Endoscopy 2001; 33(2): 126-139
DOI: 10.1055/s-2001-11666
Review

Georg Thieme Verlag Stuttgart · New York

Variceal Bleeding and Portal Hypertension: Still a Therapeutic Challenge?

S. Seewald, U. Seitz, A. M. Yang, N. Soehendra
  • Dept. of Interdisciplinary Endoscopy, University Hospital, Eppendorf, Hamburg, Germany
Further Information

Publication History

Publication Date:
31 December 2001 (online)

In the primary prevention of variceal hemorrhage, beta-blockers continue to be the first-line treatment. Newer nonselective beta-blockers with anti-alpha1-adrenergic activity, such as carvedilol, appear to have a better impact on reducing the hepatic venous pressure gradient than propranolol. The addition of isosorbide mononitrate appears to improve the effectiveness of beta-blockers in primary prophylaxis, but not that of somatostatin in the treatment of acute variceal hemorrhage. The use of vasoactive drugs alone in acute variceal bleeding has not proved to be more effective than endoscopic treatment. The advent of endoscopic variceal ligation (EVL) has strengthened the role of endoscopy in the management of bleeding esophageal varices. EVL has improved the results, particularly in terms of lowering the treatment-related morbidity, compared with endoscopic variceal sclerotherapy (EVS). However, the variceal recurrence rate after initial eradication with EVL is relatively high. In contrast to synchronous combined therapy with EVL plus EVS, metachronous combination of EVL and low-dose EVS may improve the results of EVL alone. For bleeding fundic varices, obliteration using cyanoacrylate is currently the treatment of choice. Endosonography (EUS) is coming into more widespread use in the assessment of variceal eradication and in further attempts to improve the results of endoscopic injection therapy. According to two meta-analysis studies, transjugular intrahepatic portosystemic shunt (TIPS) is not yet capable of replacing endoscopic treatment in the secondary prevention of variceal bleeding.

