Endoscopic treatments for portal hypertension

Acute esophageal variceal bleeding: Current strategies and new perspectives

Management of acute variceal bleeding has greatly improved over recent years. Available data indicates that general management of the bleeding cirrhotic patient by an experienced multidisciplinary team plays a major role in the final outcome of this complication. It is currently recommended to combine pharmacological and endoscopic therapies for the initial treatment of the acute bleeding. Vasoactive drugs (preferable somatostatin or terlipressin) should be started as soon as a variceal bleeding is suspected (ideally during transfer to hospital) and maintained afterwards for 2-5 d. After stabilizing the patient with cautious fluid and blood support, an emergency diagnostic endoscopy should be done and, as soon as a skilled endoscopist is available, an endoscopic variceal treatment (ligation as first choice, sclerotherapy if endoscopic variceal ligation not feasible) should be performed. Antibiotic prophylaxis must be regarded as an integral part of the treatment of acute variceal bleeding and should be started at admission and maintained for at least 7 d. In case of failure to control the acute bleeding, rescue therapies should be immediately started. Shunt therapies (especially transjugular intrahepatic portosystemic shunt) are very effective at controlling treatment failures after an acute variceal bleeding. Therapeutic developments and increasing knowledge in the prognosis of this complication may allow optimization of the management strategy by adapting the different treatments to the expected risk of complications for each patient in the near future. Theoretically, this approach would allow the initiation of early aggressive treatments in high-risk patients and spare low-risk individuals unnecessary procedures. Current research efforts will hopefully clarify this hypothesis and help to further improve the outcomes of the severe complication of cirrhosis.

Management of acute esophageal variceal hemorrhage

Acute esophageal variceal hemorrhage (AEVH) is a severe complication of portal hypertension. Its management has rapidly evolved in recent years. Traditional methods included vasoconstrictor and balloon tamponade. Vasoconstrictors were shown to control approximately 80% of the bleeding episodes and are generally used as a first-line therapy. Following the use of vasoconstrictors, endoscopic therapy is often used to arrest the bleeding varices and prevent early rebleeding. A meta-analysis showed that the combination of vasoconstrictor and endoscopic therapy is superior to endoscopic therapy alone for controlling AEVH. Balloon tamponade may be used to achieve temporary control of the hemorrhage in case of severe bleeding. A transjugular intrahepatic portosystemic stent shunt may be needed in patients with refractory acute variceal hemorrhage. Surgical intervention is now widely contraindicated during acute variceal hemorrhage, except for patients with good liver reserve. Conversely, apart from the control of acute variceal hemorrhage, prophylactic antibiotics were shown to be helpful in the prevention of bacterial infection and to prevent early variceal rebleeding. With the introduction of new treatment modalities and the measures taken to manage patients with AEVH, the mortality due to AEVH has significantly decreased in recent years.

The role of endoscopy in secondary prophylaxis of esophageal varices

The rate of rebleeding from esophageal varices remains appreciably high after cessation of acute esophageal variceal hemorrhage. Many measures have been developed to prevent the occurrence of rebleeding. Endoscopic therapy plays a central role in the prevention of variceal bleeding. In the 1980s sclerotherapy played a pivotal role in the prevention of variceal rebleeding, but now yields to endoscopic variceal ligation. Compared with sclerotherapy, a lower incidence of complications and rebleeding is associated with banding ligation. On the other hand, beta-blockers are also noted to be able to reduce portal pressure, leading to the reduction of variceal rebleeding. The reduction of variceal rebleeding with beta-blockers plus nitrates is as effective as banding ligation. The combination of beta-blockers and endoscopic variceal ligation has proven to be more efficacious than banding ligation alone in the reduction of variceal rebleeding and is the treatment of choice for patients with failure in either medical or endoscopic therapy. Patients with repeated rebleeding despite endoscopic therapies may require transjugular intrahepatic portosystemic stent shunt or shunt operation as a rescue therapy.

Management of acute variceal bleeding: emphasis on endoscopic therapy

Acute variceal bleeding is one of the most serious and feared complications of patients with portal hypertension. The most common cause of portal hypertension is advanced liver disease. Patients with esophageal and gastric varices may bleed because of a progressive increase in portal pressure that causes them to grow and finally rupture. This article will review the current management strategies for acute variceal bleeding with emphasis on endoscopic therapy for the acute episode.

Use of endoscopy in diagnosis and management of patients with dysphagia in an African setting

The objectives of this study were to define the utility of esophagogastroduodenoscopy in the diagnosis and management of patients presenting with dysphagia and to determine the relative incidence of the various causes of dysphagia in Sudan. This is a prospective, cross-sectional, descriptive, hospital-based study carried out at the endoscopy unit of Soba University Hospital, Khartoum, Sudan. All patients complaining of dysphagia underwent upper gastrointestinal endoscopy with therapeutic intervention when necessary. A total of 114 patients were enrolled in the study, with a mean age of 47 years SD +/- 19 and a male to female ratio of 1 : 1.04. A benign condition was diagnosed in 56% of the cases; this included esophageal strictures in 21% of the cases and achalasia in 14%. Malignant causes were mainly due to esophageal cancer (40.4%) and cancer of the stomach cardia (3.5%). Therapeutic intervention was attempted in 83% of the cases. Risk factors predictive of a malignant etiology were age over 40 years (P < 0.000), dysphagia lasting between 1 month and 1 year (P < 0.000), and weight loss (P < 0.000). A barium study was performed in 35 cases (31%) prior to endoscopic examination and proved to be inaccurate in three cases (8.6%). Upper gastrointestinal endoscopy in our African setting is an accurate and useful investigation in the diagnosis and management of patients presenting with dysphagia. Patients over the age of 40 years presenting with dysphagia and weight loss are more likely to have a neoplastic disease and should be referred for urgent endoscopy.

