Treatment Of Acute Variceal Bleeding Research Articles

Current status of treatment for acute variceal bleeding in liver cirrhosis

Acute variceal bleeding (AVB) continues to be a fatal complications of cirrhotic portal hypertension. Although the hospitalization rate of patients with acute variceal bleeding has significantly decreased with the advancement of medical technology, and the mortality rate has dropped from 50% three decades before to 15%～20% now, the in-hospital mortality rate is still high and is closely related to the severity of cirrhosis, ranging from 0 in Child A grade to 32% in Child C grade. Therefore, it is a good choice to risk stratify these patients and individualize the treatment method according to the expected risk, as the risk of death in patients with acute variceal bleeding is highly heterogeneous. This article mainly reviews the current status of risk stratification and treatment of acute variceal bleeding in cirrhosis.

Portal hypertension: recommendations for diagnosis and treatment. Consensus document sponsored by the Spanish Association for the Study of the Liver (AEEH) and the Biomedical Research Network Center for Liver and Digestive Diseases (CIBERehd).

Portal hypertension is a hemodynamic abnormality that complicates the course of cirrhosis, as well as other diseases that affect the portal venous circulation. The development of portal hypertension compromises prognosis, especially when it rises above a certain threshold known as clinically significant portal hypertension (CSPH). In the consensus conference on Portal Hypertension promoted by the Spanish Association for the Study of the Liver and the Hepatic and Digestive diseases area of the Biomedical Research Networking Center (CIBERehd), different aspects of the diagnosis and treatment of portal hypertension caused by cirrhosis or other diseases were discussed. The outcome of this discussion was a set of recommendations that achieved varying degrees of consensus among panelists and are reflected in this consensus document. The six areas under discussion were: the relevance of clinically significant portal hypertension and the non-invasive methods used for its diagnosis and that of cirrhosis, the prevention of the first episode of decompensation and its recurrence, the treatment of acute variceal bleeding and other complications of portal hypertension, the indications for the use of TIPS, and finally, the diagnosis and treatment of liver vascular diseases.

Predictors and management of post-banding ulcer bleeding in cirrhosis: A systematic review and meta-analysis.

Post-banding ulcer bleeding (PBUB) is an understudied complication of oesophageal varices endoscopic band ligation (EBL). This systematic review with meta-analysis aimed at: (a) evaluating the incidence of PBUB in patients with cirrhosis treated with EBL in primary or secondary prophylaxis or urgent treatment for acute variceal bleeding and (b) identifying predictors of PBUB. We conducted a systematic review of articles in English published in 2006-2022 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Searches were made in eight databases including Embase, PubMed and Cochrane Library. Random-effects meta-analysis was used to determine the incidence, mean interval and predictors of PBUB. Eighteen studies (9034 patients) were included. The incidence of PBUB was 5.5% (95% CI 4.3-7.1). The mean time for it to occur was 11 days (95% CI 9.94-11.97). Model for End-stage Liver Disease (MELD) score (OR 1.162, 95% CI 1.047-1.291) and EBL done in emergency setting (OR 4.902, 95% CI 2.99-8.05) independently predicted post-ligation ulcer bleeding. Treatment included drugs, endoscopic procedures and transjugular intrahepatic portosystemic shunt. Refractory bleeding was treated with self-expandable metallic stents or balloon tamponade. Mortality was on average 22.3% (95% CI 14.1-33.6). Patients with high MELD score and receiving EBL in an emergency setting are more prone to develop PBUB. Prognosis is still poor and the best therapeutic strategy to address remains to be ascertained.

