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Variceal Bleeding (variceal + bleeding)
Kinds of Variceal Bleeding Selected AbstractsEarly identification of haemodynamic response to pharmacotherapy is essential for primary prophylaxis of variceal bleeding in patients with ,high-risk' varicesALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 1 2009P. SHARMA Summary Background, A beta-blocker is recommended for primary prophylaxis of variceal bleeding; however, only one-third have hepatic venous pressure gradient (HVPG) response. The role of addition of isosorbide-5-mononitrate (ISMN) to beta-blocker and benefits of HVPG-guided ,a la carte' approach remain unclear. Aim, To determine the benefits of HVPG-guided pharmacotherapy in primary prophylaxis of variceal bleeding using beta-blocker and ISMN. Patients and methods, Consecutive patients of cirrhosis, with high-risk varices, with no previous variceal bleeding were included. After baseline HVPG, patients received incremental propranolol to achieve HR of 55/min. After one-month, HVPG was repeated to determine response (<12 mmHg or ,20% reduction). ISMN was added in nonresponders and HVPG repeated. Patients were followed up for 24 months. Results, Of 56 patients (age 47 ± 13, males 79%) from 89 eligible patients, 21 (38%) responded to beta-blocker alone. Six additional patients responded to combination. Thus, overall 48% (27/56) patients responded. Variceal bleeding occurred in seven of 56 (13%) patients [one of 27 (4%) responder, five of 23 (22%) nonresponders and one of six (17%) with unknown response; P = N.S.]. The actuarial probability of variceal bleeding at median 24 months was 4% in responders and 22% in nonresponders (P < 0.05). Ten (18%) patients developed adverse effects to propranolol and six of 35 (17%) to nitrates requiring dose reduction. Risk factors of variceal bleed were grade IV varices and haemodynamic nonresponse. Conclusions, For primary prophylaxis, a beta-blocker is effective in 38% and addition of ISMN raises the response rate to about half of patients. The HVPG-guided ,a la carte' approach may be considered for these patients. [source] Review article: primary prophylaxis for portal hypertensive bleeding in cirrhosisALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 7 2000Vlachogiannakos Variceal bleeding is a consequence of portal hypertension, which in turn is the major complication of hepatic cirrhosis. Given the high rate of mortality of the first bleeding episode, primary prophylaxis to prevent bleeding from varices and portal hypertensive gastropathy is the current optimal therapeutic approach. The difficulty in identification of patients with varices who will bleed, before they do so, can justify a strategy of treating all patients with varices prophylactically. We evaluated the various therapies that have been assessed in randomized controlled trials for prevention of first bleeding, using meta-analysis where applicable. The current first choice treatment is non-selective ,-blockers; it is cheap, easy to administer, and is effective in preventing the first variceal haemorrhage and bleeding from gastric mucosa. Combination drug therapy of ,-blockers and nitrates looks promising, but needs further evaluation in randomized controlled trials. The conflicting results of the randomized studies of endoscopic banding ligation and the small number of patients and clinical events, as well as the cost, do not warrant any change in current practice. However, endoscopic banding ligation may be a reasonable alternative for patients who cannot tolerate, or have contraindications to ,-blockers or no haemodynamic response to the drug therapy, but this must be proved in randomized trials. [source] Treatment options for hydroxyurea-refractory disease complications in myeloproliferative neoplasms: JAK2 inhibitors, radiotherapy, splenectomy and transjugular intrahepatic portosystemic shuntEUROPEAN JOURNAL OF HAEMATOLOGY, Issue 3 2010Elena Mishchenko Abstract Clinical care of patients with polycythemia vera, essential thrombocythemia and myelofibrosis (MF) requires not only a broad understanding of general treatment principles but also familiarity with the management of hydroxyurea-refractory disease complications. The latter include progressive splenomegaly, symptomatic portal hypertension (e.g. ascites, variceal bleeding), pulmonary hypertension, bone pain, intractable pruritus, constitutional symptoms (e.g. fatigue, night sweats) and cachexia (i.e. loss of lean body mass, general ill health, poor appetite). Some of these symptoms are directly or indirectly related to extramedullary hematopoiesis (EMH) and others to proinflammatory cytokine excess. Results from recent clinical trials of JAK inhibitors suggest remarkable activity in MF-associated constitutional symptoms, cachexia, pruritus and hydroxyurea-refractory splenomegaly. Involved-field radiotherapy is best utilized in the setting of EMH-associated symptoms, including ascites, bone (extremity) pain and pulmonary hypertension. Splenectomy is indicated in the presence of drug-refractory splenomegaly and frequent red cell transfusion requirement. Transjugular intrahepatic portosystemic shunt is used to alleviate symptoms of portal hypertension. [source] Propranolol plus