Management of anticoagulation before and after gastrointestinal endoscopy

The management of anticoagulants and antiplatelet agents in patients undergoing gastrointestinal endoscopic procedures is a common clinical problem. Although guidelines have been published, they are supported by little prospective or randomized trial data, but are primarily based on observational studies, expert opinion, and best clinical practices. As a general principle, the risks of thromboembolism need to be balanced against the risks of bleeding during the endoscopic procedure. By understanding these risks, management plans for individual cases may be made. This article reviews the current data and guidelines on the management of anticoagulants, antiplatelet agents, use of reversal agents, and the role and risks of concomitant proton pump inhibitors.

Intramural esophageal hematoma after elective injection sclerotherapy

CONTEXT

Although endoscopic esophageal variceal sclerotherapy has been largely supplanted by variceal band ligation, it is still performed routinely in many institutions, especially in developing countries. Intramural esophageal hematoma has been described as a rare complication of sclerotherapy. Risk factors have not been completely established.

OBJECTIVE

To demonstrate the incidence of post-sclerotherapy intramural esophageal hematoma in our hospital and discuss the possible factors involved.

METHODS

This is a retrospective observational study made at the 'Hospital Universitário Clementino Fraga Filho', Rio de Janeiro, RJ, Brazil, reviewing the medical records of all esophageal variceal sclerotherapy procedures performed from April 2000 to November 2005. The evaluation of the clinical, laboratorial and endoscopic features in our patients and those reported in the literature was also done. Review of literature was performed through MEDLINE search.

RESULTS

A total of 1,433 esophageal variceal sclerotherapy procedures were performed in 397 patients, with an intramural esophageal hematoma incidence of 4 cases (0.28%). Three of our patients developed additional complications, and one death was a direct consequence of a rupture of the hematoma. Nineteen well described cases were reported in the literature. Intramural esophageal hematoma occurred mostly after the forth esophageal variceal sclerotherapy session. Coagulation disturbances were present in the majority of cases.

CONCLUSION

Intramural esophageal hematoma is a rare complication of esophageal variceal sclerotherapy and its incidence in our institution was similar to those observed in the literature. Our study suggests that this complication occurs as a result of a fragile esophageal mucosa after previous esophageal variceal sclerotherapy sessions. Impaired coagulation, although not essential, could contribute to hematoma formation and extension through esophageal submucosa.

Management and treatment of patients with cirrhosis and portal hypertension: recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program

Cirrhosis represents the end stage of any chronic liver disease. Hepatitis C and alcohol are currently the main causes of cirrhosis in the United States. Although initially cirrhosis is compensated, it eventually becomes decompensated, as defined by the presence of ascites, variceal hemorrhage, encephalopathy, and/or jaundice. These management recommendations are divided according to the status, compensated or decompensated, of the cirrhotic patient, with a separate section for the screening, diagnosis, and management of hepatocellular carcinoma (HCC), as this applies to patients with both compensated and decompensated cirrhosis. In the compensated patient, the main objective is to prevent variceal hemorrhage and any practice that could lead to decompensation. In the decompensated patient, acute variceal hemorrhage and spontaneous bacterial peritonitis are severe complications that require hospitalization. Hepatorenal syndrome is also a severe complication of cirrhosis but one that usually occurs in patients who are already in the hospital and, as it represents an extreme of the hemodynamic alterations that lead to ascites formation, it is placed under treatment of ascites. Recent advances in the pathophysiology of the complications of cirrhosis have allowed for a more rational management of cirrhosis and also for the stratification of patients into different risk groups that require different management. These recommendations are based on evidence in the literature, mainly from randomized clinical trials and meta-analyses of these trials. When few or no data exist from well-designed prospective trials, emphasis is given to results from large series and consensus conferences with involvement of recognized experts. A rational management of cirrhosis will result in improvements in quality of life, treatment adherence, and, ultimately, in outcomes.

Efficacy and safety of terlipressin in cirrhotic patients with variceal bleeding or hepatorenal syndrome

Terlipressin is an analog of the natural hormone arginine-vasopressin. It is used in the treatment of patients with cirrhosis and bleeding esophageal varices (BEV) and in patients with hepatorenal syndrome (HRS): two of the most dramatic and feared complications of cirrhosis. Terlipressin exerts its main pharmacological effect through stimulation of vasopressin-1 receptors. These receptors are located in vascular smooth muscle and mediate vasoconstriction. In patients with cirrhosis and portal hypertension, treatment with terlipressin increases mean arterial pressure and decreases portal flow and pressure within minutes of administration. Furthermore, in patients with ascites terlipressin improves glomerular filtration and excretion of sodium. Terlipressin decreases failure of initial hemostasis by 34%, decreases mortality by 34%, and is considered a first-line treatment for BEV, when available. Terlipressin in combination with albumin reverses type 1 HRS in 33%-60% of cases and is the only treatment with proven efficacy in randomized trials. The safety profile is favorable when considering the clinical efficacy and the high mortality of these clinical entities. Adverse events are mostly cardiovascular and related to vasoconstriction. Mortality and withdrawal of terlipressin due to adverse events occurs in less than 1% of cases. Mild adverse events related to terlipressin treatment occur in 10%-20% of patients. The benefit, however, of terlipressin on long-term survival in HRS remains to be determined. At present, treatment with terlipressin and albumin is considered the most efficient therapy and should therefore be recommended for the treatment of type 1 HRS-1.

