Portal hypertension and variceal haemorrhage

The role of microRNAs on the pathogenesis, diagnosis and management of portal hypertension in patients with chronic liver disease

INTRODUCTION

Portal hypertension (PH) is the elevated pressure in the portal vein, which results in poor functioning of the liver and is influenced by various factors like liver cirrhosis, nonalcoholic fatty liver disease, schistosomiasis, thrombosis, and angiogenesis. Though the diagnosis and treatment have been advanced, early diagnosis of the disease remains a challenge, and the diagnosis methods are often invasive. Hence, the clear understanding of the molecular mechanisms of PH can give rise to the development of novel biomarkers which can pave way for early diagnosis in noninvasive methods, and also the identification of target genes can elucidate an efficient therapeutic target.

AREAS COVERED

PubMed and Embase database was used to search articles with search terms 'Portal Hypertension' or 'pathophysiology' and 'diagnosis' and 'treatment' or "role of miRNAs in portal hypertension.

EXPERT OPINION

Interestingly, biomarkers like microRNAs (miRNAs) have been studied for their potential role in various diseases including hypertension. In recent years, miRNAs have been proved to be an efficient biomarker and therapeutic target and few studies have assessed the roles of miRNAs in PH. The present paper highlights the potential roles of miRNAs in PH.

Efficacy and safety of ERCP in patients with gastroesophageal varices

Addressing pancreaticobiliary disorders concomitant with gastroesophageal varices remains challenging. The goal of this study was to evaluate and compare the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in cirrhotic and noncirrhotic patients with gastroesophageal varices.We retrospectively analyzed the data of consecutive patients with gastroesophageal varices who underwent ERCP.Two hundred seventy ERCP procedures were performed on 208 patients. The overall technical success rate was 98.5%, and no difference was found between cirrhotic and noncirrhotic patients (98.7% vs 97.7%, P = .511); of these, endoscopic retrograde biliary drainage, endoscopic metal biliary endoprosthesis placement, endoscopic retrograde pancreatic drainage, and stone extraction were conducted in 173/270 (64.1%), 27/270 (10.0%), 26/270 (9.6%), and 116/270 (43.0%) cases, respectively. Endoscopic retrograde biliary drainage and stone extraction were more frequently performed in cirrhotic cases (67.7% versus 45.5%, P = .005; 46.5% versus 25.0%, P = .009, respectively), while the noncirrhotic group had significantly higher rates of endoscopic metal biliary endoprosthesis placement (31.8% versus 5.8%, P = .000) and endoscopic retrograde pancreatic drainage (18.2% versus 8.0%, P = .036) than the cirrhotic group. The overall rate of adverse events was 21.1%, including fever (6.7%), post-ERCP pancreatitis ( 3.0%), hyperamylasemia (6.3%), duodenal papilla bleeding (3.3%), cardiac mucosal laceration (1.1%), and perforation (0.4%). No differences in any of the adverse events were found between the 2 groups. Additionally, gastroesophageal variceal bleeding occurred in 1 patient with grade III varices 7 days after ERCP.ERCP may be effective and safe for patients with gastroesophageal varices, irrespective of the etiologies caused by liver cirrhosis.

Long-term outcomes of oesophagogastric devascularization and splenectomy in patients with portal hypertension and liver cirrhosis

BACKGROUND

Research about the long-term outcomes of oesophagogastric devascularization and splenectomy (OGDS) to treat portal hypertension (PH) is scarce. This study aimed to evaluate the safety and long-term treatment efficacy of OGDS, especially in elderly patients.

METHODS

During 2010-2016, open splenectomy and oesophagogastric devascularization (OSOD) and laparoscopic splenectomy and oesophagogastric devascularization were performed in 124 (group A) and 29 (group C) patients diagnosed with PH and liver cirrhosis, respectively. All patients aged less than 65 years. Besides, 39 patients aged 65 years or older undergoing open splenectomy and oesophagogastric devascularization were classified into group B. All clinical data were retrospectively analysed.

RESULTS

Compared with group A, patients in group C had longer operative time, less blood loss and shorter post-operative hospitalization time. However, for perioperative data, there was no significant difference between group A and group B. During post-operative follow-up, compared with pre-operative condition, all haematology and liver function parameters significantly changed, except for alanine aminotransferase. For post-operative complications, only the portal vein system thrombosis rate was significantly higher in group C than group A. No significant difference was found in the overall survival rate among three groups, when non-variceal-rebleeding-related deaths were excluded.

CONCLUSION

OGDS remains safe and effective to treat PH secondary to liver cirrhosis and it can be performed successfully in elderly patients and achieve a curative effect that is not inferior to young patients.

Long-term results of the paraesophagogastric devascularization with or without esophageal transection: which is more suitable for variceal bleeding?

BACKGROUND

It has been reported that the paraesophagogastric devascularization with esophageal transection procedure, also known as the modified Sugiura procedure, was effective in the treatment of variceal bleeding. However, it was not widely accepted by other surgeons because of the high rate of rebleeding, complications, and mortality. To discover the effects of the paraesophagogastric devascularization procedure and the modified Sugiura procedure, we retrospectively analyzed the outcomes of these two procedures.

MATERIALS AND METHODS

During January 1990 and December 2009, 278 patients with variceal bleeding underwent devascularization after failed pharmacotherapy and endotherapy. In these 278 patients, 180 underwent paraesophagogastric devascularization without esophageal transection (group I), and the other 98 patients were subjected to the modified Sugiura procedure (group II).