placebo versus propranolol plus isosorbide-5-mononitrate in the prevention of a first variceal bleed: A double-blind RCTHEPATOLOGY, Issue 6 2003Juan Carlos García-Pagán M.D. Nonselective ,-blockers are very effective in preventing first variceal bleeding in patients with cirrhosis. Treatment with isosorbide-5-mononitrate (IS-MN) plus propranolol achieves a greater reduction in portal pressure than propranolol alone. The present multicenter, prospective, double-blind, randomized, controlled trial evaluated whether combined drug therapy could be more effective than propranolol alone in preventing variceal bleeding. A total of 349 consecutive cirrhotic patients with gastroesophageal varices were randomized to receive propranolol + placebo (n = 174) or propranolol + IS-MN (n = 175). There were no significant differences in the 1- and 2-year actuarial probability of variceal bleeding between the 2 groups (propranolol + placebo, 8.3% and 10.6%; propranolol + IS-MN, 5% and 12.5%). The only independent predictor of variceal bleeding was a variceal size greater than 5 mm. However, among patients with varices greater than 5 mm (n = 196), there were no significant differences in the incidence of variceal bleeding between the 2 groups. Survival was also similar. Adverse effects were significantly more frequent in the propranolol + IS-MN group due to a greater incidence of headache. There were no significant differences in the incidence of new-onset or worsening ascites or in impairment of renal function. In conclusion, propranolol effectively prevents variceal bleeding. Adding IS-MN does not further decrease the low residual risk of bleeding in patients receiving propranolol. However, the long-term use of this combination drug therapy is safe and may be an alternative in clinical conditions associated with a greater risk of bleeding. [source] TIPS versus drug therapy in preventing variceal rebleeding in advanced cirrhosis: A randomized controlled trialHEPATOLOGY, Issue 2 2002Àngels Escorsell Prevention of variceal rebleeding is mandatory in cirrhotic patients. We compared the efficacy, safety, and cost of transjugular intrahepatic portosystemic shunt (TIPS) versus pharmacologic therapy in preventing variceal rebleeding in patients with advanced cirrhosis. A total of 91 Child-Pugh class B/C cirrhotic patients surviving their first episode of variceal bleeding were randomized to receive TIPS (n = 47) or drug therapy (propranolol + isosorbide-5-mononitrate) (n = 44) to prevent variceal rebleeding. Mean follow-up was 15 months. Rebleeding occurred in 6 (13%) TIPS-treated patients versus 17 (39%) drug-treated patients (P = .007). The 2-year rebleeding probability was 13% versus 49% (P = .01). A similar number of reinterventions were required in the 2 groups; these were mainly angioplasty ± restenting in the TIPS group (90 of 98) and endoscopic therapy for rebleeding in the medical group (45 of 62) (not significant). Encephalopathy was more frequent in TIPS than in drug-treated patients (38% vs. 14%, P = .007). Child-Pugh class improved more frequently in drug-treated than in TIPS-treated patients (72% vs. 45%; P = .04). The 2-year survival probability was identical (72%). The identified cost of therapy was double for TIPS-treated patients. In summary, medical therapy was less effective than TIPS in preventing rebleeding. However, it caused less encephalopathy, identical survival, and more frequent improvement in Child-Pugh class with lower costs than TIPS in high-risk cirrhotic patients. This suggests that TIPS should not be used as a first-line treatment, but as a rescue for failures of medical/endoscopic treatments (first-option therapies). [source] The hemodynamic response to medical treatment of portal hypertension as a predictor of clinical effectiveness in the primary prophylaxis of variceal bleeding in cirrhosisHEPATOLOGY, Issue 5 2000Carlo Merkel In the prevention of variceal rebleeding, it is already established that hemodynamic response to drug treatment (decrease in hepatic venous pressure gradient [HVPG] to 12 mm Hg or by >20%) is predictive of clinical effectiveness. In primary prophylaxis very few clinical data are available. We assessed the role of the hemodynamic response to beta-blockers or beta-blockers plus nitrates in predicting clinical efficacy of prophylaxis. A total of 49 cirrhotic patients with varices at risk of bleeding, without prior variceal bleeding, were investigated by hepatic vein catheterization before and after 1 to 3 months of chronic treatment with nadolol or nadolol plus isosorbide mononitrate, and were followed during treatment for up to 5 years. A total of 30 patients (61%) were good hemodynamic responders, and among them in 12 (24%) HVPG was ,12 mm Hg during treatment. During treatment 9 patients had variceal bleeding: 7 were poor responders and 2 were good responders. The probability of bleeding at 3 years of follow-up was significantly higher in poor responders (41%) than in good responders (7%; P = .0008). No patient reaching an HVPG of 12 mm Hg or less during treatment had variceal bleeding during follow-up. Cox's regression analysis showed that poor hemodynamic response was the main factor predicting bleeding (, = 1.91; SE(,) = 0.80; P = .01). During follow-up 11 patients died