The influence of shunting left/right portal vein branch on post-TIPS hepatic encephalopathy: a study protocol for multicenter randomized blinded controlled trial

IntroductionGastroesophageal varices (GOV) bleeding is a common and serious complication of advanced liver cirrhosis with a median survival of less than 2 years. Multiple guidelines have pointed out that transjugular intrahepatic portosystemic shunt (TIPS) is the rescue treatment of acute variceal hemorrhage (AVB) after failure of standard therapy and an effective second-line treatment for preventing patients with high risks from rebleeding of GOV. The safety and stability of TIPS have been greatly improved due to the improvements of related technologies and the emergence of various novel devices, but the incidence of hepatic encephalopathy (HE) after shunting (10–50%) hindered the widespread use of TIPS. The target portal vein branch might affect the incidence of HE after TIPS. The aim of this study is to compare the rate of HE in patients with hepatitis B virus (HBV) related cirrhosis receiving TIPS either the left or right branch of the portal vein with 8mm Viatorr stent for preventing rebleeding from GOV.Methods and analysisThis study is a multicenter randomized controlled trial comparing the influence of shunting left or right portal vein branch on post-TIPS hepatic encephalopathy for preventing rebleeding from GOV in patients with HBV-related cirrhosis. A total of 130 patients will be recruited over a period of 24 months across 5 centers in China. Eligible patients will be stratified 1:1 to constructing either a left or right portal vein shunt with an 8-mm Viatorr stent. The primary objective was to compare the incidence of post-TIPS hepatic encephalopathy between the two groups. The secondary objectives were to compare the grade and duration of hepatic encephalopathy, the rate of shunt dysfunction, the rate of variceal rebleeding, the HE-free survival, the cumulative patency rate of the stent, and the overall survival at 12 months and 24 months between two groups.Ethics and disseminationThis study was approved by the ethics committee of Zhongshan Hospital of Fudan University (No. B2018-292R) and was registered at ClinicalTrials.gov (NCT03825848). All participants give written informed consent.Trial registrationClinicalTrials.gov NCT03825848. Registered on January 31, 2019Trial statusThe first patient was recruited into our study on June 19, 2019. A total of 55 patients were recruited till May 27, 2021 (27 and 28 patients assigned to shunting the left (L Group) and right (R Group) branches of the portal vein, respectively).

Executive Summary: Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations.

Executive Summary: Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations.

Salvage transjugular intrahepatic portosystemic shunt in patients with cirrhosis and refractory variceal bleeding: Asystematic review with meta-analysis.

BackgroundTransjugular intrahepatic portosystemic shunt (TIPS) may be used as a salvage treatment in patients with cirrhosis and refractory variceal bleeding.AimTo synthesize the available evidence on the efficacy of TIPS in patients with cirrhosis and refractory variceal bleeding.MethodsMeta‐analysis of trials evaluating TIPS in patients with cirrhosis and refractory variceal bleeding, including subgroup analysis to assess the impact of recent changes in the management of variceal bleeding (i.e., the use of Polytetrafluoroethylene‐covered TIPS and the availability of pre‐emptive TIPS as a first‐line treatment for acute variceal bleeding).ResultsTwenty‐three studies with 1430 patients were included. The pooled estimate rates were 0.33 (95% CI = 0.29–0.37) for death at 1 month–6 weeks, 0.46 (95% CI = 0.40–0.52) for death at 1 year, and 0.09 (95% CI = 0.06–0.11) for death due to rebleeding in the follow‐up. The pooled estimate rates for death at 1 month or 6 weeks were similar in subgroup analyses including studies that did not use covered TIPS or that did not include patients after the pre‐emptive TIPS area compared to the ones that did (pooled estimate rate 0.33 [95% CI = 0.28–0.38] and 0.32 [95% CI = 0.25–0.39], respectively). The pooled estimate rates were 0.16 (95% CI = 0.13–0.18) for rebleeding, 0.25 (95% CI = 0.17–0.36) for occurrence of hepatic encephalopathy, and 0.08 (95% CI = 0.05–0.13) for access to liver transplantation after TIPS insertion.ConclusionsOne third of patients with cirrhosis and refractory variceal bleeding treated with salvage TIPS died within the first 6 weeks. Recent improvements in the management of variceal bleeding did not improve the survival of patients presenting with refractory variceal bleeding.