Treatment of acute variceal bleeding

The management of variceal bleeding remains a clinical challenge with a high mortality. Standardisation in supportive and new therapeutic treatments seems to have improved survival within the last 25 years. Although overall survival has improved in recent years, mortality is still closely related to failure to control initial bleeding or early re-bleeding occurring in up to 30-40% of patients. Initial procedures are to secure and protect the airway, and administer volume replacement to stabilize the patient. Treatment with vasoactive drugs should be started as soon as possible, since a reduction in portal pressure is associated with a better control of bleeding and may facilitate later endoscopic procedures. Vasopressin and its analogues Terlipressin and somatostatin and analogues are the two types of medicine, which has been evaluated. In meta-analysis, only Terlipressin have demonstrated effects on control of bleeding and on mortality. Somatostatin and its analogues improve control of bleeding, but show in meta-analysis no effects on mortality. Approximately 20% of patients with variceal bleeding will suffer from an infection, when they are hospitalized. Invasive procedures will further increase the risk of bacterial infections. Meta-analysis of clinical trials comparing antibiotics with placebo demonstrates that antibiotic prophylaxis improves survival with 9% (p<0.004). Quinolones or intravenous cephalosporins should be preferred. Early endoscopy should be performed in patients with major bleeding. Endoscopic therapy increases control of bleeding and decreases the risks of rebleeding and mortality. Ligation is probably more effective than sclerotherapy with fewer complications and should therefore be preferred, if possible. In case of gastric variceal bleeding, tissue adhesives should be used.

IN CONCLUSION

Improvements in resuscitation and prevention of complications have together with introduction of vasoactive drugs and refinement of endoscopic therapy majorily changed the prognosis of the patient presenting with variceal bleeding.

Current endoscopic therapy of variceal bleeding

Variceal ligation has proved more effective and safer than sclerotherapy and is currently the endoscopic treatment of choice for oesophageal varices. In acute bleeding, vasoactive drugs should be started before endoscopy and maintained for 2-5 days. The efficacy of drugs is improved when associated with emergency endoscopic therapy. Antibiotic prophylaxis should also be used. To prevent rebleeding, both endoscopic ligation and the combination of beta-blockers and nitrates may be used. Adding beta-blockers improves the efficacy of ligation. Haemodynamic responders to beta-blockers+/-nitrates (those with a decrease in portal pressure gradient HVPG to <12 mmHg or by >20% of baseline) have a marked reduction in the risk of haemorrhage and will not need further treatment. Beta-blockers significantly reduce the risk of a first haemorrhage in patients with large varices, and they improve survival. As compared to beta-blockers, endoscopic ligation reduces the risk of first bleeding without affecting mortality, and should be used in patients with contraindications or intolerance to beta-blockers.

Current Management of Sinusoidal Portal Hypertension

Portal hypertension resulting from cirrhosis was one of the biggest challenges faced by general surgeons up until the past two decades. The management of portal hypertensive variceal hemorrhage has undergone dramatic changes during this period. Endoscopic variceal ligation and transjugular intrahepatic portosystemic shunts are currently used with great success. The degree of liver dysfunction remains the most important determinant of outcome in these patients. Patients with cirrhosis who have good liver function and recurrent variceal bleed remain candidates for shunt surgery. However, the need for surgical intervention has become a rarity. The success of liver transplantation has ensured that portal hypertension is cured permanently and one does not often see the critically ill and decompensated patient with cirrhosis on the surgical service. A review of the current treatment options in this very ill patient population is the primary focus of this article.

Clinical trial: The effect of somatostatin vs. octreotide in preventing post-endoscopic increase in hepatic venous pressure gradient in cirrhotics with bleeding varices

BACKGROUND

Hepatic venous pressure gradient (HVPG) increases significantly after endoscopic therapy in patients with bleeding oesophageal varices, which may precipitate further haemorrhage. Whether vasoactive drugs can suppress these changes remains unknown.

AIM

To investigate the efficacy of somatostatin when compared with octreotide in preventing the post-endoscopic increase in HVPG during acute bleeding and whether the changes affect outcome.

METHODS

Thirty-three cirrhotics with bleeding varices were randomized to receive somatostatin (n = 17) or octreotide (n = 16) under double-blind conditions, soon after their admission. HVPG measurements were performed before and immediately after endoscopic treatment.

RESULTS

In the somatostatin group, postendotherapy HVPG values did not change significantly when compared with pre-treatment values (18.9 vs. 17.2, P = 0.092). Conversely, in the octreotide group, HVPG increased significantly after endoscopy (18.2 vs. 20.8, P = 0.003). The probability of 6-week survival without treatment failure was significantly higher in the somatostatin group (P = 0.024). Post-endoscopic HVPG value was independently associated with 6-week failure.

CONCLUSIONS

Somatostatin, but not octreotide, effectively prevents the post-endoscopic increase in HVPG, which may be associated with low probability of treatment failure.

Prevention of recurrent esophageal variceal hemorrhage: review and current recommendations

Variceal rebleeding is a very frequent and severe complication in cirrhotic patients; therefore, its prevention should be mandatory. Lately several studies demonstrated that the rate of rebleeding was decreased by 40% and overall survival is improved by 20% with beta-blockers. However, this treatment presents some problems, such as the number of nonresponders and contraindications for its use. Recent trials found that the combination of beta-blockers with mononitrate of isosorbide to be superior to beta-blockade alone. Furthermore, endoscopic band ligation also shown to decrease the frequency of rebleeding, complications, and death compared with sclerotherapy and should be the preferred endoscopic treatment. In addition, the comparison between combined pharmacologic treatment with endoscopic treatment present similar rebleeding and mortality rates. More recently, the addition of nadolol to endoscopic band ligation increased the efficacy of endoscopy alone in the prevention of variceal rebleeding. These studies suggest that banding plus drugs could be the treatment of choice for the prophylaxis of rebleeding. When these treatments fail, the recommendation is to use transjugular intrahepatic portosystemic shunt (TIPS) or surgical shunts. Both treatments are effective in preventing rebleeding; however, they are associated with a greater risk of encephalopathy. The comparison of portacaval shunts with TIPS demonstrated that TIPS patients presented higher rebleeding, treatment failure, and transplantation. Another randomized controlled trial comparing distal splenorenal shunt with TIPS shows that variceal rebleeding was similar in both groups without differences in encephalopathy and mortality. The only difference observed was the higher rate of reintervention observed in the TIPS group to maintain his patency.