of hepatic causes. Survival was related to Child-Pugh class and to initial value of HVPG, according to Cox's analysis. In conclusion, the assessment of hemodynamic response to drugs in terms of HVPG is the best predictor of efficacy of prophylaxis of variceal bleeding in patients treated with beta-blockers or beta-blockers plus nitrates. [source] Liver transplantation for the sequelae of intra-operative bile duct injuryHPB, Issue 3 2002E De Santibañes Background Intra-operative bile duct injuries (IBDI) are potentially severe complications of the treatment of benign conditions, with unpredictable long-term results. Multiple procedures are frequently needed to correct these complications. In spite of the application of these procedures, patients with severe injuries can develop irreversible liver disease. Liver transplantation (LT) is currently the only treatment available for such patients, but little information has been published concerning the results of LT. Methods Eight patients with LT for end-stage liver disease for IBDI were studied retrospectively. They had failure of multiple previous treatments and experienced recurrent episodes of cholangitis, oesophageal variceal bleeding, severe pruritus, refractory ascites and spontaneous peritonitis. Results Mean recipient hepatectomy time was of 243 minutes (range 140,295 min), the complete procedure averages 545 minutes (260,720) and intraoperative red-blood-cells consumption was 6.5 units (1,7). One patient required reoperation due to perforation of a Roux-en-Y loop, and three developed minor complications (2 wound infections, 1 inguinal lymphocele). One patient died due to nosocomial pneumonia (mortality rate 12.5%). One patient required retransplantation due to delayed hepatic artery thrombosis. At follow-up 75% of patients are alive with normal graft function and an excellent quality of life. Conclusions LT represents a safe curative treatment for end-stage liver disease after IBDI, albeit a major undertaking in the context of a surgical complication in the treatment of benign disease. The complications of the surgical procedure and the long-standing immunosupression impart a high cost for resolutions of these sequelae but LT represents the only long-term effective treatment for these selected patients. [source] Major adverse events, pretransplant assessment and outcome predictionJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 11 2009Hui-Chun Huang Abstract Liver cirrhosis and portal hypertension pose enormous loss of lives and resources throughout the world, especially in endemic areas of chronic viral hepatitis. Although the pathophysiology of cirrhosis is not completely understood, the accumulating evidence has paved the way for better control of the complications, including gastroesophageal variceal bleeding, hepatic encephalopathy, ascites, hepatorenal syndrome, hepatopulmonary syndrome and portopulmonary hypertension. Modern pharmacological and interventional therapies have been designed to treat these complications. However, liver transplantation (LT) is the only definite treatment for patients with preterminal end-stage liver disease. To pursue successful LT, the meticulous evaluation of potential recipients and donors is pivotal, especially for living donor transplantation. The critical shortage of cadaveric donor livers is another concern. In many Asian countries, cultural and religious concerns further limit the number of the donors, which lags far behind that of the recipients. The model for end-stage liver disease (MELD) scoring system has recently become the prevailing criterion for organ allocation. Initial results showed clear benefits of moving from the Child,Turcotte,Pugh-based system toward the MELD-based organ allocation system. In addition to the MELD, serum sodium is another important prognostic predictor in patients with advanced cirrhosis. The incorporation of serum sodium into the MELD could enhance the performance of the MELD and could become an indispensable strategy in refining the priority for LT. However, the feasibility of the MELD in combination with sodium in predicting the outcome for patients on transplant waiting list awaits actual outcome data before this becomes standard practice in the Asia,Pacific region. [source] Factors predicting success of endoscopic variceal ligation for secondary prophylaxis of esophageal variceal bleedingJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 1 2006Gavin C Harewood Abstract Introduction:, Endoscopic obliteration of esophageal varices by endoscopic variceal ligation (EVL) is an effective form of secondary prophylaxis. However, there is no consensus regarding the technical aspects of EVL for secondary prophylaxis. The present study compares the technical aspects of EVL (frequency of sessions, number of sessions and number of bands used) in patients who rebled following secondary prophylaxis of esophageal varices by EVL compared to those who did not rebleed. Methods:, All patients who underwent EVL for treatment of acute variceal bleeding followed by EVL for secondary prophylaxis and who subsequently developed recurrent variceal bleeding at Mayo Clinic, Rochester between January 1995 and May 2003 were identified. A control group of patients undergoing EVL for