S3302 Acute Esophageal Obstruction: An Uncommon Complication of Variceal Ligation Treated With Band Removal and Stenting

Introduction: Esophageal varices (EV) are a complication of portal hypertension. Over time, EV enlarge and may spontaneously rupture, leading to bleeding and possibly death with a high mortality rate of up to 20%. Esophageal variceal ligation (EVL) is used for prophylaxis, as well as treatment of acute variceal bleeding with the goal of eradicating varices. EVL is an effective therapy with rare but serious complications including bleeding, ulcers, strictures, and rarely acute obstruction. Amongst the few reported cases of esophageal obstruction, treatment has varied but mostly involved conservative management or band removal. We present a case of post EVL acute esophageal obstruction that was uniquely treated with band removal and esophageal stenting. Case Description/Methods: A 79yo female with nonalcoholic steatohepatitis cirrhosis and a MELD-Na of 12, complicated by portal hypertension and EV status post previous banding one year prior came to the emergency room two days after esophagogastroduodenoscopy (EGD) for routine EV surveillance with placement of two bands resulting in complete eradication. She presented with one episode of hematemesis and dysphagia to liquids, and regurgitation; denied odynophagia and chest pain. Hematologic parameters were at baseline. EGD revealed near-complete occlusion of the esophagus from banding at 40cm from the incisors (fig1). One band was dislodged with the gastroscope, which permitted the obstructed area to be traversed after downsizing the gastroscope. No active bleeding was evident. To prevent recurrent bleeding given hematemesis at presentation, the area of obstruction was stented with a 16mm x 100mm fully covered stent (fig2), proximal and distal margins at 30cm and 40cm respectively. She was discharged home after 24 hours able to tolerate soft foods. The stent was kept for seven days. At follow-up EGD for stent removal, there was slight luminal narrowing treated with graded balloon dilation from 18mm to 20mm. She continued to do well and nine months later had EGD surveillance with banding of grade II varices only. Discussion: Acute esophageal obstruction, though rare, is a complication of variceal banding that should be considered in patients with dysphagia after banding. This is a case that required innovative thinking and priority to treatment options that provide hemostasis while relieving obstruction in a cirrhotic patient with a high risk of bleeding.Figure 1.: 1. Near complete occlusion of esophagus Fig 2. After placement of esophageal stent.

What's new in portal hypertension?

Portal hypertension is defined as increased pressure in the portal venous system. The most common cause of portal hypertension is cirrhosis. In this setting, there is an increase in intrahepatic resistance leading to an increase in portal pressure. By increasing portal blood flow, splanchnic vasodilation further aggravates portal hypertension. New pathogenic pathways are being established which might result in new therapeutic strategies. The presence of varices at endoscopy and/or other abdominal portosystemic collaterals confirms the diagnosis of portal hypertension. The role of non-invasive and imaging tests in the diagnosis and prognosis of portal hypertension has been clarified. Non-selective beta-blockers decrease both the risk of variceal haemorrhage and hepatic decompensation. Terlipressin, somatostatin or octreotide, in combination with early endoscopic therapy, are recommended for the treatment of acute variceal haemorrhage. EarlyTransjugular intrahepatic portosystemicshunt (TIPS) is effective as salvage therapy in acute variceal bleeding in selected patients and prevents rebleeding more effectively than endoscopic and medical therapyresulting in an increased survival.

P202 ESOPHAGEAL VARICEAL BANDING LIGATION: SIX-YEAR EXPERIENCE OF A TERTIARY CENTER

Abstract Aim Esophageal variceal bleeding is a potentially lethal complication of portal hypertension. Endoscopic variceal band ligation (EVL) is the cornerstone of treatment for acute variceal bleeding, as well as its primary and secondary prophylaxis. Herein, we present our experience on EVL. Materials and methods Retrospective analysis of all cases subjected to EVL in our department from 01.01.2013 to 30.09.2018. Demographics, epidemiological data, outcomes -including number of sessions required to treat- and complications were recorded. Results One hundred and seventeen patients (males: 94=80.3%, mean age: 62.2±12.3 years), subjected to 224 sessions of EVL were recorded. The majority were cirrhotic (97.8%), mainly due to viral hepatitis (45.1%) and alcohol abuse (32.5%). Twenty patients (17.1%) had been previously subjected to EVL; fourty-five (39.1%) underwent EVL due to acute variceal bleeding, whereas 43 (36.7%) and 29 (25.2%) for primary and secondary prophylaxis, respectively. Variceal eradication was documented endoscopically in 49.7% of the patients treated with EVL. Performing 2 sessions of EVL showed the best discriminative ability associated with variceal eradication [ΑUC(95%CI)=0.72(0.63-0.82), sensitivity 78%, specificity 72%]. Presence of cirrhosis, indication and endoscopic findings were not associated with success of variceal eradication (p=0.15, p=0.52 and p>0.68), whereas the etiology of cirrhosis was associated with successful eradication, as patients suffering of cirrhosis attributed to viral hepatitis had lower success rates (61% vs. 28.2%, p=0.01). In 14 (25%) patients, varices relapsed after successful eradication. Twelve patients required rescue treatment (9 required TIPS and 3 Sensgstaken-Blakemore tube placement) to control bleeding. Complications related to EVL were documented in 13 (11.1%) patients, 69.2% of which was bleeding from post-EVL ulcers, for which however no further treatment was required. Conclusion In our series, 2 sessions of EVL are associated with the best therapeutic results with regards to variceal eradication, whilst patients with cirrhosis of viral etiology have lower eradication success rates.

