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Gastroesophageal Variceal Hemorrhage

DR.RAJ KUMAR LOHANA FCPS(MEDICINE) ASSISTANT PROFESSORMUHAMMAD MEDICAL COLLEGE

MIRPURKHAS

introduction

3. Up to 30 percent of initial bleeding episodes are fatal, and as many as 70 percent of survivors have recurrent

bleeding after a first variceal hemorrhage

4.the one-year survival rate after variceal hemorrhage can be poor (32 to 80 percent).

introduction

5. Treatment

A: the prevention of the initial bleeding

episode (primary prophylaxis),

B.the control of active hemorrhage

C: the prevention of recurrent bleeding

after a first episode (secondary

prophylaxis).

pathogenesis

1. from increased intrahepatic resistance (at the presinusoidal, sinusoidal, and postsinusoidal locations) .

2. increased flow through a hyperdynamic

splanchnic system.3. an imbalance between the potent

vasoconstrictor endothelin-1 and the potent vasodilator nitric oxide.

pathogenesis

4.The distal 2 to 5 cm of the esophagus — the most common site of varices.

5.Dilatation of varices depends on the hepatic venous pressure gradient.

6. less than 12 mm Hg, varices do not form.

7. Varices do not invariably develop in pts with gradients of 12 mm Hg or more

prediction of variceal bleeding

1. bleeding only occurs in about one third of patients.2. A.Physical factors: Laplace's law (T=[TPxr]xw–1),elastity. B.Clinical factors :continued alcohol use and poor liver function C:Endoscopic predictors:large varices and endoscopic red signs (e.g., red wale markings) on the variceal wall.

prediction of variceal bleeding

D. Hemodynamic measurement:

the hepatic venous pressure gradient,

the intravariceal pressure, and the

Doppler ultrasonographic

measurement of portal pressure.

prevention of the initial bleeding

detection of large varices

1.Screening endoscopy

2.Notice clinical features, such as a low platelet count


2. pharmacologic therapy Goal : to reduce portal pressure and,

consequently, intravariceal pressure. Drugs that reduce the collateral portal venous

flow or intrahepatic vascular resistance have been used; these include beta-blockers, nitrates, a2-adrenergic blockers, spironolactone,

pentoxifylline, and molsidomine.


Beta-blockers : Propranolol and nadolol, nonselective beta-

blockers

@blockade of B1-adrenergic receptors causes splanchnic vasoconstriction by means of reflex

activation of a-adrenergic receptors

@ blockade of B2-adrenergic receptors results in splanchnic and peripheral vasoconstriction by eliminating B2-receptor–mediated vasodilation


Beta-blockers:

@In the absence of a determination of the hepatic venous pressure gradient, the dose of beta-blockers is titrated on the basis of clinical measurements to achieve

a resting heart rate of 55 beats per minute or a reduction of 25 percent from the base-line rate.


Beta-blockers: @meta-analyses have revealed a 40 to 50

percent reduction in the risk of bleeding and a trend toward improved survival.

@an analysis comparing propranolol with sclerotherapy and shunt surgery found propranolol to be the only cost effective

form of primary prophylaxis.


Isosorbide mononitrate

@nitrates cannot currently be recommended as monotherapy (even for those with an intolerance of beta-blockers), because of

their potential to accentuate the vasodilative hemodynamics typical of cirrhosis


Isosorbide mononitrate

@The addition of isosorbide mononitrate to propranolol results in an enhanced reduction in portal pressure

@ pts of Child A or B, isosorbide mononitrate (20 mg twice daily) plus nadolol resulted in a reduction in the incidence of variceal bleeding that was more than 50 percent greater than the reduction achieved with nadolol monotherapy


3. Endoscopic therapies

@Endoscopic sclerotherapy

@Endoscopic variceal band ligation

@ ligation is an acceptable option for patients at high risk of variceal bleeding who have an intolerance of or contraindications to medical therapy

management of variceal bleeding

Although variceal bleeding is common in cirrhosis pts who , other causes of bleeding, like peptic ulcer.

Empirical pharmacologic therapy esophagogastroduodenoscopy endotracheal intubation Systemic antibiotics (e.g., third-generation

cephalosporins)


pharmacologic therapies :

@A critical advantage of pharmacologic therapies for acute hemorrhage is that they can be administered early and do not require special

technical expertise

@Pharmacologic therapy has thus evolved into an attractive first-line approach in patients with probable variceal hemorrhage.


Vasopressin1.↓splanchnic blood flow , portal pressure.2. short half-life, vasopressin must be given by continuous intravenous

infusion.3. cause systemic vasoconstriction and severe vascular complications such as myocardial and mesenteric ischemia and infarction4. The addition of nitroglycerine to vasopressin results in improved therapeutic efficacy and a reduction in the vascular side effects.


Terlipressin 1.a synthetic vasopressin analogue with fewer side

effects and a longer half-life than vasopressin and thus can be used in bolus form.

2.This advantage has led to its successful use for suspected variceal bleeding.

3. because terlipressin appears to be at least as effective as vasopressin, somatostatin, or endoscopic therapy, it is currently not available in the United States.


Somatostatin:

1. a naturally occurring peptide, and its synthetic analogues, octreotide and vapreotide, stop variceal hemorrhage in up to 80 percent of patients and are generally considered to be equivalent to vasopressin, terlipressin, and endoscopic therapy for the control of acute variceal bleeding.