secondary prophylaxis who did not rebleed was identified. Results:, During the study period, 216 patients with acute esophageal variceal hemorrhage underwent emergent EVL treatment with follow-up EVL for secondary prophylaxis, of whom 20 (9.3%) subsequently rebled. Both rebleeding and non-rebleeding patient groups were well-matched with respect to liver function (Child,Pugh class), number and size of variceal trunks, endoscopic stigmata of hemorrhage and beta-blocker usage. The median interval between EVL sessions in the rebleeding group (2 weeks, interquartile range 0,2 weeks) was significantly shorter compared to the non-rebleeding group (5 weeks, interquartile range 3,7 weeks; P = 0.004). Adjusting for age, gender, and Child,Pugh class, interbanding interval , 3 weeks was associated with increased likelihood of not rebleeding, hazard ratio 3.84 (95% confidence interval: 1.69,11.79; P = 0.0007). Conclusions:, These findings demonstrate the importance of technical aspects of EVL on patient outcome, suggesting the benefit of longer interbanding intervals. Future prospective studies are required to define the optimal intersession interval. Standardizing procedural aspects of EVL will aid in objectively evaluating the benefit of this procedure when compared to other modalities such as medical treatment. [source] Evolution of hypoxemia in patients with severe cirrhosisJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 10 2002Isabelle Colle Abstract Background and Aim: Hypoxemia is common in patients with cirrhosis but the natural history of this syndrome is unknown. The aim of this study was to follow a series of patients with cirrhosis and to compare patients with and without hypoxemia to determine their risk of complications and survival rate. Methods: Fifty-eight consecutive Child,Pugh C patients with cirrhosis were included and followed up for 1,18 months. Blood gas measurements and plasma endothelin levels were measured in all patients. Blood gas measurements were repeated in 34 patients. Results: Hypoxemia was present in 35 patients (60%) (alveolar-arterial oxygen (AaO2) gradient > 20 mmHg) but none had pulmonary symptoms. There was no significant difference in liver tests and plasma endothelin levels between hypoxemic and non-hypoxemic patients. The occurrence of variceal bleeding and survival rate was not significantly different between the two groups. The AaO2 gradient worsened in nine patients and normalized in six of the hypoxemic patients. The AaO2 gradient increased to more than 20 mmHg in seven non-hypoxemic patients. There was no relationship between AaO2 gradient changes and Child,Pugh score grade changes. Conclusion: Asymptomatic hypoxemia is common in patients with severe cirrhosis but it is not a predictive factor of short-term complications or mortality. These results should be considered when deciding on liver transplantation. [source] Meta-analysis: isosorbide-mononitrate alone or with either beta-blockers or endoscopic therapy for the management of oesophageal varicesALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 7 2010L. L. Gluud Aliment Pharmacol Ther 2010; 32: 859,871 Summary Background, The evidence concerning the use of isosorbide-mononitrate (IsMn) for oesophageal varices is equivocal. Aim, To assess the effects of IsMn for patients with oesophageal varices and no previous bleeding (primary prevention) or previous variceal bleeding (secondary prevention). Methods, Systematic review with meta-analyses of randomized trials on IsMn alone or with beta-blockers or endoscopic therapy for oesophageal varices. Electronic and manual searches were combined. Randomized trials on primary and secondary prevention were included. The primary outcome measure was mortality. Intention-to-treat random effects meta-analyses were performed. The robustness of the results was assessed in trial sequential analyses. Results, Ten randomized trials on primary and 17 on secondary prevention were included. Evidence of bias was identified. No apparent effect of IsMn on mortality compared with placebo or beta-blockers or IsMn plus beta-blockers vs. beta-blockers was identified. Compared with endoscopic therapy, IsMn plus beta-blockers had no apparent effect on bleeding, but did seem to reduce mortality in secondary prevention (RR 0.73, 95% CI 0.59,0.89), but not in primary prevention. The effect of IsMn plus beta-blockers on mortality in secondary prevention was not confirmed in trial sequential analysis. Conclusions, Isosorbide-mononitrate used alone or in combination with beta blockers does not seem to offer any reduction in bleeding in the primary or secondary prevention of oesophageal varices. Compared with endoscopic therapy, there may be a survival advantage in using IsMn and beta-blockers, but additional large multicentre trials are needed to verify this finding. [source] Predicting the advent of ascites and other complications in primary biliary cirrhosis: a staged model approachALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 5 2010C.