Early TIPS with covered stents versus standard treatment for acute variceal bleeding in patients with advanced cirrhosis: a randomised controlled trial

The survival benefit of early placement of transjugular intrahepatic portosystemic shunts (TIPS) in patients with cirrhosis and acute variceal bleeding is controversial. We aimed to assess whether early TIPS improves survival in patients with advanced cirrhosis and acute variceal bleeding. We did an investigator-initiated, open-label, randomised controlled trial at an academic hospital in China. Consecutive patients with advanced cirrhosis (Child-Pugh class B or C) and acute variceal bleeding who had been treated with vasoactive drugs plus endoscopic therapy were randomly assigned (2:1) to receive either early TIPS (done within 72 h after initial endoscopy [early TIPS group]) or standard treatment (vasoactive drugs continued to day 5, followed by propranolol plus endoscopic band ligation for the prevention of rebleeding, with TIPS as rescue therapy when needed [control group]). Randomisation was done by web-based randomisation system using a Pocock and Simon's minimisation method with Child-Pugh class (B vs C) and presence or absence of active bleeding as adjustment factors. The primary outcome was transplantation-free survival, analysed in the intention-to-treat population, excluding individuals subsequently found to be ineligible for enrolment. This study is registered with ClinicalTrials.gov, number NCT01370161, and is completed. From June 26, 2011, to Sept 30, 2017, 373 patients were screened and 132 patients were randomly assigned to the early TIPS group (n=86) or to the control group (n=46). After exclusion of three individuals subsequently found to be ineligible for enrolment (two patients in the early TIPS group with non-cirrhotic portal hypertension or hepatocellular carcinoma, and one patient in the control group due to non-cirrhotic portal hypertension), 84 patients in the early TIPS group and 45 patients in the control group were included in the intention-to-treat population. 15 (18%) patients in the early TIPS group and 15 (33%) in the control group died; two (2%) patients in the early TIPS group and one (2%) in the control group underwent liver transplantation. Transplantation-free survival was higher in the early TIPS group than in the control group (hazard ratio 0·50, 95% CI 0·25-0·98; p=0·04). Transplantation-free survival at 6 weeks was 99% (95% CI 97-100) in the early TIPS group compared with 84% (75-96; absolute risk difference 15% [95% CI 5-48]; p=0·02) and at 1 year was 86% (79-94) in the early TIPS group versus 73% (62-88) in the control group (absolute risk difference 13% [95% CI 2-28]; p=0·046). There were no significant differences between the two groups in the incidence of hepatic hydrothorax (two [2%] of 84 patients in the early TIPS group vs one [2%] of 45 in the control group; p=0·96), spontaneous bacterial peritonitis (one [1%] vs three [7%]; p=0·12), hepatic encephalopathy (29 [35%] vs 16 [36%]; p=1·00), hepatorenal syndrome (four [5%] vs six [13%]; p=0·10), and hepatocellular carcinoma (four [5%] vs one [2%]; p=0·68). There was no significant difference in the number of patients who experienced other serious adverse events (ten [12%] vs 11 [24%]; p=0·07) or non-serious adverse events (21 [25%] vs 19 [42%]; p=0·05) between groups. Early TIPS with covered stents improved transplantation-free survival in selected patients with advanced cirrhosis and acute variceal bleeding and should therefore be preferred to the current standard of care. National Natural Science Foundation of China, National Key Technology R&D Program, Optimized Overall Project of Shaanxi Province, Boost Program of Xijing Hospital.