The effects of the number of rubber bands placed at each endoscopic session upon variceal outcomes: a prospective, randomized study

AIM

To determine the role of the number of bands placed per session upon patient-related and procedural-related outcomes.

METHODS

Patients were assigned to receive as many bands as could be possibly placed (group 1) or up to a maximum of six bands (group 2) per session. The primary outcome measured was the number of sessions to achieve obliteration. Other outcomes measured included: rebleeding, variceal recurrence, mortality (within 6 wk and within 1 yr), complications, banding and total procedure times, and number of bands misfired.

RESULTS

A total of 86 patients were enrolled: 45 in group 1 and 41 in group 2. The two groups had similar age, Child-Pugh scores, grade of varices at entry. The overall proportion of patients achieving obliteration was 56% (53% and 59% for groups 1 and 2, respectively). Despite receiving significantly more mean bands per session, patients in group 1 required similar (mean +/- SEM) number of sessions to obliteration (2.9 +/- 0.3 vs 3.3 +/- 0.3) and total number of bands (20.0 +/- 2.4 vs 16.6 +/- 1.8) to achieve this goal compared with group 2. The overall proportion of patients with variceal rebleeding was 25%, the 1-yr variceal recurrence 31.3%, and the overall early- and 1-yr mortality were 18.6% and 33.7%, respectively. These proportions were similar in the two groups. Banding and total procedure times were significantly longer and associated with significantly more misfired bands per session in group 1.

CONCLUSION

Compared with a maximum of six bands per session, the placement of >6 bands per session was not associated with better patient outcomes but with significantly more prolonged banding and total procedure times and significantly more misfired bands.

Pretransplant management of the cirrhotic patient

Cirrhosis is the twelfth commonest cause of death in the United States, with more than 27,000 deaths and more than 421,000 hospitalizations annually. Currently, there are more than 17,000 patients awaiting liver transplantation in the United States across the 11 United Network for Organ Sharing regions. Approximately 10% of such patients will die awaiting transplantation.

Prevention of recurrent haemorrhage

Patients who survive a first bleeding episode of oesophageal varices have a high risk of rebleeding, which is associated with a high mortality rate. Prevention of a recurrent haemorrhage is therefore recommended. Patients who were not on a primary prophylaxis should be treated with non-selective beta-adrenoceptor antagonists, endoscopic band ligation or both. If beta-blockers are not tolerated or are contraindicated, patients should be treated with endoscopic band ligation. If these preventive strategies fail, transjugular intrahepatic portosystemic shunt (covered) or a small-diameter surgical shunt is indicated.

Preventing complications of endoscopic hemostasis in acute upper gastrointestinal hemorrhage

Over the last 20 years, endoscopic hemostasis has become the primary method of controlling acute, overt upper gastrointestinal hemorrhage (UGIH) and prevent rebleeding. Although uncommon, procedure-related complications may occur. This article reviews the risks attributable to endoscopic hemostasis in acute UGIH and how to help prevent these complications.

Prevention of esophageal variceal rebleeding

The rate of rebleeding of esophageal varices remains high after cessation of acute esophageal variceal hemorrhage. Many measures have been developed to prevent the occurrence of rebleeding. When considering their effectiveness in reduction of rebleeding, the associated complications cannot be neglected. Due to unavoidable high incidence of complications, shunt surgery and endoscopic injection sclerotherapy are now rarely used. Transjugular intrahepatic portosystemic stent shunt was developed to replace shunt operation but is now reserved for rescue therapy. Nonselective beta-blockers alone or in combination with isosorbide mononitrate and endoscopic variceal ligation are currently the first choices in the prevention of variceal rebleeding. The combination of nonselective beta-blockers and endoscopic variceal ligation appear to enhance the efficacy. With the advent of newly developed measures, esophageal variceal rebleeding could be greatly reduced and the survival of cirrhotics with bleeding esophageal varices could thereby be prolonged.

Natural history of a randomized trial comparing distal spleno-renal shunt with endoscopic sclerotherapy in the prevention of variceal rebleeding: A lesson from the past

AIM: To compare endoscopic sclerotherapy (ES) with distal splenorenal shunt (DSRS) in the prevention of recurrent variceal bleeding in cirrhotic patients during a long-term follow-up period.

METHODS: In 1984 we started a prospective, controlled study of patients with liver cirrhosis. Long-term follow-up presents a natural history of liver cirrhosis complicated by advanced portal hypertension. In this study the effects of 2 types of treatment, DSRS or ES, were evaluated. The study population included 80 patients with cirrhosis and portal hypertension referred to our department from October 1984 to March 1991. These patients were drawn from a pool of 282 patients who underwent either elective surgery or ES during the same period of time. Patients were assigned to one of the 2 groups according to a random number table: 40 to DSRS and 40 to ES using polidocanol.

