Endoscopy 2003; 35(2): 136-144
DOI: 10.1055/s-2003-37020
State of the Art Review
Series
© Georg Thieme Verlag Stuttgart · New York

Variceal Bleeding and Portal Hypertension: Has There Been Any Progress in the Last 12 Months?

S.  Seewald1 , G.  Mendoza1 , U.  Seitz1 , O.  Salem1 , N.  Soehendra1
  • 1Dept. of Interdisciplinary Endoscopy, Hamburg-Eppendorf Hospital, University of Hamburg, Hamburg, Germany
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
30. Januar 2003 (online)

A review of the literature on the management of esophagogastric varices published in the last 12 months shows that the data are still quite conflicting. In the primary and secondary prophylaxis of variceal bleeding, β-blockers are still the mainstay of pharmacotherapy. Measurement of the hepatic portal venous pressure gradient is considered to be a reliable parameter for successful reduction of portal pressure using medical therapy. However, intolerance of propranolol requiring discontinuation of therapy has been observed in approximately 30 % of patients. Patients’ compliance with medication may represent another drawback of medical therapy.
The role of endoscopic band ligation in secondary prophylaxis is now indisputable, especially in comparison with sclerotherapy. In the primary prevention of variceal bleeding, band ligation is beginning to have a competitive edge over pharmacological therapy.
Acute variceal bleeding is no longer a frequent morbid emergency. Most cases of bleeding can now be managed successfully with band ligation and N-butyl-2-cyanoacrylate obliteration. N-butyl-2-cyanoacrylate has come into increasingly widespread use in the treatment of bleeding gastric fundal varices in which surgery or transjugular intrahepatic portosystemic shunting were previously regarded as the preferred therapies.

