver transplantation, again with excellent survival. In those grade C patients not deemed suitable for OLT (especially alcoholic patients), long-term endoscopic sclerotherapy is the best option. Changes in patient status may sometimes require revision of the treatment decision.

Vasopressin/Nitroglycerin Infusion Vs. Esophageal Tamponade in the Treatment of Acute Variceal Bleeding: A Randomized Controlled Trial

Vasopressin infusion and esophageal tamponade are still widely used to arrest variceal bleeding, but no objective evidence exists on the superiority of either of the two procedures. In this study, 108 cirrhotic patients bleeding from varices were included in a prospective, randomized trial to investigate the comparative effectiveness and safety of balloon tamponade (using the Sengstaken-Blakemore tube for esophageal varices and the Linton-Nachlas tube for gastric varices) (n = 52) and intravenous vasopressin infusion (0.4 to 0.8 mu/min) plus intravenous nitroglycerin infusion (40 to 400 micrograms/min) (n = 56). Both treatments were maintained for 24-hr. The hemostatic efficacy according to the intention to treat was 86.5% for tamponade and 66% for pharmacological therapy (p less than 0.01). No significant differences were found with respect to rebleeding during the first 72 hr after treatment, mortality rate or side effects. These results suggest that esophageal tamponade is more effective than vasopressin/nitroglycerin infusion in the treatment of variceal bleeding in cirrhotic patients.

Treatment of Variceal Hemorrhage in Children

The etiology and management of portal hypertension in infants and children differ from those in adults. Both the plan of management and the prognosis of portal hypertension vary considerably depending upon the nature of the underlying pathologic process. It is essential to determine the type of obstruction as accurately as possible before definitive treatment is initiated. This article considers the management of extrahepatic, intrahepatic, and suprahepatic portal venous obstruction; treatment of the unshuntable patient; portosystemic shunts; and liver transplantation.

Nonoperative Emergency Treatment of Variceal Hemorrhage

The nonoperative management of acute variceal hemorrhage can control acute hemorrhage and allow stabilization of the patient prior to definitive therapy to prevent further bleeding episodes. Balloon tamponade, endoscopic sclerotherapy, and pharmacotherapy can stop acute variceal bleeding. Endoscopic sclerotherapy has the highest reported success rate, decreases the incidence of early rebleeding, and is the recommended first method to control bleeding.

Emergency Surgical Treatment of Variceal Hemorrhage

Emergency surgery should be considered one of the treatment options for the patient with acute variceal bleeding in whom the usual nonsurgical modes of therapy fail, and who is deemed fit to tolerate a major operation. A total shunt (portacaval or mesocaval) is recommended for most of these patients, although a distal splenorenal shunt might be considered for some very good risk, nonalcoholic patients who have only moderate bleeding. Devascularization procedures have a limited role in the emergency situation, but they may be useful in patients who are nonshuntable because of splanchnic venous thrombosis. The Sugiura type of operation is appropriate for the nonalcoholic patient, and esophageal transection is appropriate for the alcoholic patient with cirrhosis. Patients with end-stage nonalcoholic liver disease should also be considered for liver transplantation.

Taking the Tension out of the Portal System: An Approach to the Management of Portal Hypertension in the 1990s

The past decade saw the emergence of sclerotherapy and vasoactive pharmacologic agents as alternatives to surgery in the prevention and treatment of variceal haemorrhage. Despite encouraging results from clinical trials with regard to the prevention of rebleeding, these modalities of therapy have made no major impact on survival. This failure to alter radically the clinical outcome results from the fact that in many patients with cirrhosis death is primarily related to the degree of hepatic decompensation rather than the prevention or control of variceal bleeding. Advances in our knowledge of vasoactive mediators, receptor function, and altered vascular reactivity have provided increased insight into the circulatory disturbances that characterise cirrhosis and portal hypertension. Earlier and more aggressive pharmacologic intervention with single or combination drug therapy may inhibit fibrogenesis, reduce portal vascular resistance, and improve liver function and therefore provide effective prophylaxis against variceal haemorrhage. The emergence of reliable prognostic indices for variceal bleeding should help identify patients at risk who would benefit from prophylaxis with either drugs or sclerotherapy. Transplantation will be increasingly considered in the patient at high risk of recurrent bleeding before the stage of severe hepatic decompensation (the risks of the transplant then become very much greater), as the definitive means for reducing mortality in cirrhosis and portal hypertension.

