Portal hypertension: pre-primary and primary prophylaxis of variceal bleeding

Numerical assessment of portal pressure gradient (PPG) based on clinically measured hepatic venous pressure gradient (HVPG) for liver cirrhosis patients

Portal hypertension (PH) is the initial and main consequence of liver cirrhosis. Hepatic venous pressure gradient (HVPG) measurement has been widely used to estimate portal pressure gradient (PPG) and detect portal hypertension. However, some clinical studies have found poor correlation between HVPG and PPG, which may lead to the misdiagnosis of portal hypertension. In this study, we provided a method to evaluate patients' PPG based on clinically measured HVPG with computational fluid dynamics (CFD). Twenty-five patients who underwent HVPG measurement were recruit for analysis. Results show that HVPG significantly correlates with PPG (R = 0.7499, P < 0.0001), with an accuracy to distinguish clinically significant portal hypertension (CSPH) as high as 92 %. However, PH severity classification was underestimated for 36 % patients, especially for patients with hepatic venous collateral formation and presinusoidal portal vein occlusion. It is concluded that HVPG is a relatively reliable diagnostic method for PH when PPG cannot be directly measured. For patients who have clinical symptoms of PH but their HVPG are within a normal range, numerical evaluation of PPG with CFD is an excellent way for their diagnosis.

Primary prophylaxis of variceal bleeding

Primary prevention of variceal bleeding is an important and long-debated topic in the management of patients with cirrhosis and esophageal varices. Prophylaxis is recommended for high-risk patients with small esophageal varices (advanced liver disease and/or presence of red wale marks) and those with medium/large varices. Nonselective β-blockers and endoscopic band ligation have been shown to be equally effective in primary prevention of variceal bleeding and are the only currently recommended therapies. Controversy still exists, however, regarding which one of these strategies is preferred. This article reviews the established recommendations and recent advances in the prevention of first esophageal variceal bleeding.

Detection of early portal hypertension with routine data and liver stiffness in patients with asymptomatic liver disease: a prospective study

BACKGROUND & AIMS

Detecting portal hypertension (PH) before the development of varices is important for prognosis and for designing interventional studies. None of the available strategies is used in practice. We evaluated a sequential screening-diagnostic strategy based on clinical data and transient elastography (TE) to detect PH in asymptomatic outpatients with liver disease.

METHODS

Consecutive patients with chronic liver disease and no previous diagnosis of PH were screened by TE. Patients with liver stiffness (LS) ⩾ 13.6 kPa were further evaluated by endoscopy and hepatic venous pressure gradient (HVPG). For analysis, patients were classified in 3 groups: group A, platelets ⩾ 150,000/mm(3), normal abdominal ultrasound; group B, platelets <150,000/mm(3), normal ultrasound; group C, platelets <150,000/mm(3), abnormal ultrasound (splenomegaly, nodular liver surface).

RESULTS

250 patients were evaluated (69% group A, 20% group B, 11% group C). In 9% elastography was non-valid. LS ⩾ 13.6 was found in 54 patients (8% A, 43% B, and 81% C, p<0.001). Endoscopy was performed in 49 of these: 20% had small varices, 0% high-risk varices. No patients from group A had varices, and 90% with varices belonged to group C. HVPG was obtained in 40 patients: 93% had PH (HVPG >5 mmHg) and 65% clinically significant PH (CSPH, HVPG ⩾ 10). Only 3 patients, all from group A, had HVPG <5. All patients from groups B and C with LS ⩾ 13.6 had PH. The LS 25 cut-off was excellent at ruling-in CSPH.

CONCLUSIONS

A simple strategy based on routine clinical data and TE could be useful to detect early PH among asymptomatic patients with chronic liver disease.

Assessment of risk of bleeding from esophageal varices during management of biliary atresia in children

OBJECTIVES

The management of esophageal varices (EV) in children experiencing biliary atresia (BA) remains controversial. Recent studies in children proposed initiating a prophylactic treatment in patients with severe (grade III) EV and/or EV associated with red color signs. Our study was aimed at assessing the risk of bleeding from EV in a series of patients with BA, identifying risk factors for bleeding to develop a predictive model of bleeding.

METHODS

This was a retrospective study including 83 eligible patients with BA. Clinical, ultrasonographic, endoscopic, and laboratory parameters were studied from the beginning of medical management up to the occurrence of upper gastrointestinal bleeding. In patients not presenting any bleeding, data were analyzed until liver transplantation, endoscopic treatment of EV was performed, or last follow-up. Risk factors were investigated using univariate and multivariate statistical analyses.

RESULTS

Seventeen of 83 patients (20%) presented gastrointestinal bleeding, with a median age of 9.5 months (6-50 months). In univariate and multivariate analyses, high-grade EV, red color signs on endoscopic examination, and low fibrinogen levels, at first endoscopy, were identified as risk factors for bleeding. When tested in >10,000 different models, these 3 variables appeared to play the most significant role in predicting bleeding.