References

  • 1 Cioni G, Turrini F, Tincani E, et al. Prevention of a first episode of variceal bleeding: role of duplex Doppler sonographic measurement of the acute response to beta-blockers.  J Ultrasound Med. 1999;  18 633-638
  • 2 Escorsell A, Bordas J M, Castaneda B, et al. Predictive value of the variceal pressure response to continued pharmacological therapy in patients with cirrhosis and portal hypertension.  Hepatology. 2000;  31 1061-1067
  • 3 Moitinho E, Escorsell A, Bandi J C, et al. Prognostic value of early measurements of portal pressure in acute variceal bleeding.  Gastroenterology. 1999;  117 626-631
  • 4 Banares R, Moitinho E, Piqueras B, et al. Carvedilol, a new nonselective beta-blocker with intrinsic anti-alpha1-adrenergic activity, has a greater portal hypotensive effect than propranolol in patients with cirrhosis.  Hepatology. 1999;  30 79-83
  • 5 Merkel C, Marin R, Sacerdoti D, et al. Long-term results of a clinical trial of nadolol with or without isosorbide mononitrate for primary prophylaxis of variceal bleeding in cirrhosis.  Hepatology. 2000;  31 324-329
  • 6 Villanueva C, Ortiz J, Sabat M, et al. Somatostatin alone or combined with emergency sclerotherapy in the treatment of acute esophageal variceal bleeding: a prospective randomized trial.  Hepatology. 1999;  30 384-389
  • 7 Zuberi B F, Baloch Q. Comparison of endoscopic variceal sclerotherapy alone and in combination with octreotide in controlling acute variceal hemorrhage and early rebleeding in patients with low-risk cirrhosis.  Am J Gastroenterol. 2000;  95 768-771
  • 8 Escorsell A, Bordas J M, del Arbol L R, et al. Randomized controlled trial of sclerotherapy versus somatostatin infusion in the prevention of early rebleeding following acute variceal hemorrhage in patients with cirrhosis. Variceal Bleeding Study Group.  J Hepatol. 1998;  29 779-788
  • 9 Sivri B, Oksuzoglu G, Bayraktar Y, Kayhan B. A prospective randomized trial from Turkey comparing octreotide versus injection sclerotherapy in acute variceal bleeding.  Hepatogastroenterology. 2000;  47 168-173
  • 10 Bildozola M, Kravetz D, Argonz J, et al. Efficacy of octreotide and sclerotherapy in the treatment of acute variceal bleeding in cirrhotic patients: a prospective, multicentric, and randomized clinical trial.  Scand J Gastroenterol. 2000;  35 419-425
  • 11 Junquera F, Lopez-Talevera J C, Mearin F, et al. Somatostatin plus isosorbide 5-mononitrate versus somatostatin in the control of acute gastro-oesophageal variceal bleeding: a double blind, randomised, placebo controlled clinical trial.  Gut. 2000;  46 127-132
  • 12 Gournay J, Masliah C, Martin T, et al. Isosorbide mononitrate and propranolol compared with propranolol alone for the prevention of variceal rebleeding.  Hepatology. 2000;  31 1239-1245
  • 13 Iwakiri R, Koyama T, Hirano M, et al. Endoscopic injection sclerotherapy for esophageal varices prolonged survival of patients with hepatocellular complicating liver cirrhosis.  Gastrointest Endosc. 2000;  51 569-572
  • 14 Matsumoto H, Suzuki F, Souda K, et al. Improved long-term survival following complete eradication of esophageal varices by sclerotherapy.  Hepatogastroenterology. 1999;  46 172-176
  • 15 Meirelles-Santos J O, Carvalho A F, Callejas-Neto F, et al. Absolute ethanol and 5 % ethanolamine oleate are comparable for sclerotherapy of esophageal varices.  Gastrointest Endosc. 2000;  51 573-576
  • 16 Nishida R, Inoue R, Takimoto Y, Kita T. A sclerosant with astringent properties developed in China for oesophageal varices: comparison with ethanolamine oleate and polidocanol.  J Gastroenterol Hepatol. 1999;  14 481-488
  • 17 Goncalves M EP, Cardosa S R, Maksoud J G. Prophylactic sclerotherapy in children with esophageal varices: long-term results of a controlled prospective randomized trial.  J Pediatr Surg. 2000;  35 401-405
  • 18 Hepworth C C, Burnham W R, Swain C P. Development and application of Endoloops for the treatment of bleeding esophageal varices.  Gastrointest Endosc. 1999;  50 677-684