Association of Transdermal Nitroglycerin to Vasopressin Infusion in the Treatment of Variceal Hemorrhage: A Placebo–Controlled Clinical Trial

The aim of this study was to evaluate, using a double-blind technique, the efficacy of the association of transdermal nitroglycerin to vasopressin infusion for the treatment of variceal bleeding. Sixty-nine cirrhotic patients with active variceal bleeding were randomly allocated to receive vasopressin (0.4 to 0.8 unit per min until variceal bleeding has been controlled for 12 hr) associated with nitroglycerin administered transdermically in a slow-release preparation (10 mg in 24 hr) or placebo. An initial control of variceal hemorrhage was achieved in 83% of the patients receiving vasopressin-nitroglycerin and in 74% in the vasopressin-placebo group. Owing to a lower frequency of recurrent bleeding during therapy (18 vs. 42%, p = 0.11), vasopressin-nitroglycerin achieved a definitive control of bleeding in a higher proportion of patients than vasopressin-placebo (73 vs. 54%, p = 0.13). The group treated with the drug combination showed favorable results in relation to transfusion requirements (2.9 +/- 0.4 vs. 4.2 +/- 0.5 units, p = 0.05), total dose of vasopressin required (453 +/- 47 vs. 587 +/- 50 units, p less than 0.05), need of balloon tamponade (6 vs. 15, p less than 0.05) and requirement for emergency surgery (0 vs. 4, p = 0.07). There were no significant differences in the undesirable effects associated with treatment, observed in 37 and 49% of cases, respectively. Hospital mortality was similar (33 vs. 25%). This study demonstrates that transdermal nitroglycerin improves the effectiveness of vasopressin for controlling variceal hemorrhage.

Partial portal decompression for variceal hemorrhage

To test the hypothesis that partial portal decompression in the treatment of variceal hemorrhage will diminish subsequent encephalopathy, 50 consecutive patients were studied after construction of a small-stoma (10 to 12 mm) side-to-side portacaval shunt, with the goal of a postoperative portacaval pressure gradient of 10 mm Hg. During follow-up averaging 26 months, six patients (12 percent) died. Four patients (8 percent) had episodes of rebleeding, only one from varices. All patients had patent shunts at subsequent angiography or ultrasonography. Despite consistent (100 percent) postoperative reversal or stagnation of portal flow on duplex scan, encephalopathy on clinical and psychometric grounds was observed in only three patients (6 percent). This study suggests that small-stoma portacaval shunt can be performed with reliably low rates of rebleeding and encephalopathy. That encephalopathy was rare despite loss of hepatic portal perfusion incriminates other factors besides portal flow in the genesis of postshunt hepatic failure.

Review: the pharmacological control of variceal bleeding.

The haemodynamic effects and clinical uses of drugs used in the management of patients with oesophageal variceal bleeding are reviewed. Vasoconstrictor agents (vasopressin, teripressin) alone or in combination with nitrates continue to be used for acute bleeding episodes, while somatostatin is an alternative. Alpha- and beta-adrenergic blocking drugs and vasodilators which lead to a sustained decrease in portal pressure can be used for the prevention of bleeding episodes, but despite numerous studies the pharmacological treatment of variceal bleeding remains controversial.

Value of endoscopic injection sclerotherapy in the treatment of bleeding varices

Endoscopic injection sclerotherapy is effective for controlling active bleeding in 72% of the patients with an initial acute hemorrhage from œsophageal variees. One week survival was related to the liver function: 95% in Child A, 78% in Child and 62% in Child C. Aspiration pneumonia occured in one third of the patients with high mortality. The long-term sclerotherapy provides one year survival of 88% in Child A, 72% in Child and 44% in Child C. Only one long-term complication occured. Our study emphasizes the good long-term results of scherotherapy in patients with preserved liver function.