CONCLUSIONS

Our study confirmed that grade III EV and red color signs are risk factors for bleeding in patients followed up for BA. We identified low fibrinogen levels as an additional risk factor. The relevance of these 3 factors to predict bleeding from EV requires validation in a prospective study.

Variceal bleeding: consensus meeting report from the Brazilian Society of Hepatology

In the last decades, several improvements in the management of variceal bleeding have resulted in a significant decrease in morbidity and mortality of patients with cirrhosis and bleeding varices. Progress in the multidisciplinary approach to these patients has led to a better management of this disease by critical care physicians, hepatologists, gastroenterologists, endoscopists, radiologists and surgeons. In this respect, the Brazilian Society of Hepatology has, recently, sponsored a consensus meeting in order to draw evidence-based recommendations on the management of these difficult-to-treat subjects. An organizing committee comprised of four people was elected by the Governing Board and was responsible to invite 27 researchers from distinct regions of the country to make a systematic review of the subject and to present topics related to variceal bleeding, including prevention, diagnosis, management and treatment, according to evidence-based medicine. After the meeting, all participants met together for discussion of the topics and the elaboration of the aforementioned recommendations. The organizing committee was responsible for writing the final document. The meeting was held at Salvador, May 6th, 2009 and the present manuscript is the summary of the systematic review that was presented during the meeting, organized in topics, followed by the recommendations of the Brazilian Society of Hepatology.

[Prevention of esophageal variceal bleeding]

Esophageal varices(EV) are present in 40% and 60% of Child-Pugh A and C patients, respectively when cirrhosis is diagnosed. EV bleeding is a life-threatening complication of liver cirrhosis with a high probability of recurrence. Treatment to prevent first EV bleeding or rebleeding is mandatory. In small EV with high risk of bleeding, nonselective β-blockers should be used for the prevention of first variceal bleeding. For medium to large EV, nonselective β-blockers or endoscopic variceal ligation (EVL) may be recommended to high risk varices. But, nonselective β-blockers are the first treatment option to non-high risk varices and EVL is an alternative when nonselective β-blockers are contraindicated or not tolerated. For the prevention of rebleeding, a combination of nonselective β-blockers and EVL may be the best option. A great improvement in the prevention of variceal bleeding has emerged over the last years. However, further therapeutic options that combine higher efficacy, better tolerance and fewer side effects are needed.

[Portosystemic shunt in the treatment of portal hypertension]

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Gastric varices in patients with portal hypertension: evaluation with multidetector row CT

BACKGROUND

Gastric varices (GVs) are a major cause of gastrointestinal bleeding in patients with portal hypertension. Few studies have evaluated GVs with multidetector row computed tomography (MDCT).

GOALS

To assess the diagnostic performance of MDCT in detecting GVs and revealing variceal hemodynamic changes in patients with cirrhosis.

STUDY

A total of 127 consecutive cirrhotic patients who underwent both liver MDCT and esophagogastroduodenoscopy (EGD) were analyzed retrospectively. Two independent radiologists reviewed MDCT images for the detection of GVs. The variceal hemodynamic changes were assessed by the 2 radiologists in consensus on MDCT portography.

RESULTS

On the basis of EGD, of the 127 patients, 36 had GVs (28.4%), including small GVs in 15 patients and large GVs (>or=5 mm) in 21 patients. In detecting and grading GVs, there were moderate agreements (kappa value: 0.514 to 0.563) between MDCT and EGD, but in differentiating large varices requiring prophylactic therapy, a substantial agreement (kappa value: 0.804 for radiologist 1 and 0.796 for radiologist 2) was found. For radiologist 1, the sensitivity, specificity, accuracy, and positive and negative predictive values of MDCT for the identification of large GVs were 85.7%, 96.2%, 94.5%, 81.8%, and 97.1%, respectively; whereas for radiologist 2, they were 81.0%, 97.2%, 94.5%, 85.0%, and 96.3%, respectively. In evaluating the afferent and efferent veins of varices, the sensitivity, specificity, accuracy, and positive predictive value of MDCT portography were more than 80.0%.

CONCLUSIONS

MDCT is an effective screening tool for differentiating large GVs and revealing the afferent and efferent veins of varices in patients with cirrhosis.

Massive bleeding from ectopic varices in the postpartum period: rare but serious complication in women with portal hypertension

Portal hypertension (PHT) often leads to collateralization of blood flow through variceal vessels that shunt blood from the portal to the systemic circulation. Life-threatening bleeding from esophageal and ectopic varices often complicates severe PHT. Increase in PHT occurs during the last stages of the second trimester of pregnancy and is associated with increased risk of PHT bleeding in the later stages of pregnancy. In this report, we present two rare cases of pregnant women with PHT, who had postpartum bleeding from very uncommon sites. The first had a rupture of an intra-abdominal varix and the second had two episodes of bleeding from abdominal wall varices, after two emergent cesarean sections, in two consecutive pregnancies. On the basis of a literature review, we constructed an algorithm that includes instructions on how to handle women with PHT during the various stages of pregnancy and labor.