  • 19 Shim C S, Cho J Y, Park Y J, et al. Mini-detachable snare ligation for the treatment of esophageal varices.  Gastrointest Endosc. 1999;  50 673-676
  • 20 Ell C, May A, Wurster H. The first reusable multiple-band ligator for endoscopic hemostasis of variceal bleeding, nonvariceal bleeding and mucosal resection.  Endoscopy. 1999;  31 738-740
  • 21 Lo G H, Lai K H, Cheng J S, et al. Endoscopic variceal ligation plus nadolol and sucralfate compared with ligation alone for the prevention of variceal rebleeding: a prospective, randomized trial.  Hepatology. 2000;  32 461-465
  • 22 Hou M C, Lin H C, Kuo B IT, et al. The rebleeding course and long-term outcome of esophageal variceal hemorrhage after ligation: comparison with sclerotherapy.  Scand J Gastroenterol. 1999;  34 1071-1076
  • 23 Masci E, Stigliano R, Mariani A, et al. Prospective multicenter randomized trial comparing banding ligation with sclerotherapy of esophageal varices.  Hepatogastroenterology. 1999;  46 1769-1773
  • 24 De la Peña J, Rivero M, Sanchez E, et al. Variceal ligation compared with endoscopic sclerotherapy for variceal hemorrhage: prospective randomized trial.  Gastrointest Endosc. 1999;  49 417-423
  • 25 Djurdjevic D, Janosevic S, Dapcevic B, et al. Combined ligation and sclerotherapy versus ligation alone for eradication and bleeding esophageal varices: a randomized and prospective trial.  Endoscopy. 1999;  31 286-290
  • 26 Al Traif I, Fachartz F S, Jumah A A, et al. Randomized trial of ligation versus combined ligation and sclerotherapy for bleeding esophageal varices.  Gastrointest Endosc. 1999;  5 1-6
  • 27 Argonz J, Kravetz D, Suarez A, et al. Variceal band ligation and variceal band ligation plus sclerotherapy in the prevention of recurrent variceal bleeding in cirrhotic patients: a randomized, prospective and controlled trial.  Gastrointest Endosc. 2000;  51 157-163
  • 28 Umehara M, Onda M, Tajiri T, et al. Sclerotherapy plus ligation versus ligation for the treatment of esophageal varices: a prospective randomized study.  Gastrointest Endosc. 1999;  50 7-12
  • 29 Dhiman R K, Chawla Y K. Is the technique of endoscopic sclerotherapy and ligation (ESL) optimum?.  Gastrointest Endosc. 2000;  51 639-640
  • 30 Sarin S, Guptan R K, Jain A K, Sundaram K R. A randomized controlled trial of endoscopic variceal band ligation for primary prophylaxis of variceal bleeding.  Eur J Gastroenterol Hepatol. 1996;  8 337-342
  • 31 Lo G H, Lai K H, Cheng J S, et al. Prophylactic banding ligation of high-risk esophageal varices in patients with cirrhosis: a prospective, randomized trial.  J Hepatol. 1999;  31 451-456
  • 32 Lay C S, Tsai Y T, Teg C Y, et al. Endoscopic variceal ligation in prophylaxis of first variceal bleeding in cirrhotic patients with high-risk esophageal varices.  Hepatology. 1997;  25 1346-1350
  • 33 Sarin S K, Lamba G S, Kumar M, et al. Comparison of endoscopic ligation and propanolol for the primary prevention of variceal bleeding.  N Engl J Med. 1999;  340 988-993
  • 34 Masumoto H, Toyonaga A, Oho K, et al. Ligation plus low-volume sclerotherapy for high-risk esophageal varices: comparisons with ligation therapy or sclerotherapy alone.  J Gastroenterol. 1998;  33 1-5
  • 35 Matsumoto A, Hamamoto N, Ohnishi A, et al. Left gastric vein hemodynamics and variceal recurrence in patients undergoing prophylactic endoscopic ligation of high-risk esophageal varices.  Gastrointest Endosc. 1999;  50 768-774
  • 36 Yoshida T, Harada T, Shigemitsu T, et al. Endoscopic management of gastric varices using a detachable snare and simultaneous endoscopic sclerotherapy and O-ring ligation.  J Gastroenterol Hepatol. 1999;  14 730-735
  • 37 Kind R, Guglielmi A, Rodella L, et al. Bucrylate treatment of bleeding gastric varices: 12 years' experience.  Endoscopy. 2000;  32 512-519
  • 38 Huang Y H, Yeh H ZY, Chen G H, et al. Endoscopic treatment of bleeding gastric varices by N-butyl- 2-cyanoacrylate (Histoacryl) injection: long-term efficacy and safety.  Gastrointest Endosc. 2000;  52 160-167
  • 39 Lee Y T, Chan F KL, Ng E KW, et al. EUS-guided injection of cyanoacrylate for bleeding gastric varices.  Gastrointest Endosc. 2000;  52 168-174
