Subscribe to RSS
DOI: 10.1055/s-2002-19845
© Georg Thieme Verlag Stuttgart · New York
Variceal Bleeding and Portal Hypertension: Much to Learn, Much to Explore
Publication History
Submitted
Accepted after Revision
Publication Date:
14 August 2002 (online)
![](https://www.thieme-connect.de/media/endoscopy/200202/lookinside/thumbnails/10.1055-s-2002-19845-1.jpg)
The newer diagnostic and therapeutic options continue to evolve and important developments have been made in the field of variceal bleeding and portal hypertension. A meeting was held at Baveno to update consensus on different terminologies in relation to portal hypertension. β-blockers continue to be the mainstay for primary prophylaxis of variceal bleeding, and endoscopic variceal ligation (EVL) is fast emerging as a strong contender. The role of vasoactive drugs in the management of variceal bleeding was assessed. Octreotide and terlipressin were shown to be as effective as sclerotherapy in achieving initial hemostasis, and octreotide was shown to be safe and efficacious in the prevention of rebleeding. EVL was superior to endoscopic sclerotherapy (EST) for obliteration of esophageal varices. Sequential and simultaneous ligation and sclerotherapy were more effective than ligation alone, in reducing the recurrence rate after variceal obliteration. For gastric varices, cyanoacrylate glue continues to be the first line of treatment, and band ligation is being assessed further. Bleeding ectopic varices were dealt by appropriate endoscopic means. Endosonography has developed strongly in the assessment of variceal eradication and prediction of variceal recurrence. Transjugular intrahepatic portosystemic shunting (TIPS) significantly reduces rebleeding rates compared to EVL.
References
- 1 de Franchis R. Updating consensus in portal hypertension: report of Baveno III consensus workshop on definitions, methodology and therapeutic strategies in portal hypertension. J Hepatol. 2000; 33 846-852
- 2 Schepis F, Camma C, Niceforo D. et al . Which patients with cirrhosis should undergo endoscopic screening for esophageal varices detection?. Hepatology. 2001; 33 333-338
- 3 Watanabe S, Hosomi N, Kitade Y. et al . Assessment of the presence and severity of esophagogastric varices by splenic index in patients with liver cirrhosis. J Comput Assist Tomogr. 2000; 24 788-794
- 4 Merkel C, Zoli M, Siringo S. et al . Prognostic indicators of risk for first variceal bleeding in cirrhosis: a multicentric study in 711 patients to validate and improve the North Italian Endoscopic Club (NIEC) Index. Am J Gastroenterol. 2000; 95 2915-2920
- 5 Murachima N, Ikeda K, Kobayashi M. et al . Incidence of appearance of the red color signs on esophageal varices and its predictive factors: long-term observation of 359 patients with cirrhosis. J Gastroenterol. 2001; 36 368-374
- 6 Imperiale T F, Chalasani N. A meta-analysis of endoscopic variceal ligation for primary prophylaxis of esophageal variceal bleeding. Hepatology. 2001; 33 802-807
- 7 Aoki N, Kajiyama T, Beck R. et al . Decision analysis of prophylactic treatment for patients with high risk esophageal varices. Gatrointest Endosc. 2000; 52 707-714
- 8 Imazu H, Matsui T, Noguchi R. et al . Magnetic resonance angiography for monitoring prophylactic endoscopic treatment of high risk esophageal varices. Endoscopy. 2000; 32 766-772
- 9 Merkel C, Bolognesi M, Sacerdoti D. et al . The hemodynamic response to medical treatment of portal hypertension as a predictor of clinical effectiveness in the primary prophylaxis of variceal bleeding in cirrhosis. Hepatology. 2000; 32 930-934
- 10 Yin X Y, Lu M D, Huang J F. et al . Color Doppler velocity profile assessment of portal hemodynamics in cirrhotic patients with portal hypertension: correlation with esophageal variceal bleeding. J Clin Ultrasound. 2001; 29 7-13