-W. CHAN Aliment Pharmacol Ther,31, 573,582 Summary Background, Current survival models for primary biliary cirrhosis have limited precision for medium and long-term survival. Aim, To describe a prognostic model for the advent of complications in primary biliary cirrhosis as the first approach to a staged prognostic model. Methods, From an established database of 289 consecutive primary biliary cirrhosis patients referred to Royal Free Hospital over 12 years (mean follow-up of 4.1 years), baseline characteristics at referral were evaluated by Cox-proportional hazards regression modelling. Results, The following complications occurred de novo: 85 ascites/peripheral oedema, 40 oesophagogastric varices, 63 encephalopathy, 29 spontaneous bacterial peritonitis and/or septicaemia, 59 symptomatic urinary tract infections. Age, albumin, log10(bilirubin), presence of ascites at referral, variceal bleeding within 6 weeks before referral, detection of oesophagogastric varices at or before referral were significant at multivariate analysis with different combinations and coefficients for each complication. The model for predicting ascites and/or peripheral oedema best fitted the observed data (ROC = 0.7682, S.E. = 0.0385). Conclusions, The known prognostic factors in primary biliary cirrhosis also model the advent of complications. In view of the prognostic importance of ascites and its more robust statistical model, ascites and/or peripheral oedema could represent, following validation, the most suitable staged model in primary biliary cirrhosis to improve precision in survival modelling. [source] Endoscopic variceal ligation alone or with pharmacological therapy for recurrent variceal bleeding: the importance of intention-to-treat analysesALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 2 2010A. Krag No abstract is available for this article. [source] Systematic review: endoscopic and imaging-based techniques in the assessment of portal haemodynamics and the risk of variceal bleedingALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 10 2009S. N. SGOUROS Summary Background, Invasive measurement of the hepatic venous pressure gradient (HVPG) is regarded as the gold standard for risk stratification and the evaluation of pharmaceutical agents in patients with portal hypertension. Aim, To review the techniques for endoscopic and imaging-based assessment of portal haemodynamics, with particular emphasis on trials where the results were compared with HVPG or direct portal pressure measurement. Methods, Systematic search of the MEDLINE electronic database with keywords: portal hypertension, variceal bleeding, variceal pressure, endoscopic ultrasound, Doppler ultrasonography, magnetic resonance angiography, CT angiography, hepatic venous pressure gradient. Results, Computed tomography angiography and endoscopic ultrasound (EUS) have been both employed for the diagnosis of complications of portal hypertension and for the evaluation of the efficacy of endoscopic therapy. Colour Doppler ultrasonography and magnetic resonance angiography has given discrepant results. Endoscopic variceal pressure measurements either alone or combined with simultaneous EUS, correlate well with HVPG and risk of variceal bleeding and have a low interobserver variability. Conclusions, Endoscopic and imaging-based measurements of portal haemodynamics provide an alternate means for the assessment of complications of portal hypertension. Further studies are required to validate their use in risk stratification and the evaluation of drug therapies in patients with portal hypertension. [source] Systematic review: secondary prevention with band ligation, pharmacotherapy or combination therapy after bleeding from oesophageal varicesALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 6 2009J. CHEUNG Summary Background, Variable methods are available for secondary prevention after oesophageal variceal bleeding (EVB). Aim, To compare band ligation (BL), pharmacotherapy (PT) and BL+PT for EVB secondary prevention. Methods, A systematic search of databases, references and meeting abstracts was conducted for randomized trials of BL, PT or BL+PT. The outcomes were mortality, rebleeding and adverse events. A random-effects model was used for meta-analyses. Results, Twelve trials were included (6 BL vs. PT, 4 BL+PT vs. BL, 2 BL+PT vs. PT). All trials used beta-blockers ± isosorbide mononitrate (ISMN) as PT. Mortality was not significantly different among trials. Rebleeding was not significantly different for BL vs. PT (RR 1.00, 95% CI 0.73,1.37). BL reduced rebleeding compared with PT for trials with mean beta-blocker dose <80 mg/day (RR 0.67, 95% CI 0.49,0.91). There were nonsignificant differences in rebleeding for BL+PT vs. BL (RR 0.57, 95% CI 0.31,1.08) and BL+PT vs. PT (RR 0.76, 95% CI 0.56,1.03). There was no difference in adverse events between BL vs. PT, but was higher with BL+PT vs. BL. Conclusion, Band ligation and PT alone are comparable for secondary prevention of rebleeding after EVB. Further trials with adequate PT dosing are required to determine the efficacy of combination BL+PT therapy. [source] Early identification of haemodynamic response to pharmacotherapy is essential for primary prophylaxis of variceal bleeding in patients with ,high-risk' varicesALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 1 2009P. SHARMA Summary Background, A beta-blocker is recommended for primary prophylaxis of variceal bleeding; however, only one-third have hepatic venous pressure gradient (HVPG) response. The role of addition of isosorbide-5-mononitrate (ISMN) to beta-blocker and benefits of HVPG-guided ,a la carte' approach remain unclear. Aim, To determine the benefits of HVPG-guided pharmacotherapy in primary prophylaxis of variceal bleeding using beta-blocker and ISMN. Patients and methods, Consecutive patients of cirrhosis, with high-risk varices, with no previous variceal bleeding were included. After baseline HVPG, patients received incremental propranolol to achieve HR of 55/min. After one-month, HVPG was repeated to determine response (<12 mmHg or ,20% reduction). ISMN was added in nonresponders and HVPG repeated. Patients were followed up for 24 months. Results, Of 56 patients (age 47 ± 13, males 79%) from 89 eligible patients, 21 (38%) responded to beta-blocker alone. Six additional patients responded to combination. Thus, overall 48% (27/56) patients responded. Variceal bleeding occurred in seven of 56 (13%) patients [one of 27 (4%) responder, five of 23 (22%) nonresponders and one of six (17%) with unknown response; P = N.S.]. The actuarial probability of variceal bleeding at median 24 months was 4% in responders and 22% in nonresponders (P < 0.05). Ten (18%) patients developed adverse effects to propranolol and six of 35 (17%) to nitrates requiring dose reduction. Risk factors of variceal bleed were grade IV varices and haemodynamic nonresponse. Conclusions, For primary prophylaxis, a beta-blocker is effective in 38% and addition of ISMN raises the response rate to about half of patients. The HVPG-guided ,a la carte' approach may be considered for these patients. [source] Clinical trial: a randomized controlled study on prevention of variceal rebleeding comparing nadolol + ligation vs. hepatic venous pressure gradient-guided pharmacological therapyALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 4 2009C. VILLANUEVA Summary Background, Hepatic venous pressure gradient (HVPG) monitoring of therapy to prevent variceal rebleeding provides strong prognostic information. Treatment of nonresponders to ,-blockers ± nitrates has not been clarified. Aim, To assess the value of HVPG-guided therapy using nadolol + prazosin in nonresponders to nadolol + isosorbide-5-mononitrate (ISMN) compared with a control group treated with nadolol + ligation. Methods, Cirrhotic patients with variceal bleeding were randomized to HVPG-guided therapy (n = 30) or nadolol + ligation (n = 29). A Baseline haemodynamic study was performed and repeated within 1 month. In the guided-therapy group, nonresponders to nadolol + ISMN received nadolol and carefully titrated prazosin and had a third haemodynamic study. Results, Nadolol + prazosin decreased HVPG in nonresponders to nadolol + ISMN (P < 0.001). Finally, 74% of patients were responders in the guided-therapy group vs. 32% in the nadolol + ligation group (P < 0.01). The probability of rebleeding was lower in responders than in nonresponders in the guided therapy group (P < 0.01), but not in the nadolol + ligation group (P = 0.41). In all, 57% of nonresponders rebled in the guided-therapy group and 20% in the nadolol + ligation group (P = 0.05). The incidence of complications was similar. Conclusions, In patients treated to prevent variceal rebleeding, the association of nadolol and prazosin effectively rescued nonresponders to nadolol and ISMN, improving the haemodynamic response observed in controls receiving nadolol and endoscopic variceal ligation. Our results also suggest that ligation may rescue nonresponders. [source] Liver cirrhosis in HIV-infected patients: prevalence, aetiology and clinical outcomeJOURNAL OF VIRAL HEPATITIS, Issue 3 2008C. Castellares Summary., Liver disease is frequently seen in HIV+ patients as a result of coinfection with hepatitis B (HBV) or C (HCV) viruses, alcohol abuse and/or exposure to hepatotoxic drugs. The aim of this study was to assess the prevalence of liver cirrhosis, its main causes and clinical presentation in HIV+ patients. Observational, cross-sectional, retrospective study of all HIV+ individuals followed at one reference HIV outpatient clinic in Madrid. Liver fibrosis was measured in all cases using transient elastometry (FibroScan®). All 2168 HIV+ patients on regular follow-up (76% males, 46% injecting drug users) were successfully examined by FibroScan® between October 2004 and August 2006. Liver cirrhosis was recognized in 181 (overall prevalence, 8.3%), and the main aetiologies were HCV, 82.3%; HBV, 1.6%; dual HBV/HCV, 2.8%; and triple HBV/HCV/ hepatitis delta virus (HDV) infection, 6.6%. The prevalence of cirrhosis differed among patients with distinct chronic viral hepatitis: HCV, 19.2%; HBV, 6.1%; HBV/HCV, 41.7%; and HBV/HCV/HDV, 66.7%. In 12 patients with cirrhosis (6.7%), no definite aetiology was recognized. Overall, cirrhotics had lower mean CD4 counts than noncirrhotics (408 vs 528 cells/,L respectively; P = 0.02), despite similar proportion of subjects with undetectable viraemia on highly active antiretroviral therapy. Clinical manifestations of liver cirrhosis were: splenomegaly, 61.5%; oesophageal varices, 59.8%; ascites, 22.6%; encephalopathy, 12.1%; and variceal bleeding, 6.1%. Liver cirrhosis and hepatic decompensation events are relatively frequent in HIV+ individuals. Chronic