References

  • 1 Ichikawa S, Okamura S, Tujigami K. et al . Quantitative analysis of red color sign in the endoscopic evaluation of esophageal varices.  Endoscopy. 2001;  33 747-753
  • 2 Miller E S, Kim J K, Gandehok J. et al . A new device for measuring esophageal variceal pressure.  Gastrointest Endosc. 2002;  56 284-291
  • 3 Lin H C, Yang Y Y, Hou M C. et al . Hemodynamic effects of a combination of octreotide and terlipressin in patients with viral hepatitis related cirrhosis.  Scand J Gastroenterol. 2002;  37 482-487
  • 4 Cales P, Masliah C, Bernard B. et al . Early administration of vapreotide for variceal bleeding in patients with cirrhosis. French Club for the Study of Portal Hypertension.  N Engl J Med. 2001;  344 23-28
  • 5 Gross M, Schiemann U, Muhlhofer A, Zoller W G. Meta-analysis: efficacy of therapeutic regimens in ongoing variceal bleeding.  Endoscopy. 2001;  33 737-746
  • 6 Lee M S, Cho J Y, Cheon Y K. et al . Use of detachable snares and elastic bands for endoscopic control of bleeding from large gastric varices.  Gastrointest Endosc. 2002;  56 83-88
  • 7 Kitamoto M, Imamura M, Kamada K. et al . Balloon-occluded retrograde transvenous obliteration of gastric fundal varices with hemorrhage.  Am J Roentgenol. 2002;  178 1167-1174
  • 8 Akahoshi T, Hashizume M, Shimabukuro R. et al . Long-term results of endoscopic Histoacryl injection sclerotherapy for gastric variceal bleeding: a 10-year experience.  Surgery. 2002;  131 S176-181
  • 9 Dhiman R K, Chawla Y, Taneja S. et al . Endoscopic sclerotherapy of gastric variceal bleeding with N-butyl-2-cyanoacrylate.  J Clin Gastroenterol. 2002;  35 222-227
  • 10 Sarin S K, Jain A K, Jain M, Gupta R. A randomized controlled trial of cyanoacrylate versus alcohol injection in patients with isolated fundic varices.  Am J Gastroenterol. 2002;  97 1010-1015
  • 11 Nguyen A J, Baron T H, Burgart L J. et al . 2-Octyl-cyanoacrylate (Dermabond), a new glue for variceal injection therapy: results of a preliminary animal study.  Gastrointest Endosc. 2002;  55 572-575
  • 12 Heneghan M A, Byrne A, Harrison P M. An open pilot study of the effects of a human fibrin glue for endoscopic treatment of patients with acute bleeding from gastric varices.  Gastrointest Endosc. 2002;  56 422-426
  • 13 Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding: a meta-analysis.  Ann Intern Med. 1995;  123 280-287
  • 14 de la Pena 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
  • 15 Lopes C V, Pereira-Lima J C, Marroni C A. Efficacy of endoscopic variceal band ligation according to Child-Pugh grade [abstract].  Gastrointest Endosc. 2001;  53 AB158
  • 16 Orozco H, Mercado M A, Chan C. et al . A comparative study of the elective treatment of variceal hemorrhage with beta-blockers, transendoscopic sclerotherapy, and surgery: a prospective, controlled, and randomized trial during 10 years.  Ann Surg. 2000;  232 216-219
  • 17 Villanueva C, Minana J, Ortiz J. et al . Endoscopic ligation compared with combined treatment with nadolol and isosorbide mononitrate to prevent recurrent variceal bleeding.  N Engl J Med. 2001;  345 647-655
  • 18 Patch D, Sabin C A, Goulis J. et al . A randomized, controlled trial of medical therapy versus endoscopic ligation for the prevention of variceal rebleeding in patients with cirrhosis.  Gastroenterology. 2002;  123 1013-1019
  • 19 Lo G H, Chen W C, Chen M H. et al . Banding ligation versus nadolol and isosorbide mononitrate for the prevention of esophageal variceal rebleeding.  Gastroenterology. 2002;  123 728-734
  • 20 Chen W C, Hou M C, Lin H C. et al . Feasibility and potential benefit of maintenance endoscopic variceal ligation in patients with unresectable hepatocellular carcinoma and acute esophageal variceal hemorrhage: a controlled trial.  Gastrointest Endosc. 2001;  54 18-23
  • 21 Singh P, Pooran N, Indaram A, Bank S. Combined ligation and sclerotherapy versus ligation alone for secondary prophylaxis of esophageal variceal bleeding: a meta-analysis.  Am J Gastroenterol. 2002;  97 623-629
  • 22 Baroncini D, Milandri G L, Borioni D. et al . A prospective randomized trial of sclerotherapy versus ligation in the elective treatment of bleeding esophageal varices.  Endoscopy. 1997;  29 235-240
  • 23 Takase Y, Shibuya S, Chikamori F. et al . Recurrence factors studied by percutaneous transhepatic portography before and after endoscopic sclerotherapy for esophageal varices.  Hepatology. 1990;  11 348-352
  • 24 Al T raif, Fachartz F S, Al J umah. et al . Randomized trial of ligation versus combined ligation and sclerotherapy for bleeding esophageal varices.  Gastrointest Endosc. 1999;  50 1-6
  • 25 Lo G H, Lai K H, Cheng J S. et al . The additive effect of sclerotherapy to patients receiving repeated endoscopic variceal ligation: a prospective, randomized trial.  Hepatology. 1998;  28 391-395
  • 26 Polski J M, Brunt E M, Saeed Z A. Chronology of histological changes after band ligation of esophageal varices in humans.  Endoscopy. 2001;  33 443-447
  • 27 Nakamura S, Mitsunaga A, Murata Y. et al . Endoscopic induction of mucosal fibrosis by argon plasma coagulation (APC) for esophageal varices: a prospective randomized trial of ligation plus APC vs. ligation alone.  Endoscopy. 2001;  33 210-215