RESULTS: During the postoperative period, no DSRS patient died, while one ES patient died of uncontrolled hemorrhage. One DSRS patient had mild recurrent variceal hemorrhage despite an angiographically patent DSRS and another patient suffered duodenal ulcer rebleeding. Eight ES patients suffered at least one episode of gastrointestinal bleeding: 4 from varices and 4 from esophageal ulcerations. Eight ES patients developed transitory dysphagia. Long-term follow-up was completed in all patients except for 5 cases (2 DSRS and 3 ES patients). Five-year survival rates for shunt (73%) and ES (56%) groups were statistically different: in this follow-up period and in subsequent follow-ups this difference decreased and ceased to be of statistical relevance. The primary cause of death became hepatocellular carcinoma (HCC). Four DSRS patients rebled due to duodenal ulcer, while eleven ES patients had recurrent bleeding from esophago-gastric sources (seven from varices, three from hypertensive gastropathy, one from esophageal ulcerations) and two from unknown sources. Nine DSRS and 2 ES patients developed a chronic encephalopathy; 13 DSRS and 5 ES patients suffered at least one episode of acute encephalopathy. Five ES patients had esophageal stenoses, which were successfully dilated.

CONCLUSION: In a subgroup of patients with good liver function, DSRS with a correct portal-azygos disconnection more effectively prevents variceal rebleeding than ES. However, this positive effect did not influence the long-term survival because other factors (e.g. HCC) were more important in deciding the fate of the cirrhotic patients with portal hypertension.

A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding

BACKGROUND/AIMS

The currently recommended treatment for acute variceal bleeding is the association of vasoactive drugs and endoscopic therapy. However, which emergency endoscopic treatment combines better with drugs has not been clarified. This study compares the efficacy and safety of variceal ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin.

METHODS

Patients admitted with acute gastrointestinal bleeding and with suspected cirrhosis received somatostatin infusion (for 5 days). Endoscopy was performed within 6h and those with esophageal variceal bleeding were randomized to receive either sclerotherapy (N=89) or ligation (N=90).

RESULTS

Therapeutic failure occurred in 21 patients treated with sclerotherapy (24%) and in nine treated with ligation (10%) (RR=2.4, 95% CI=1.1-4.9). Failure to control bleeding occurred in 15% vs 4%, respectively (P=0.02). Treatment group, shock and HVPG >16 mmHg were independent predictors of failure. Side-effects occurred in 28% of patients receiving sclerotherapy vs 14% with ligation (RR=1.9, 95% CI=1.1-3.5), being serious in 13% vs 4% (P=0.04). Six-week survival probability without therapeutic failure was better with ligation (P=0.01).

CONCLUSIONS

The use of variceal ligation instead of sclerotherapy as emergency endoscopic therapy added to somatostatin for the treatment of acute variceal bleeding significantly improves the efficacy and safety.

Comparative study between nadolol and 5-isosorbide mononitrate vs. endoscopic band ligation plus sclerotherapy in the prevention of variceal rebleeding in cirrhotic patients: a randomized controlled trial

BACKGROUND

After variceal bleeding, cirrhotic patients should receive secondary prophylaxis.

AIM

To compare nadolol plus 5-isosorbide mononitrate (5-ISMN) with endoscopic band ligation. The end points were rebleeding, treatment failure and death.

METHODS

One hundred and nine cirrhotic patients with a recent variceal bleeding were randomized: nadolol plus 5-ISMN in 57 patients and endoscopic band ligation in 52 patients.

RESULTS

The mean follow-up was 17 and 19 months in nadolol plus 5-ISMN and endoscopic band ligation groups, respectively. No differences were observed between groups in upper rebleeding (47% vs. 46%), variceal rebleeding (40% vs. 36%), failure (32% vs. 22%), major complications (7% vs. 13.5%) and death (19% vs. 20%), respectively. The actuarial probability of remaining free of rebleeding, failure and deaths were similar in both groups. Time to rebleeding shows that endoscopic band ligation patients had an early rebleed, with a median of 0.5 month (95% CI: 0.0-4.2) compared with patients from nadolol plus 5-ISMN, 7.6 months (95% CI: 2.9-12.3, P < 0.013). Multivariate analysis indicated that outcome-specific predictive factor(s) for rebleeding was Child A vs. B + C (P < 0.01); for failure was Child A vs. B + C (P < 0.02); and for death ascites (P < 0.01) and rebleeding (P < 0.02).

CONCLUSION

This trial suggests no superiority of endoscopic band ligation over nadolol plus 5-ISMN mononitrate for the prevention of rebleeding in cirrhotic patients.

Pharmacologic therapy of portal hypertension

Portal hypertension is a progressively debilitating complication of cirrhosis and a principal cause of mortality in patients who have hepatic decompensation. During the last few decades, significant clinical advances in the prevention of initial variceal hemorrhage, the management of acute variceal hemorrhage, and the prevention of recurrent variceal hemorrhage have reduced the morbidity and mortality of this lethal complication of cirrhosis. This article discusses the pharmacologic treatment of portal hypertension, including preprimary prophylaxis, prevention of a first variceal hemorrhage, treatment of acute variceal hemorrhage, and secondary prophylaxis of a variceal hemorrhage.

[Secondary prophylaxis with elastic band ligation in esophageal-gastric varices]

The aim of the present study was to determine the usefulness of elastic band ligation in the prevention of hemorrhage recurrence due to esophageal-gastric varices. Sixty-five patients who survived an episode of variceal hemorrhage were included in the study. Twenty-nine patients (45%) were Child-Pugh class A, 25 (38%) were class B, and 11 (17%) were class C. The cause of cirrhosis was hepatitis C virus and alcohol in 45% and 31% of the patients, respectively. The first ligation session was performed between the third and fifth day after the hemorrhagic episode and subsequent sessions were carried out at intervals of 3-4 weeks. The ligation sessions were performed with antibiotic prophylaxis. A mean of 2.7 bands were placed per session (range 1-5), and the mean number of sessions required per patient to achieve variceal eradication was 2.5 (range 1-6). The rate of bleeding recurrence was 24.6% (16 episodes). In conclusion, endoscopic elastic band ligation is a useful technique for the eradication of esophageal varices and for the prevention of bleeding recurrence.