HCV and alcohol abuse, but not chronic HBV, play a major role. Transient elastometry may allow the identification of a significant number of HIV+ individuals with asymptomatic liver cirrhosis. [source] Review article: the therapeutic and prognostic benefit of portal pressure reduction in cirrhosisALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 8 2008C. K. TRIANTOS Summary Background, Hepatic venous pressure gradient (HVPG) measurement is not a routinely used technique, despite its therapeutic and prognostic value. Aim, To review the role of HVPG from published literature. Methods, Systematic literature review. Results, In acute variceal bleeding, HVPG is prognostic identifying ,difficult to treat' group, which now has defined clinical correlations. In secondary prevention of portal hypertensive bleeding, a reduction to ,12 mmHg confers near complete protection against rebleeding. The target of ,20% HVPG reduction from baseline needs prospective assessment to test a change of therapy, if no reduction occurs. The acute HVPG response to beta-blockade needs further assessment. In primary prevention, the cost-effectiveness of HVPG measurement is not favourable given the efficacy of medical therapy. In chronic liver disease, wedge hepatic venous pressure (WHVP) is prognostic for survival. Pharmacological reduction in portal pressure decreases complications and improves survival, possibly independent of a concomitant improvement in liver function. This latter requires urgent confirmation as it is clinically very relevant. HVPG monitoring can be used to assess anti-viral therapy particularly in cirrhosis, ergonomically combined with transjugular biopsy. Conclusions, The prognostic and therapeutic value of HVPG is established beyond portal hypertensive bleeding for which there are some clinical surrogates. HVPG measurement should now be part of everyday clinical practice. [source] Review article: recent advances in the management of bleeding gastric varicesALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 1 2006D. TRIPATHI Summary Gastric variceal bleeding can be challenging to the clinician. Tissue adhesives can control acute bleeding in over 80%, with rebleeding rates of 20,30%, and should be first-line therapy where available. Endoscopic ultrasound can assist in better eradication of varices. The potential risks of damage to equipment and embolic phenomena can be minimized with careful attention to technique. Variceal band ligation is an alternative to tissue adhesives for the management of acute bleeding, but not for secondary prevention due to a higher rate of rebleeding. Endoscopic therapy with human thrombin appears promising, with initial haemostasis rates typically over 90%. The lack of controlled studies for thrombin prevents universal recommendation outside of clinical trials. Balloon occluded retrograde transvenous obliteration is a recent technique for patients with gastrorenal shunts, although its use is limited to clinical trials. Transjugular intrahepatic portosystemic stent shunt is an option for refractory bleeding and secondary prophylaxis, with uncontrolled studies demonstrating initial haemostasis obtained in over 90%, and rebleeding rates of 15,30%. Non-cardioselective , -blockers are an alternative to transjugular intrahepatic portosystemic stent shunt for secondary prophylaxis, although the evidence is limited. Shunt surgery should be considered in well-compensated patients. Splenectomy or embolization is an option in patients with segmental portal hypertension. [source] Octreotide in liver cirrhosis: a salvage for variceal bleeding can be a gunshot for kidneysLIVER INTERNATIONAL, Issue 3 2005Deniz Güney Duman Abstract Background: The renal effects of octreotide, used for bleeding esophageal varices in cirrhosis, are controversial. Methods: Fourteen cirrhotic patients (Child,Pugh; A/B/C: 1/12/1) were enrolled. Plasma nitrite and endothelin (ET) levels, urinary nitrite output, free water clearance (FWC) and fractional excretion of filtered sodium (FENa) were measured and renal Doppler ultrasound was carried out. Octreotide was infused at a rate of 0.75 ,g/kg/h for 3 h after a bolus of 0.75 ,g/kg body weight. All the parameters were reevaluated during octreotide administration while the patients acted as their own controls. Results: Octreotide induced significant reductions in urinary nitrite, FENa and FWC. Plasma ET levels increased (baseline: 6.7 pg/ml, octreotide: 8.4 pg/ml), whereas the plasma nitrite level did not change significantly after octreotide infusion. Overall, no significant change in renal resistive index (RRI) could be demonstrated on Doppler after octreotide administration. However, patients with elevated baseline RRI values had significantly more deterioration in FWC and FENa compared with patients with normal RRI in response to octreotide. Conclusion: A marked decrease in FENa, FWC and urinary nitrite output, together with a significant increase in plasma ET level in response to octreotide, may indicate renal dysfunction in cirrhotic patients. This deleterious renal effect of octreotide may be more enhanced in patients with elevated baseline RRI. [source] Clinical trials for variceal bleeding: And the winner is,The patient,LIVER TRANSPLANTATION, Issue 9 