- 11 Schepke M, Raab P, Hoppe A. et al . Comparison of portal vein velocity and hepatic venous pressure gradient in assessing the acute portal hemodynamic response to propranolol in patients with cirrhosis. Am J Gastroenterol. 2000; 95 2905-2909
- 12 Corley D A, Cello J P, Adkisson W. et al . Octreotide for acute esophageal variceal bleeding: a meta-analysis. Gastroenterology. 2001; 120 946-954
- 13 Escorsell A, Bandi J C, Andreu V. et al . Densensitization to the effect of intravenous octreotide in cirrhotic patients with portal hypertension. Gastroenterology. 2001; 120 161-169
- 14 Villanueva C, Ortiz J, Minana J. et al . Somatostatin treatment and risk stratification by continuous portal pressure monitoring during acute variceal bleeding. Gastroenterology. 2001; 121 110-117
- 15 Cales P, Masliah C, Bernald B. et al . Early administration of vapreotide for variceal bleeding in patients with cirrhosis. N Engl J Med. 2001; 344 23-28
- 16 Escorsell A, Arbo R D, Planas R. et al . Multicentric randomized controlled trial of terlipressin versus sclerotherapy in the treatment of acute variceal bleeding: the TEST study. Hepatology. 2000; 32 471-476
- 17 Gonzales-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
- 18 Hou M C, Chen W C, Lin H C. et al . A new “sandwich” method of combined endoscopic variceal ligation and sclerotherapy versus ligation alone in the treatment of esophageal variceal bleeding: a randomized trial. Gastrointest Endosc. 2001; 53 572-578
- 19 Cheng Y S, Pan S, Lien G S. et al . Adjuvant sclerotherapy after ligation for the treatment of esophageal varices: a prospective, randomized long term study. Gastrointest Endosc. 2001; 53 566-571
- 20 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
- 21 Maluf-Filho F, Sakai P, Ishioka S, Matuguma S E. Endoscopic sclerosis versus cyanoacrylate endoscopic injection for the first episode of variceal bleeding: a prospective, controlled and randomized study in Child-Pugh class C patients. Endoscopy. 2001; 33 421-427
- 22 Madonia S, D'Amico G, Traina M. et al . Prognostic indicators of successful endoscopic sclerotherapy for prevention of rebleeding from esophageal varices in cirrhosis: a long-term cohort study. Dig Liver Dis. 2000; 32 782-791
- 23 Orozco H, Mercado M A, Chan C. et al . A comparative study of the elective treatment of variceal hemorrhage with β-blockers, transendoscopic sclerotherapy, and surgery. Ann Surg. 2000; 232 216-219
- 24 Kitano S, Baatar D, Bandoh T. et al . Transvenous sclerotherapy for huge esophagogastric varices using open injection sclerotherapy. Br J Surg. 2000; 87 926-930
- 25 Schmitz R J, Sharma P, Badr A S. et al . Incidence and management of esophageal stricture formation, ulcer bleeding, perforation and massive hematoma formation from sclerotherapy versus band ligation. Am J Gastroenterol. 2001; 96 437-441
- 26 Toyoda H, Fukuda Y, Katano Y. et al . Fatal bleeding from a residual vein at the esophageal ulcer base after successful endoscopic variceal ligation. J Clin Gastroenterol. 2001; 32 158-160
- 27 Iwase H, Maeda O, Shimada M. et al . Endoscopic ablation with cyanoacrylate glue for isolated gastric variceal bleeding. Gastrointest Endosc. 2001; 53 585-592
- 28 Lo G H, Lai K H, Cheng J S. et al . A prospective randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices. Hepatology. 2001; 33 1060-1064
- 29 Imazu H, Matsui T, Kobayasi Y. et al . Balloon-catheter assisted endoscopic sclerotherapy for gastric fundal varices using α-cyanoacrylate monomer. J Clin Gastroenterol. 2001; 33 49-52
- 30 Turler A, Wolff M, Dorlors D, Hirner A. Embolic and septic complications after sclerotherapy of fundal varices with cyanoacrylate. Gastrointest Endosc. 2001; 53 228-230