Early identification of haemodynamic response to pharmacotherapy is essential for primary prophylaxis of variceal bleeding in patients with 'high-risk' varices

BACKGROUND

A beta-blocker is recommended for primary prophylaxis of variceal bleeding; however, only one-third have hepatic venous pressure gradient (HVPG) response. The role of addition of isosorbide-5-mononitrate (ISMN) to beta-blocker and benefits of HVPG-guided 'a la carte' approach remain unclear.

AIM

To determine the benefits of HVPG-guided pharmacotherapy in primary prophylaxis of variceal bleeding using beta-blocker and ISMN.

PATIENTS AND METHODS

Consecutive patients of cirrhosis, with high-risk varices, with no previous variceal bleeding were included. After baseline HVPG, patients received incremental propranolol to achieve HR of 55/min. After one-month, HVPG was repeated to determine response (<12 mmHg or >or=20% reduction). ISMN was added in nonresponders and HVPG repeated. Patients were followed up for 24 months.

RESULTS

Of 56 patients (age 47 +/- 13, males 79%) from 89 eligible patients, 21 (38%) responded to beta-blocker alone. Six additional patients responded to combination. Thus, overall 48% (27/56) patients responded. Variceal bleeding occurred in seven of 56 (13%) patients [one of 27 (4%) responder, five of 23 (22%) nonresponders and one of six (17%) with unknown response; P = N.S.]. The actuarial probability of variceal bleeding at median 24 months was 4% in responders and 22% in nonresponders (P < 0.05). Ten (18%) patients developed adverse effects to propranolol and six of 35 (17%) to nitrates requiring dose reduction. Risk factors of variceal bleed were grade IV varices and haemodynamic nonresponse.

CONCLUSIONS

For primary prophylaxis, a beta-blocker is effective in 38% and addition of ISMN raises the response rate to about half of patients. The HVPG-guided 'a la carte' approach may be considered for these patients.

Endoscopic haemostasis

Endoscopic haemostasis should be attempted as the initial approach in most cases of gastrointestinal (GI) bleeding, although cross-disciplinary collaboration is a prerequisite. For variceal bleeding, band ligation is the method of choice in the elective setting, although injection therapy still has a role in acute bleeding. Histoacryl remains preferable for fundic varices in most parts of the world. For peptic ulcer bleeds, injection therapy should be combined with at least one 'mechanical' modality, thermal treatment or clipping. In rebleeding, a single endoscopic retreatment can be attempted, but alternative approaches must be considered. Acute lower GI bleeding is primarily a diagnostic challenge but, if the focus is found, the regular techniques for haemostasis can usually be applied. If small bowel haemorrhage is suspected after upper and lower endoscopy, capsule endoscopy and balloon enteroscopy offer make it possible to address even small bowel foci.

Staging of portal hypertension and portosystemic shunts using dynamic nuclear medicine investigations

AIM

To explore portal hypertension and portosystemic shunts and to stage chronic liver disease (CLD) based on the pathophysiology of portal hemodynamics.

METHODS

Per-rectal portal scintigraphy (PRPS) was performed on 312 patients with CLD and liver angioscintigraphy (LAS) on 231 of them. The control group included 25 healthy subjects. We developed a new model of PRPS interpretation by introducing two new parameters, the liver transit time (LTT) and the circulation time between right heart and liver (RHLT). LTT for each lobe was used to evaluate the early portal hypertension. RHLT is useful in cirrhosis to detect liver areas missing portal inflow. We calculated the classical per-rectal portal shunt index (PRSI) at PRPS and the hepatic perfusion index (HPI) at LAS.

RESULTS

The normal LTT value was 24 +/- 1 s. Abnormal LTT had PPV = 100% for CLD. 27 non-cirrhotic patients had LTT increased up to 35 s (median 27 s). RHLT (42 +/- 1 s) was not related to liver disease. Cirrhosis could be excluded in all patients with PRSI < 5% (P < 0.01). PRSI > 30% had PPV = 100% for cirrhosis. Based on PRPS and LAS we propose the classification of CLD in 5 hemodynamic stages. Stage 0 is normal (LTT = 24 s, PRSI < 5%). In stage 1, LTT is increased, while PRSI remains normal. In stage 2, LTT is decreased between 16 s and 23 s, whereas PRSI is increased between 5% and 10%. In stage 3, PRSI is increased to 10%-30%, and LTT becomes undetectable by PRPS due to the portosystemic shunts. Stage 4 includes the patients with PRSI > 30%. RHLT and HPI were used to subtype stage 4. In our study stage 0 had NPV = 100% for CLD, stage 1 had PPV = 100% for non-cirrhotic CLD, stages 2 and 3 represented the transition from chronic hepatitis to cirrhosis, stage 4 had PPV = 100% for cirrhosis.

CONCLUSION

LTT allows the detection of early portal hypertension and of opening of transhepatic shunts. PRSI is useful in CLD with extrahepatic portosystemic shunts. Our hemodynamic model stages the evolution of portal hypertension and portosystemic shunts. It may be of use in the selection of patients for interferon therapy.