2007Thomas D. Boyer [source] Transjugular intrahepatic portosystemic shunts: an updateLIVER TRANSPLANTATION, Issue 3 2003Barbara Rosado Transjugular intrahepatic portosystemic shunts (TIPS) have been used in the treatment of complications of portal hypertension. TIPS is used for the control of acute variceal bleeding and for the prevention of vericeal rebleeding when pharmacologic therapy and endoscopic therapy have failed. Patients with refractory ascites with adequate hepatic reserve and renal function who fail to respond to large volume paracentesis may be reasonable candidates for TIPS. Promising indications for TIPS are Budd-Chiari syndrome uncontrolled by medical therapy, severe portal hypertensive gastropathy, refractory hepatic hydrothorax, and hepatorenal syndrome. TIPS cannot be recommended for preoperative portal decompression solely to facilitate liver transplantation. Special care should be taken to insure proper placement of the stent to avoid increasing the technical difficulty of the transplantation procedure. The major limiting factors for TIPS success are shunt dysfunction and hepatic encephalopathy. Because shunt stenosis is the most important cause of recurrent complications of portal hypertension, a surveillance program to monitor shunt patency is mandatory. The MELD score may be useful in predicting post-TIPS survival, and also in counseling patients and their families. [source] Clinical improvement in patients with decompensated liver disease caused by hepatitis B after treatment with lamivudineLIVER TRANSPLANTATION, Issue 6 2000Craig A. Sponseller Lamivudine is effective in inhibiting hepatitis B virus (HBV) replication, and its clinical use in patients with chronic hepatitis B is associated with improvements in serum aminotransferase levels and liver histopathologic characteristics. Few data are available on its use in patients with advanced liver disease. We report on the outcomes of 5 patients with hepatic decompensation caused by chronic hepatitis B treated long term with lamivudine. All patients were adult white men seropositive for hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) before therapy. All 5 patients had biopsy-proven cirrhosis with clinical and biochemical evidence of hepatic decompensation. Two patients had Child's class C cirrhosis; 2 patients, class B; and 1 patient, class A (although this patient had persistent portasystemic encephalopathy and developed variceal bleeding). HBV DNA became undetectable in all patients and remained so throughout the study. Both patients with Child's class C and 1 patient with class B cirrhosis had significant clinical improvement. Child-Pugh scores improved from 12 to 7 and 11 to 7 in the 2 patients with Child's class C cirrhosis, and the patient with class B cirrhosis had complete resolution of troublesome encephalopathy. Serum aminotransferase, albumin, and total bilirubin levels improved significantly in 3 of 5 patients. One patient with Child's class B cirrhosis underwent orthotopic liver transplantation at week 13 after dramatic increases in liver tests and clinical worsening. The patient subsequently cleared HBeAg and HBsAg from serum posttransplantation. In conclusion, prolonged therapy with lamivudine resulted in improved serum biochemical values and loss of HBV DNA in patients with decompensated cirrhosis. Clinical improvements, reflected in Child-Pugh classification and functional status, may also occur, particularly among those with Child's class C disease initially. [source] Transjugular intrahepatic portosystemic shunt: an analysis of outcomesANZ JOURNAL OF SURGERY, Issue 10 2009Timothy P. Kurmis Abstract Background:, Transjugular intrahepatic portosystemic shunts (TIPS) are utilized for the management of complications of portal hypertension, particularly diuretic-resistant ascites and recurrent variceal bleeding. It has also been applied in Budd,Chiari syndrome and hepatorenal syndrome. We report the results in a small series, over 9 years, from a single centre, and compare these to those published in the literature. Methods:, A retrospective case note review of 20 consecutive TIPS procedures performed at Flinders Medical Centre from January 1997 to December 2005 was completed. All indications were included in the analysis. Underlying liver disease, peri-procedure complications, relief of symptoms and patient survival were recorded. Data on type of TIPS, shunt patency and method of follow-up were recorded. Results:, Thirty-six TIPS were performed in 20 subjects. All initial TIPS attempts were successful. Indications were: refractory ascites (18), acute variceal bleeding (12) and hepatorenal syndrome (2). There were no peri-procedure deaths, however. Ninety-day mortality was 20%. Outcomes in model of end-stage liver disease score and biochemical characteristics post-TIPS were comparable to those reported. Overall, TIPS dysfunction rate was 35% at 1 year. TIPS follow-up and patency surveillance was an ad hoc combination of Doppler ultrasound and venography. Conclusion:, TIPS procedure outcomes in our centre are similar to those reported in the literature from large centres. TIPS patency rates may be improved with regular monitoring and early intervention when stenosis occurs. [source] | |||||||||||||||||||||||||