- 31 Irisawa A, Obara K, Sato Y. et al . Adherence of cyanoacrylate which leaked from gastric varices to the left renal vein during endoscopic injection sclerotherapy: a histopathologic study. Endoscopy. 2000; 32 804-806
- 32 Hwang S S, Kim H H, Park S H. et al . N-buty1-2-cyanoacrylate pulmonary embolism after endoscopic injection sclerotherapy for gastric variceal bleeding. J Comput Assist Tomogr. 2001; 25 16-22
- 33 Chen W C, Hou M C, Lin H C. et al . Bacteremia after endoscopic injection of N-butyl-2-cyanoacrylate for gastric variceal bleeding. Gastrointest Endosc. 2001; 54 214-218
- 34 Nagi B, Kochhar R, Bhasin D, Singh K. Cholangiopathy in extrahepatic portal venous obstruction: radiological appearances. Acta Radiol. 2000; 41 612-615
- 35 Gupta D, Chawla Y K, Dhiman R K. et al . Clinical significance of patent paraumbilical vein in patients with liver cirrhosis. Dig Dis Sci. 2000; 45 1861-1864
- 36 Getzlaff S, Benz C A, Schilling D, Riemann J F. Enteroscopic cyanoacrylate sclerotherapy of jejunal and gallbladder varices in patients with portal hypertension. Endoscopy. 2001; 33 462-464
- 37 Shudo R, Yazaki Y, Sakurai S. et al . Combined endoscopic variceal ligation and sclerotherapy for bleeding rectal varices associated with primary biliary cirrhosis: a case showing a long lasting favorable response. Gastrointest Endosc. 2001; 53 661-665
- 38 Faigel D O, Rosen H R, Sasaki A. et al . EUS in cirrhotic patients with and without prior variceal hemorrhage in comparison with noncirrhotic control subjects. Gastrointest Endosc. 2000; 52 455-462
- 39 Irisawa A, Saito A, Obara K. et al . Endoscopic recurrence of esophageal varices is associated with the specific EUS abnormalities: severe peri-esophageal collateral veins and large perforating veins. Gastrointest Endosc. 2001; 53 77-84
- 40 Suzuki T, Matsutani S, Umebara K. et al . EUS changes predictive for recurrence of esophageal varices in patients treated by combined endoscopic ligation and sclerotherapy. Gastrointest Endosc. 2000; 52 611-617
- 41 Kassem A M, Salama Z A, Zakaria M S. et al . Endoscopic ultrasonographic study of the azygous vein before and after obliteration of esophagogastric varices by injection sclerotherapy. Endoscopy. 2000; 32 630-639
- 42 Sarin S K, Shahi H M, Jain M. et al . Natural history of portal hypertensive gastropathy: influence of variceal eradication. Am J Gastroenterol. 2000; 95 2888-2893
- 43 Lo G H, Lai K H, Cheng J S. et al . The effects of endoscopic variceal ligation on portal hypertensive gastropathy: a prospective, controlled trial. Gastrointest Endosc. 2001; 53 579-584
- 44 Cales P, Oberti F, Delmotte J S. et al . Gastric mucosal surface in cirrhotics evaluated by magnifying endoscopy and scanning electronic microscopy. Endoscopy. 2000; 32 614-623
- 45 Bini E J, Lascarids C E, Micale P L, Weinshel E H. Mucosal abnormalities of the colon in patients with portal hypertension: an endoscopic study. Gastrointest Endosc. 2000; 52 511-516
- 46 Ghoshal U C, Biswas P K, Roy G. et al . Colonic mucosal changes in portal hypertension. Trop Gastroenterol. 2001; 22 25-27
- 47 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
- 48 Helton W S, Maves R, Wicks K, Johansen K. Transjugular intrahepatic portosystemic shunt vs. surgical shunt in good risk cirrhotic patients: a case-control comparison. Arch Surg. 2001; 136 17-20
- 49 Han S W, Joo Y E, Kim H S. et al . Clinical results of transjugular intrahepatic portosystemic shunt (TIPS) for the treatment of variceal bleeding. Korean J Intern Med. 2000; 15 179-186
- 50 Malki S, Allen R, Pavli P. Transjugular intrahepatic portosystemic shunt for intractable colonic bleeding in a patient with cirrhosis. J Gastroenterol Hepatol. 2000; 15 815-818
D. K. Bhasin, M.D., D.M.
Department of Gastroenterology · Postgraduate Institute of Medical Education and Research
#1041, Sector 24-B · Chandigarh 160023 · India
Fax: + 91-172-744401
Email: dkbhasin@sancharnet.in