PS-024-Early TIPS with covered stent versus standard treatment for acute variceal bleeding among patients with advanced cirrhosis: A randomised controlled trial

PS-024-Early TIPS with covered stent versus standard treatment for acute variceal bleeding among patients with advanced cirrhosis: A randomised controlled trial

Model for end-stage liver disease score and hemodynamic instability as a predictor of poor outcome in early transjugular intrahepatic portosystemic shunt treatment for acute variceal hemorrhage.

To evaluate the outcome of early transjugular portosystemic shunt (TIPS) treatment in patients with a trial-compatible high-risk variceal bleeding and secondly to disclose other predictors of early mortality. A cohort study was conducted on patients referred for a TIPS procedure with or without combined variceal embolization to control acute esophageal variceal bleeding. A total of 32 patients with Child-Pugh C score less than 14 or Child-Pugh B plus active bleeding at endoscopy, admitted for early-TIPS treatment (<72 h), were included. We noted one (3.7%) failure to control bleeding and no rebleeding during 1-year follow-up. Ten (31.3%) patients died within 6 weeks after TIPS placement. Early mortality was associated with model for end-stage liver disease (MELD) score (P=0.025), MELD score of at least 19 (P=0.008) and hemodynamic instability at time of admission (P=0.001). If hemodynamic instability is associated with a high MELD score, the 6-week mortality peaks at 77.8% (P=0.000). This study confirms the excellent survival results of early-TIPS treatment for acute variceal bleeding in a selected patient group with a low MELD score. Poor survival in hemodynamically unstable patients with high MELD scores (≥19) contests the guidelines that patients with Child-Pugh class C cirrhosis or Child-Pugh class B with active bleeding on endoscopy should deliberately receive preemptive TIPS treatment after endoscopic haemostasis.

An evidence-based terlipressin therapy for gastroesophageal variceal hemorrhage

Gastroesophageal variceal bleeding is one of the major complications of cirrhosis and also the leading causes of death in patients with decompensated cirrhosis. Terlipressin is a triglycyl-lysine vasopressin, a synthetic vasopressin analogue that is mainly used for the treatment of acute variceal hemorrhage. This article aims to review the current status of treatment of gastroesophageal variceal bleeding with terlipressin from the perspective of evidence-based medicine.

SAT-199 - Effectiveness of “early” TIPS implantation versus “late” TIPS versus standard endoscopic treatment for acute variceal bleeding in patients with liver cirrhosis

SAT-199 - Effectiveness of “early” TIPS implantation versus “late” TIPS versus standard endoscopic treatment for acute variceal bleeding in patients with liver cirrhosis

Hemodynamic effects of renin-angiotensin-aldosterone inhibitor and β-blocker combination therapy vs. β-blocker monotherapy for portal hypertension in cirrhosis: A meta-analysis.

β-blockers are commonly used for the treatment of acute variceal bleeding in cirrhosis. Renin-angiotensin-aldosterone antagonists (angiotensin I-converting enzyme inhibitors, angiotensin receptor blockers and aldosterone antagonists) are potential therapies for portal hypertension. Several studies have compared the renin-angiotensin-aldosterone system (RAAS) inhibitor and β-blocker combination therapy vs. β-blocker monotherapy, with inconsistent results. The aim of the present study was to assess the efficacy of the RAAS inhibitor and β-blocker combination therapy vs. β-blocker monotherapy for hepatic vein pressure gradient (HVPG) reduction in cirrhosis. Studies were obtained using PubMed, Embase, Medline and Cochrane library databases up to July 2015, and the weighted mean difference (WMD) in HVPG reduction was used as a measure of treatment efficacy. In total, three studies (91 patients) were included. When compared to the β-blocker monotherapy, the RAAS inhibitor and β-blocker combination therapy resulted in a significant HVPG reduction [WMD 1.70; 95% confidence interval (CI): 0.52-2.88]. However, there was no significant difference in the heart rate reduction between the monotherapy and combination therapy groups (WMD -0.11; 95% CI: -3.51-3.29). In addition, no significant difference in the hemodynamic response was observed between the two groups (WMD 1.46; 95% CI: 0.93-2.30). In conclusion, the RAAS inhibitor and β-blocker combination therapy reduces portal hypertension significantly and to a greater extent than β-blocker monotherapy. Both therapies reduced the heart rate to similar levels; however, the RAAS inhibitor and β-blocker combination therapy reduced the mean arterial pressure to a greater extent. Due to the limited number of studies included, the data available do not allow a satisfactory comparison of adverse events. Moreover, further larger-scale trials are required in order to strengthen the results of the present study.