  • 28 Hino S, Kakutani H, Ikeda K. et al . , et al. Low power diode laser treatment using indocyanine green for eradication of esophageal varices.  Endoscopy. 2001;  33 873-875
  • 29 Lebrec D, Hillon P, Munoz C. et al . The effect of propranolol on portal hypertension in patients with cirrhosis: a hemodynamic study.  Hepatology. 1982;  2 523-527
  • 30 Abraczinskas D R, Ookubo R, Grace N D. et al . Propranolol for the prevention of first esophageal variceal hemorrhage: a lifetime commitment?.  Hepatology. 2001;  34 1096-1102
  • 31 González-Abraldes J, Albillos A, Banares R. et al . Randomized comparison of long-term losartan versus propranolol in lowering portal pressure in cirrhosis.  Gastroenterology. 2001;  121 382-388
  • 32 Schepke M, Werner E, Biecker E. et al . Hemodynamic effects of the angiotensin II receptor antagonist irbesartan in patients with cirrhosis and portal hypertension.  Gastroenterology. 2001;  121 389-395
  • 33 Lui H F, Stanley A J, Forrest E H. et al . Primary prophylaxis of variceal hemorrhage: a randomized controlled trial comparing band ligation, propranolol, and isosorbide mononitrate.  Gastroenterology. 2002;  123 735-744
  • 34 Irisawa A, Shibukawa G, Obara K. et al . Collateral vessels around the esophageal wall in patients with portal hypertension: comparison of EUS imaging and microscopic findings at autopsy.  Gastrointest Endosc. 2002;  56 249-253
  • 35 Konishi Y, Nakamura T, Kida H. et al . Catheter US probe EUS evaluation of gastric cardia and perigastric vascular structures to predict esophageal variceal recurrence.  Gastrointest Endosc. 2002;  55 197-203
  • 36 Hino S, Kakutani H, Ikeda K. et al . Hemodynamic analysis of esophageal varices using color Doppler endoscopic ultrasonography to predict recurrence after endoscopic treatment.  Endoscopy. 2001;  33 869-872
  • 37 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
  • 38 Luca A, D’Amico G, La G alla. et al . TIPS for prevention of recurrent bleeding in patients with cirrhosis: meta-analysis of randomized clinical trials.  Radiology. 1999;  212 411-421
  • 39 Pomier-Layrargues G, Villeneuve J P, Deschenes M. et al . Transjugular intrahepatic portosystemic shunt (TIPS) versus endoscopic variceal ligation in the prevention of variceal rebleeding in patients with cirrhosis: a randomised trial.  Gut. 2001;  48 390-396
  • 40 Sauer P, Hansmann J, Richter G M. et al . Endoscopic variceal ligation plus propranolol vs. transjugular intrahepatic portosystemic stent shunt: a long-term randomized trial.  Endoscopy. 2002;  34 690-697
  • 41 Gülberg V, Schepke M, Geigenberger G. et al . Transjugular intrahepatic portosystemic shunting is not superior to endoscopic variceal band ligation for prevention of variceal rebleeding in cirrhotic patients: a randomized, controlled trial.  Scand J Gastroenterol. 2002;  37 338-343
  • 42 Escorsell A, Banares R, Garcia-Pagan J C. et al . TIPS versus drug therapy in preventing variceal rebleeding in advanced cirrhosis: a randomized controlled trial.  Hepatology. 2002;  35 385-392
  • 43 Jalan R, Bzeizi K I, Tripathi D. et al . Impact of transjugular intrahepatic portosystemic stent-shunt for secondary prophylaxis of oesophageal variceal haemorrhage: a single-centre study over an 11-year period.  Eur J Gastroenterol Hepatol. 2002;  14 615-626
  • 44 Burroughs A K, Vangeli M. Transjugular intrahepatic portosystemic shunt versus endoscopic therapy: randomized trials for secondary prophylaxis of variceal bleeding: an updated meta-analysis.  Scand J Gastroenterol. 2002;  37 249-252
  • 45 Azoulay D, Castaing D, Majno P. et al . Salvage transjugular intrahepatic portosystemic shunt for uncontrolled variceal bleeding in patients with decompensated cirrhosis.  J Hepatol. 2001;  35 590-597
  • 46 Rössle M, Siegerstetter V, Olschewski M. et al . How much reduction in portal pressure is necessary to prevent variceal rebleeding? A longitudinal study in 225 patients with transjugular intrahepatic portosystemic shunts.  Am J Gastroenterol. 2001;  96 3379-3383
  • 47 Illuminati G, Smail A, Azoulay D. et al . Association of transjugular intrahepatic portosystemic shunt with embolization in the treatment of bleeding duodenal varix refractory to sclerotherapy.  Dig Surg. 2000;  17 398-400
  • 48 Chaves D M, Sakai P, Mucenic M. et al . Comparative study of portal hypertensive gastropathy in schistosomiasis and hepatic cirrhosis.  Endoscopy. 2002;  34 199-202
  • 49 Yeh J L, Peng Y C, Tung C F. et al . Clinical predictors of large esophagogastric varices in patients with hepatocellular carcinoma.  Dig Dis Sci. 2002;  47 723-729
  • 50 Okada K, Koda M, Murawaki Y, Kawasaki H. Changes in esophageal variceal pressure after transcatheter arterial embolization for hepatocellular carcinoma.  Endoscopy. 2001;  33 595-600
  • 51 Shudo R, Yazaki Y, Sakurai S. et al . Clinical study comparing bleeding and nonbleeding rectal varices.  Endoscopy. 2002;  34 189-194

S. Seewald, M.D.

Dept. of Interdisciplinary Endoscopy · Hamburg-Eppendorf Hospital ·

University of Hamburg · Martinistrasse 52 · 20246 Hamburg · Germany

Fax: + 49-40-42803-4420 ·

eMail: seewald@uke.uni-hamburg.de