Beta blockers in portal hypertension. Are they really a good option?

Non-selective beta blockers are very useful drugs in preventing first variceal bleeding and re-bleeding in patients with cirrhosis. These drugs work in two ways: 1) by blocking beta1 receptors and reducing cardiac output, and 2) by blocking beta2 receptors, producing splanchnic vasoconstriction and reducing portal flow. Consequently, they reduce portal pressure. In primary prophylaxis, beta blockers reduced the bleeding risk from 30 to 15%; in secondary prophylaxis, this risk decreased from 60 to 42% in the first year. Heart rate decrease does not necessary correlate with reduction in hepatic venous pressure gradient (HVPG). When this gradient is reduced to less than 12 mmHg, the patient will not bleed; when this is reduced > 20% from basal values bleeding risk is extremely low, estimated at 9% at 2 years. The only way to know whether the patient has become a responder is to measure the HVPG. Additionally, by means of this method we also can identify the non-responders, who have a higher rate of re-bleeding, between 54 and 64%, and can attempt to utilize a more aggressive therapy, such as adding isosorbide mononitrate to the beta blocker or combining the beta blocker with endoscopic ligation. These options are discussed in the present review.

Treatment of esophageal varices: a randomized controlled trial comparing endoscopic sclerotherapy and EUS-guided sclerotherapy of esophageal collateral veins

BACKGROUND

Endoscopic sclerotherapy (ES) and band ligation are standard treatments for esophageal varices. Unfortunately, recurrence is common and seems to be related to esophageal collateral vessels, easily identified by EUS. Eradication of these vessels might lead to a more durable therapeutic effect.

OBJECTIVE

To compare ES with EUS-guided sclerotherapy of collateral vessels (EUS-ES).

DESIGN

Randomized controlled trial.

SETTING

Endoscopy Unit, Division of Gastroenterology. Universidade Federal de São Paulo, São Paulo, Brazil.

PATIENTS AND INTERVENTIONS

Fifty cirrhotic patients with esophageal varices were randomized into 2 groups: ES (n = 25) and EUS-ES (n = 25). EUS-ES was targeted at collateral veins. Patients were followed-up for at least 6 months after eradication.

MAIN OUTCOME MEASUREMENTS

Efficacy in eradication, complications, and recurrence of varices.

RESULTS

Varices were eradicated in 48 patients who adhered to the study protocol. The mean (SD) number of sessions until eradication was 4.3 (1.5) for the ES group and 4.1 (1.2) for the EUS-ES group. In ES group, 4 patients had mild bleeding. In EUS-ES group, 4 patients had pain. The mean (SD) length of the follow-up period was 22.6 (6.9) months for the ES group and 24.9 (8.1) months for the EUS-ES group. Recurrence was seen in 4 patients after ES and in 2 after EUS-ES (P = .32). The presence of collateral vessels was associated with recurrence (P = .003).

CONCLUSION

EUS-ES is as safe and effective as ES in variceal eradication. Recurrence tends to be less frequent and occurs later. Persistence of esophageal collateral vessels after sclerotherapy is a risk factor for recurrence.

Emergency endoscopic variceal ligation versus somatostatin for acute esophageal variceal bleeding

BACKGROUND

Endoscopic variceal ligation and somatostatin are widely used for treating acute esophageal variceal bleeding. This study compared the efficacy, safety, and survival of both therapies.

METHODS

Acute esophageal variceal bleeding patients were randomized to undergo emergency ligation or receive a bolus of 250 microg somatostatin plus infusion at 250 microg/hour for 48 hours and undergo ligation subsequently.

RESULTS

Three (4.8%) of 62 patients in the ligation group and 20 (31.7%) of 63 patients in the somatostatin group encountered treatment failure (p = 0.0001). Transfusion requirements were 4.7 +/- 3.2 units in the ligation group and 6.9 +/- 7.3 units in the somatostatin group (p = 0.03). Hospital stay was 7.7 +/- 4.0 days in the ligation group and 10.2 +/- 9.9 days in the somatostatin group (p = 0.07). Adverse effects occurred in the ligation group (20 episodes) and the somatostatin group (27 episodes) (p = 0.2). The 42-day mortality rates were 5 patients (8.1%) in the ligation group and 3 patients (4.8%) in the somatostatin group (p = 0.5).

CONCLUSION

Emergency ligation was superior to somatostatin in treating acute esophageal variceal bleeding, with fewer requirements of transfusion and a tendency toward shorter hospital stay. The adverse effects and 42-day mortality rates were similar between both treatments.

Factors predicting success of endoscopic variceal ligation for secondary prophylaxis of esophageal variceal bleeding

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.