Prevention and treatment of variceal haemorrhage in 2017.

Variceal haemorrhage is a major complication of portal hypertension that still causes high mortality in patients with cirrhosis. Improved knowledge of the pathophysiology of portal hypertension has recently led to a more comprehensive approach to prevent all the complications of this condition. Thus, optimal treatment of portal hypertension requires a strategy that takes into account the clinical stage of the disease and all the major variables that affect the risk of progression to the next stage and death. In patients with compensated liver disease, the correction of factors influencing the progression of fibrosis, in particular aetiologic factors, is now feasible in many cases and should be achieved to prevent the development or progression of gastroesophageal varices and hepatic decompensation. Once gastroesophageal varices have developed, non-selective beta-blockers remain the cornerstone of therapy. Carvedilol provides a greater decrease in portal pressure and is currently indicated as a first-choice therapy for primary prophylaxis. The treatment of acute variceal haemorrhage includes a combination of vasoactive drugs, antibiotics and endoscopic variceal band ligation. In high-risk patients, the early use of transjugular intrahepatic portosystemic shunt (TIPS) lowers the risk of re-bleeding and improves survival. Transjugular intrahepatic portosystemic shunt is the choice for uncontrolled variceal bleeding; a self-expandable metal stent or balloon tamponade can be used as a bridging measure. The combination of non-selective beta-blockers and endoscopic variceal band ligation reduces the risk of recurrent variceal bleeding and improves survival. In these cases, statins seem to further improve survival. Transjugular intrahepatic portosystemic shunt is indicated in patients who rebleed during secondary prophylaxis.

Effectiveness of early TIPS for the treatment of acute variceal bleeding – the Viennese experience

Background: Early implantation of a transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours is recommended in selected cirrhotic patients with acute variceal bleeding (AVB) at high risk for treatment failure (Child-Pugh stage (CPS) C or B patients with active bleeding at endoscopy). Yet, effectiveness of early TIPS in unselected real-life cohorts has not been evaluated.

Three‐day versus five‐day somatostatin infusion combination with endoscopic variceal ligation in the prevention of early rebleeding following acute variceal hemorrhage: A randomized controlled trial

Combined pharmacological and endoscopic therapy is recommended for initial treatment of acute variceal bleeding (AVB). The optimal duration of therapy with a vasoactive agent is not well established. The aim of this study was to compare the efficacy and safety of 3-day and 5-day somatostatin treatment in the prevention of early rebleeding after endoscopic variceal ligation (EVL). In a double-blind, prospective trial, cirrhotic patients with AVB who underwent EVL were randomly assigned to receive a continuous infusion of somatostatin for either 3 days or 5 days. A total of 95 patients were enrolled; 50 patients in the 3-day group and 45 patients in the 5-day group after initial hemostasis by combination therapy with somatostatin and EVL. Both groups were comparable in terms of baseline data. Very early and early rebleeding within 5 days and 42 days occurred in one and three patient (2%, 6%) in the 3-day group and three and two patients (6.67%, 4.45%) in the 5-day group (P = 0.342, 0.735), respectively. Overall, eight patients died (three from variceal rebleeding and five from causes other than variceal bleed); four (8%) in the 3-day group and four (8.89%) in the 5-day group (P = 0.876). Multivariate analysis revealed that none of the factors was a predictor of rebleeding. No serious side-effects and complications were observed. A 3-day course of somatostatin is as effective as a 5-day course for the control of variceal bleeding and prevention of early rebleeding when used as combination therapy with EVL.