  • 40 Battaglia G, Morbin T, Paternello E, et al. Diagnostic et traitement endoscopique des varices gastriques.  Acta Endosc. 1999;  29 116-117
  • 41 Battaglia G, Morbin T, Paternello E, et al. Visceral fistula as a complication of endoscopic treatment of esophageal and gastric varices using isobutyl-2-cyanoacrylate: report of two cases.  Gastrointest Endosc. 2000;  52 267-270
  • 42 Bhasin D K, Sharma B C, Prasad H, Singh K. Endoscopic removal of sclerotherapy needle from gastric varix after N -butyl-2-cyanoacrylate injection.  Gastrointest Endosc. 2000;  51 497-498
  • 43 Kulling D, Vournakis J N, Woo S, et al. Endoscopic injection of bleeding esophageal varices with a poly-N -acetyl glucosamine gel formulation in the canine portal hypertension model.  Gastrointest Endosc. 1999;  49 764-771
  • 44 Irisawa A, Obara K, Sato Y, et al. EUS analysis of collateral veins inside and outside the esophageal wall in portal hypertension.  Gastrointest Endosc. 1999;  5 374-380
  • 45 Koutsomanis D, Papakonstantinou V. Fractal-assisted EUS image-analysis in the evaluation of variceal eradication after elastic band ligation.  Hepatogastroenterology. 1999;  46 3142-3147
  • 46 Schiano T D, Adrain A L, Vega K J, et al. High-resolution endoluminal sonography assessment of the hematocystic spots of esophageal varices.  Gastrointest Endosc. 1999;  49 424-427
  • 47 Chung C Y, McCray W H, Dhaliwal S, et al. Three-dimensional esophageal varix model quantification of variceal volume by high-resolution endoluminal US.  Gastrointest Endosc. 2000;  52 87-90
  • 48 Lee Y T, Sung J J, Yung M Y, et al. Use of color Doppler EUS in assessing azygos blood flow for patients with portal hypertension.  Gastrointest Endosc. 1999;  50 47-52
  • 49 Lahoti S, Catalano M F, Alcocer E, et al. Obliteration of esophageal varices using EUS-guided sclerotherapy with color Doppler.  Gastrointest Endosc. 2000;  51 331-333
  • 50 Papatheodoridis G V, Goulis J, Leandro G, et al. Transjugular intrahepatic portosystemic shunt compared with endoscopic treatment for prevention of variceal rebleeding: a meta-analysis.  Hepatology. 1999;  30 612-622
  • 51 Luca A, D'Amico G, La Galla R, et al. TIPS for prevention of recurrent bleeding in patients with cirrhosis: meta-analysis of randomized clinical trials.  Radiology. 1999;  212 411-421
  • 52 Russo M W, Zacks S L, Sandler R S, Brown R S. Cost-effectiveness analysis of transjugular intrahepatic portosystemic shunt (TIPS) versus endoscopic therapy for the prevention of recurrent esophageal variceal bleeding.  Hepatology. 2000;  31 358-363
  • 53 Chalasani N, Clark W S, Martin L, et al. Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic shunting.  Gastroenterology. 2000;  118 138-144
  • 54 Barange K, Peron J M, Imani K, et al. Transjugular intrahepatic portosystemic shunt in the treatment of refractory bleeding from ruptured gastric varices.  Hepatology. 1999;  30 1139-1143
  • 55 Shibata D, Brophy D P, Gordon F D, et al. Transjugular intrahepatic portosystemic shunt for treatment of bleeding ectopic varices with portal hypertension.  Dis Colon Rectum. 1999;  42 1581-1585
  • 56 De Simone J A, Beavis K G, Eschelman D J, Henning K J. Sustained bacteremia associated with transjugular intrahepatic portosystemic shunt (TIPS).  Clin Infect Dis. 2000;  30 384-386
  • 57 Petit P, Lazar I, Chagnaud C, et al. Iatrogenic dissection of the portal vein during TIPS procedure.  Eur Radiol. 2000;  10 930-934
  • 58 Lotterer E, Wengert A, Fleig W. Transjugular intrahepatic portosystemic shunt: short-term and long-term effects on hepatic and systemic hemodynamics in patients with cirrhosis.  Hepatology. 1999;  29 632-639
  • 59 Chikamori F, Kuniyoshi N, Shibuya S, Takase Y. Urgent transjugular retrograde obliteration for prophylaxis of rebleeding from gastric varices in patients with a spontaneous portosplenorenal shunt.  Dig Surg. 2000;  17 23-28

N. Soehendra,M.D. 

Dept. of Interdisciplinary Endoscopy
University Hospital, Hamburg-Eppendorf

Martinistrasse 52
20246 Hamburg
Germany


Fax: Fax:+ 49-40-42-803-4420

Email: E-mail:soehendr@uke.uni-hamburg.de