Endoscopic band ligation in the treatment of portal hypertension

The evidence that endoscopic band ligation (EBL) has greater efficacy and fewer side effects than endoscopic injection sclerotherapy has renewed interest in endoscopic treatments for portal hypertension. The introduction of multishot band devices, which allow the placement of 5-10 bands at a time, has made the technique much easier to perform, avoiding the use of overtubes and their related complications. EBL sessions are usually repeated at 2 week intervals until varices are obliterated, which is achieved in about 90% of patients after 2-4 sessions. Variceal recurrence is frequent, with 20-75% of patients requiring repeated EBL sessions. According to current evidence, nonselective beta-blockers are the preferred treatment option for prevention of a first variceal bleed, whereas EBL should be reserved for patients with contraindications or intolerance to beta-blockers. Nonselective beta-blockers, probably in association with the vasodilator isosorbide mononitrate, and EBL are good treatment options to prevent recurrent variceal rebleeding. The efficacy of EBL might be increased by combining it with beta-blocker therapy. Patients who are intolerant, have contraindications or bled while receiving primary prophylaxis with beta-blockers must be treated with EBL. In the latter situation, EBL should be added to rather than replace beta-blocker therapy. EBL, in combination with vasoactive drugs, is the recommended form of therapy for acute esophageal variceal bleeding; however, endoscopic injection sclerotherapy can be used in the acute setting if EBL is technically difficult.

The management of portal hypertension

Portal hypertension is an almost unavoidable complication of cirrhosis, and it is responsible for the more lethal complications of this syndrome. Appearance of these complications represents the major cause of death and liver transplantation in patients who have cirrhosis. This article highlights treatment modalities in use for managing portal hypertension and those that may be available in the future.

Endoscopic variceal ligation vs. propranolol for prevention of first variceal bleeding: a randomized controlled trial

OBJECTIVES

Data in the literature regarding the role of endoscopic variceal ligation for the prevention of first variceal bleeding in cirrhotic patients are controversial. To further explore this issue we have compared ligation and propranolol treatment in a prospective randomized study.

METHODS

Sixty patients with cirrhosis and oesophageal varices with no history but at high risk of bleeding were randomized to ligation treatment (30 patients) or propranolol (30 patients). Patients were followed for approximately 27.5 months.

RESULTS

Variceal obliteration was achieved in 28 patients (93.3%) after 3+/-1 sessions. The mean daily dose of propranolol was 60.3+/-13.3 mg. Two patients (6.7%) in the ligation group and nine patients (30%) in the propranolol group developed variceal bleeding (P = 0.043). The actuarial risks of variceal bleeding at 2 years were 6.7% and 25%, respectively. On multivariate analysis, propranolol treatment and grade III varices turned out to be predictive factors for the risk of variceal bleeding. Mortality was not different between the two groups. There were no serious complications due to ligation. Propranolol treatment was discontinued in four patients because of side effects.

CONCLUSIONS

Variceal ligation is a safe and more effective method than propranolol treatment for the prevention of first variceal bleeding in cirrhotic patients with high-risk varices.

Modern management of portal hypertension

The development of portal hypertension plays a major role in the pathogenesis of many of the complications of chronic liver disease. In developed countries, most patients with portal hypertension have cirrhosis, and, in this condition, portal pressure is elevated as a result of both an increase in hepatic resistance to portal perfusion and increased mesenteric blood flow. Bleeding from oesophageal varices is a major cause of mortality in patients with significant portal hypertension. This review concentrates on the recognition, prevention and acute management of this life threatening complication of cirrhosis.

Diagnosis and treatment of portal hypertension

Prevention of the first variceal haemorrhage should start when the patients have developed medium-sized to large varices. Non-selective beta-blockers and band ligation are equally effective in preventing the first bleeding episode. Rubber band ligation is the first choice for patients with contraindications or intolerance to beta-blockers. Treatment of acute bleeding should aim at controlling bleeding and preventing early rebleeding and complications, especially infections. Combined endoscopic (band ligation or sclerotherapy) and pharmacological treatment with vasoactive drugs can control bleeding in up to 90% of patients. Antibiotic prophylaxis is an integral part of the treatment of acute variceal haemorrhage, and must be started as soon as possible. Emergency transjugular intrahepatic portosystemic stent shunt (TIPS) is the standard rescue therapy for patients failing combined endoscopic and pharmacological treatment. All patients who survive a variceal bleed should be treated with beta-blockers or band ligation to prevent rebleeding. All patients in whom bleeding cannot be controlled or who continue to rebleed can be treated with salvage TIPS or, in selected cases, with surgical shunts. Liver transplantation should be considered for patients with severe liver insufficiency in which first-line treatments fail.

Management of gastrointestinal bleeding in patients with cirrhosis of the liver

Ruptured gastroesophageal varices are the most severe and frequent cause of gastrointestinal bleeding in cirrhotic patients, leading to death in 5% to 8% of patients during the first 48 hours. In recent times, the 6-week mortality rate has fallen to 20% due to the development of effective treatment strategies. Initial treatment is aimed at achieving hemostasis and preventing bleeding-related complications such as renal failure, infection, and hepatic decompensation. Blood volume replacement is initiated as soon as possible and antibiotic prophylaxis is instituted from admission. Hemostatic treatment for variceal bleeding includes vasoactive drugs to decrease portal pressure, endoscopic procedures, and portosystemic shunts-either a surgical or transjugular intrahepatic portosystemic shunt (TIPS). Treatment of coagulopathy has only been recently assessed in clinical studies, but results to date are promising. This article reviews the current clinical data on management strategies for variceal bleeding and presents the risks and benefits for each type of treatment. Specific sections on gastric varices and portal hypertensive gastropathy are included.