Aktif özofagus varis kanamasının kontrolünde farmakolojik tedavi ve endoskopik band ligasyonu kombinasyonunun etkinliği

Giriş ve Amaç: Bu çalışmada akut özofagus varis kanaması ile hastaneye başvuran hastalarda farmakolojik ve endoskopik tedavi kombinasyonunun etkinliği değerlendirildi. Gereç ve Yöntem: Çalışma İzmir Atatürk Eğitim ve Araştırma Hastanesi Gastroenteroloji Kliniğinde retrospektif olarak yapıldı. Ocak 2008Haziran 2010 tarihleri arasında akut özofagus varis kanaması düşünülerek somatostatin tedavisi başlanan ve üst gastrointestinal sistem endoskopisi sonrası aktif özofagus varis kanaması saptanarak, endoskopik band ligasyonu yapılan hastalar değerlendirildi. Bulgular: Aktif özofagus varis kanaması saptanan 43 hastanın 41'inde (%95) endoskopik tedavi ile kanama kontrolü sağlandı. Somatostatin ve endoskopik tedavi kombinasyonu ile 5 hastada (%11,7) kanama tekrarı (Hgb düşüşü, melena, hematemez) saptandı. Kanama tekrarı saptanan 3 hastada Sengstaken balon tamponadı sonrasında ikinci kez endoskopik tedavi yapıldı ve kanama kontrol altına alındı. Ancak 2 hasta yapılan tüm girişimlere rağmen kaybedildi. Hastalarda işleme bağlı ciddi komplikasyon (kanamanın şiddetlenmesi, perforasyon, aspirasyon) saptanmadı. Sonuç: Sonuç olarak bu çalışmada akut varis kanaması düşünülen hastalara ön tanı konulduğu andan itibaren farmakolojik tedavi başlanması ve 12 saat içinde endoskopik tedavi ile endoskopik tedavi yapılmasının etkin ve güvenilir bir tedavi yaklaşımı olduğu saptandı.

Management of variceal hemorrhage: current concepts.

IntroductionThe treatment of portal hypertension is complex and the the best strategy depends on the underlying disease (cirrhosis vs. schistosomiasis), patient's clinical condition and time on it is performed (during an acute episode of variceal bleeding or electively, as pre-primary, primary or secondary prophylaxis). With the advent of new pharmacological options and technical development of endoscopy and interventional radiology treatment of portal hypertension has changed in recent decades.AimTo review the strategies employed in elective and emergency treatment of variceal bleeding in cirrhotic and schistosomotic patients.MethodsSurvey of publications in PubMed, Embase, Lilacs, SciELO and Cochrane databases through June 2013, using the headings: portal hypertension, esophageal and gastric varices, variceal bleeding, liver cirrhosis, schistosomiasis mansoni, surgical treatment, pharmacological treatment, secondary prophylaxis, primary prophylaxis, pre-primary prophylaxis.ConclusionPre-primary prophylaxis doesn't have specific treatment strategies; the best recommendation is treatment of the underlying disease. Primary prophylaxis should be performed in cirrhotic patients with beta-blockers or endoscopic variceal ligation. There is controversy regarding the effectiveness of primary prophylaxis in patients with schistosomiasis; when indicated, it is done with beta-blockers or endoscopic therapy in high-risk varices. Treatment of acute variceal bleeding is systematized in the literature, combination of vasoconstrictor drugs and endoscopic therapy, provided significant decline in mortality over the last decades. TIPS and surgical treatment are options as rescue therapy. Secondary prophylaxis plays a fundamental role in the reduction of recurrent bleeding, the best option in cirrhotic patients is the combination of pharmacological therapy with beta-blockers and endoscopic band ligation. TIPS or surgical treatment, are options for controlling rebleeding on failure of secondary prophylaxis. Despite the increasing evidence of the effectiveness of pharmacological and endoscopic treatment in schistosomotic patients, surgical therapy still plays an important role in secondary prophylaxis.