Somatostatin:

2. The mechanism:unclear @ possible mechanism

A. preventing postprandial hyperemia (blood in the gut stimulates splanchnic blood flow)

B. reducing portal pressure through effects on vasoactive peptides (i.e., substance P or glucagon).


Somatostatin:

3. given intravenously, few side effects (mild

hyperglycemia and abdominal cramping).

4. Because of their excellent safety profile and the absence of systemic circulatory effects, they can be used without special monitoring.


Somatostatin:

5. new approach:the use of pharmacologic agents such as octreotide in combination with endoscopic therapy.

6.Addition of octreotide to endoscopic therapy

orfor a period of five days resulted in improved control bleeding and reduced transfusion ,particularly within the first 24 to 48 hours.


Endoscopic therapy

1.Randomized trials :endoscopic variceal

band ligation equivalent to sclerotherapy

in initial hemostasis.

2.Sclerotherapy:easy superficial ulcerations ,

the formation of strictures.

3.band ligation: visualization of the (bloody)

endoscopic field difficult.


Endoscopic therapy

4. gastric varices are located deeper in the submucosa than esophageal varices, sclerotherapy and ligation are usually ineffective in controlling acute bleeding from gastric varices

5. N-butyl-2-cyanoacrylate (tissue glue) has been shown to be effective for bleeding gastric varices, but no data are available from a randomized trial. In addition,


Balloon tamponade

1..Only experienced physicians should use..

2. achieves hemostasis in the majority of cases.

3. recurrent bleeding after the decompression of the balloon is common

4.thus, tamponade should be used as a rescue procedure and a bridge to more definitive therapy in cases of uncontrolled hemorrhage.


transjugular itrahepatic portosystemic shunt:

1.lower morbidity and mortality than surgical shunts.

2.major advantage:for 5~10% of pts with refractory bleeding, including those with gastric variceal bleeding.


Surgical Therapy 1.those can”t be controlled by other means . 2.Surgical options include portosystemic shunting

or esophageal staple transection with or without esophagogastric devascularization.

3.morbidity is high in pts with advanced liver disease, and the 30-day mortality associated with emergency surgery approaches 80 % in such pts.

prevention of recurrent bleeding

Pharmacologic Therapy

1. Reducing the portal pressure by more than 20 percent from the base-line value pharmacologically results in a reduction in the cumulative probability of recurrent bleeding from 28 percent at one year, 39 percent at two years, and 66 percent at three years to 4 percent, 9 percent, and 9 percent, respectively.



2. Several randomized, placebo-controlled

trials, have demonstrated that nonselective

beta-blockers decrease the risk of recurrent bleeding and prolong survival.

3.A consideration regarding beta-blockers,

however, is their side effects, which limit their usefulness in pts with cirrhosis.



5. nadolol plus isosorbide mononitrate was found to be superior to sclerotherapy and endoscopic variceal band ligation

for the prevention of recurrent bleeding.



4. 『 isosorbide mononitrate ＋ beta-blockers 』 low down recurrent bleeding than beta-blockers alone but offers no

survival advantage and reduces the tolerability of therapy.


Endoscopic therapy

1.Sclerotherapy reduces the risk of recurrent

bleeding from 60% to 30 % at one year,but

it no reduce overall mortality.

2. Ligation has a lower risk of recurrent

bleeding than is sclerotherapy (25 vs. 30

% at one year), fewer complications.


Endoscopic therapy

3. 『 sclerotherapy ＋ B-blockers 』 led to lower

recurrent bleeding than B-blockers alone .

4. 『 ligation ＋ nadolol 』 ignificantly more effective

than ligation alone in preventing recurrences.

5. Although 『 sclerotherapy ＋ ligation 』 theoretically offer great protection of recurrent

bleeding, this combination isn’t advantageous.


Transjugular Intrahepatic Portosystemic Shunt

1.It is better than endoscopic therapy for the prevention of recurrent variceal bleeding.

2.The risk of recurrence after transjugular

shunting is 8 ~18 percent at one year.

3. however, is an increased incidence of clinically

significant hepatic encephalopathy


Transjugular Intrahepatic Portosystemic Shunt

4. Stenosis and dysfunction of the shunt an important complication;

5. Doppler ultrasonographic examination is routinely performed.

6. Balloon dilation or replacement of the occluded stent is often required.7. best used as a bridge to transplantation.


Surgical Therapy 1. Commonly used shunts include the distal

splenorenal shunt and the low-diameter (mesocaval or portacaval) interposition shunt.

2. Rates of recurrent bleeding range from 10 to 20 %.

3. Devascularization procedures considered in patients who cant receive shunts because of splanchnic venous thrombosis.


Surgical therapy

3. are preferred for pts who are noncompliant with medical or endoscopic therapy and for those who are not candidates for liver transplantation.

4. Although nonselective shunts are effective in eradicating varices and preventing recurrent

bleeding, they are associated with important operative and postoperative complications.

Conclusion

1.Although the role of endoscopic variceal band

ligation in primary prophylaxis is not established, treatment with beta-blockers is well accepted

2.The treatment of acute variceal hemorrhage is aimed at volume restoration and ensuring

hemostasis with pharmacologic agents, endoscopic techniques (ligation or sclerotherapy), or both.

Conclusion

3.Because there is a high risk of recurrence after an initial hemorrhage, preventive strategies are required.

4.As with the treatment of acute hemorrhage, treatment with a combination of methods is likely to gain in popularity.

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