Review article: a critical comparison of drug therapies in currently used therapeutic strategies for variceal haemorrhage

Vasoactive drugs are safe and easy to administer, and universal treatment is the first-line approach for all patients with suspected variceal bleeding. There are strong arguments that the combination of vasoactive drugs, started as soon as possible, and endotherapy later on is the best therapeutic option, particularly in cases of ongoing bleeding at the time of endoscopy. The main action of vasoactive drugs is to reduce variceal pressure. This can be achieved by diminishing the variceal blood flow and/or by increasing resistance to variceal blood flow inside the varices. Changes in variceal pressure parallel changes in portal pressure. Drugs for the treatment of variceal bleeding can therefore be assessed by measuring the changes in portal pressure, azygos blood flow and variceal pressure. Vasoactive drugs can be divided into two categories: terlipressin (Glypressin), and somatostatin and its analogues, especially octreotide. Terlipressin significantly reduces portal and variceal pressure and azygos flow, is superior to placebo in the control of variceal haemorrhage and improves mortality. It is beneficial when combined with sclerotherapy. It also has the advantage that it might preserve renal function, one of the most important factors affecting the outcome of cirrhosis. As such, terlipressin is the most potent of the various vasoactive drugs. Somatostatin significantly reduces portal and variceal pressure and azygos flow, is superior to placebo in controlling variceal haemorrhage, and improves the success of sclerotherapy. The effect of octreotide is well established for preventing the increase in portal pressure after a meal (similar to blood in the intestines) though the effect of ocreotide on variceal pressure is controversial.

Review article: definition and diagnosis in portal hypertension--continued problems with the Baveno consensus?

The goals of the Baveno workshops were to develop consensus definitions of key events related to portal hypertension and variceal bleeding, and to produce guidelines to facilitate the conduct and reporting of clinical trials. The consensus definitions concern the diagnosis of active bleeding, failure to control bleeding, the criteria to distinguish continuing bleeding from rebleeding, and the means of assessing failure to prevent rebleeding. The guidelines concern the timing of diagnostic endoscopy, the policy for blood volume restitution, the measures to prevent infection and encephalopathy, and the treatment options for acute bleeding, as well as primary and secondary prophylaxis. The intention of the experts who developed the guidelines was that, as feedback from their practical application develops, they should be adapted to better fit the practical needs. The applicability of the Baveno definitions has been evaluated in a study where the definitions of clinically significant bleeding, failure to control bleeding, the time frame for the acute bleeding episode and the definition of rebleeding were tested. The main criticism raised in this study was that tachycardia, one of the criteria that define failure to control bleeding, was misleading in 15% of patients who had the symptom but were not bleeding.

Cost-effectiveness of hepatic venous pressure gradient measurements for prophylaxis of variceal re-bleeding

BACKGROUND

Measurement of the hepatic venous pressure gradient may identify a sub-optimal response to drug prophylaxis in patients with a history of variceal bleeding. However, the cost-effectiveness of routine hepatic venous pressure gradient measurements to guide secondary prophylaxis has not been examined.

METHODS

A Markov model was constructed using specialized software (DATA 3.5, Williamstown, MA, USA). Three strategies involved secondary prophylaxis without haemodynamic monitoring using beta-blockers alone, beta-blockers plus isosorbide mononitrate or endoscopic variceal ligation alone. Four strategies involved secondary prophylaxis with beta-blockers plus isosorbide mononitrate or beta-blockers alone, accompanied by one or two hepatic venous pressure gradient measurements to identify haemodynamic non-responders, who underwent endoscopic variceal ligation as an alternative. The total expected costs, variceal bleeding episodes and total deaths were calculated for each strategy over 3 years.

RESULTS

The two most effective strategies were combination therapy alone and combination therapy with two hepatic venous pressure gradient measurements. The incremental cost-effectiveness ratio of the latter strategy was 136,700 dollars per year of life saved compared with combination therapy alone. The ratio improved as the time horizon was extended or the rates of variceal re-bleeding were increased.

CONCLUSIONS

The cost-effectiveness of haemodynamic monitoring to guide secondary prophylaxis of recurrent variceal bleeding is highly dependent on local hepatic venous pressure gradient measurement costs, life expectancy and re-bleeding rates.

Endoscopic ligation vs. nadolol in the prevention of first variceal bleeding in patients with cirrhosis

BACKGROUND

The value of band ligation for prevention of the first episode of variceal bleeding has not been fully evaluated. This study compared the efficacy and safety of band ligation vs. treatment with a beta-blocker for the prophylactic prevention of first bleeding in patients with cirrhosis and high-risk esophageal varices.

METHODS

A total of 100 patients with cirrhosis and endoscopically determined high-risk esophageal varices but no history of bleeding were randomized to band ligation (50 patients) or treatment with nadolol (50 patients). In the ligation group, two to 4 elastic bands were deployed during each session. Ligation was repeated at intervals of 3 to 4 weeks until variceal obliteration was achieved. In the nadolol group, the dose of the drug, administered once daily, was sufficient to reduce the pulse rate by 25%.

RESULTS

In the ligation group, variceal obliteration was achieved in 41 patients (82%), at a mean of 2.7 (1.1) ligation sessions. In the nadolol group, the mean daily dose of nadolol administered was 60 (20) mg. During follow-up (median approximately 22 months), 10 patients (20%) in the ligation group and 16 (32%) in the nadolol group had upper-GI bleeding (p=0.23). Esophageal variceal bleeding occurred in 5 patients (10%) in the ligation group and 9 (18%) in the nadolol group (p=0.31). By multivariate Cox analysis, Child-Pugh class was the only factor predictive of variceal bleeding. Minor complications were noted in 9 patients (18%) in the ligation group and 4 (8%) in the nadolol group (p=0.35). No serious complication was encountered. Twelve patients in the ligation group and 11 in the nadolol group died (p=0.62). One patient in the ligation group and 3 in the nadolol group died from uncontrollable variceal hemorrhage.

CONCLUSIONS

Variceal ligation is as effective and as safe as treatment with nadolol for prevention of first variceal bleeding in patients with cirrhosis.