RESULTS

Postoperative mortality was 7.2% in group I, and 9.2% in group II (P = 0.563). The postoperative rebleeding rate in the two groups was 2.2 and 3.1%, respectively (P = 0.474). After a mean follow-up of 67.9 ± 37.3 months and 67.4 ± 44.6 months, respectively, esophageal transaction-related morbidity (leak, bleeding, and stricture) was 8.2% (8/98) in group II and 0% (0/180) in group I (P < 0.001). The overall rebleeding rate was 27% (41/152) in group I, and 27.2% (22/81) in group II (P = 0.976). The overall mortality was 28.3% (43/152) in group I, and 28.4% (23/81) in group II (P = 0.986).

CONCLUSIONS

In the management of variceal bleeding, paraesophagogastric devascularization without esophageal transection is as effective and safe as devascularization with esophageal transaction, but with less esophageal transection-related morbidity.

Primary prevention of variceal bleeding: pharmacological therapy versus endoscopic banding

Variceal bleeding is one of the most feared complications in patients with liver cirrhosis. It continues to be a leading cause of death among patients with liver cirrhosis. Although its prognosis has improved over the last several decades, it still carries substantial mortality. Preventing variceal bleeding has been extensively studied and evaluated in several studies in the recent years and the comparison between the different modalities available to prevent variceal bleeding has been an area of discussion. Currently the two most widely used modalities to prevent variceal bleeding are pharmacologic (non-selective beta-blockers [NSBB]) and endoscopic (variceal band ligation [VBL]) which have replaced sclerotherapy in the recent years. In addition to NSBB and recent carvedilol, different other medications have been evaluated including isosorbide mononitrates, spironolactone and angiotensin blocking agents. Comparing the outcomes and adverse effects of these two modalities has been evaluated in different studies. Some studies have showed superiority of VBL until recently, when carvedilol has been included, however; overall mortality has been similar in most trials. Despite that, NSBB remain the first line treatment, as they are cheaper and relatively effective in preventing both esophageal and gastric bleeding. The following sections discuss the primary prevention of variceal bleeding with a focus on NSBB, carvedilol and VBL.

Fatal upper gastrointestinal bleed arising from duodenal varices secondary to undiagnosed portal hypertension

Duodenal varices are an unexpected source of upper gastrointestinal haemorrhage associated with high mortality. The prevalence of ectopic variceal bleeding accounts for 2-5% of all variceal bleeding; of this, only 17% occurs in the duodenum. Diagnosis is difficult, and insufficient evidence exists to demonstrate the best treatment option when haemorrhage occurs. We report the case of a 69-year-old man with a history of chronic alcoholism who presented to the emergency department (ED) with nausea, vomiting and several episodes of haematochezia. Diagnostic workup in the ED included CT with multiplanar reconstruction, which revealed a network of large tortuous blood vessels running near the second portion of the duodenum between the inferior vena cava and portal vein. The patient was emergently treated with endoscopic therapy and clipping of the vessel. This failed, and he was subsequently taken to the operating room for suture ligation of the bleeding duodenal varices.

Esophageal variceal ligation in the secondary prevention of variceal bleeding: Result of long term follow-up

Introduction

Long-term outcome of patients after band ligation have been poorly defined. Therefore, we conducted a long-term follow-up study to delineate the outcome of ligation in patients with portal hypertension in the Hassan II university hospital, Fes, Morocco.

Methods

Over 118 months patients treated by endoscopic variceal ligation were received regular follow- up and detailed clinical assessment of at least 24 months.

Results

One hundred twenty five patients were followed up for a mean of 31 months (range 12-107 months). Obliteration of the varices was achieved in 89.6 % (N = 112) of patients, with 3 +/-1.99 (range 1-8) endoscopy sessions over a period of 14 + /-6.8 weeks (range 3-28). The percentage of variceal recurrence during follow-up after ligation was 20.5 % (N = 23). Recurrence were observed in a mean of 22 months +/- 7.3 (range 3-48). Bleeding rate from recurrent varices was 30.4 % (7/23). Rebleeding from esophageal ulcers occurred in 5.6 % (7/125) of patients. Portal hypertensive gastropathy before and after eradication of varices was 17.6% (N = 22) and 44.6% (N = 50) respectively; p< 0.05. Fundal gastric varices was 30.4% (N = 38) and 35.7% (N = 40) before and after eradication of varices respectively; p> 0.05. The overall mortality was 4 % (N = 5).

Conclusion

Band ligation was an effective technical approach for variceal obliteration with low rates of variceal recurrence, rebleeding and development of gastric varices. Furthermore, it was associated with frequent development of portal hypertensive gastropathy.

Long-term results with the modified Sugiura procedure for the management of variceal bleeding: standing the test of time in the treatment of bleeding esophageal varices

Background

The surgical approaches to the treatment of bleeding esophageal varices in cirrhotic patients have been reduced since the clinical development of endoscopic sclerotherapy, transjugular intrahepatic portosystemic shunt (TIPS), and liver transplantation. However, when acute sclerotherapy fails, and in cases where no further treatment is accessible, emergency surgery may be life saving. In the present study we retrospectively analyzed the results of the modified Sugiura procedure, performed as emergency and semi-elective treatment in the patient with bleeding esophageal varices.

Methods

Ninety patients with cirrhosis and portal hypertension were managed in our department for variceal esophageal bleeding between January 1985 and December 1992. The modified Sugiura procedure was performed in 46 patients on an emergency (25 patients) or semi-elective (21 patients) basis. Liver cirrhosis stage according to Child classification was A in 4 patients, B in 16 patients, and C in 26 patients.

Results

Acute bleeding was controlled in all patients. Postoperative mortality was 23.9% (11 of 46 patients). The mortality rate was 34.6% in Child class C patients (9 of 26 patients), and 12.5% in Child class B patients (2 of 16 patients). Twenty-four patients had long-term follow-up extending from 14 months to 22 years (mean 83.1 months). Ten of 24 patients (41.6%) did not develop rebleeding for 5–22 years (mean 10.3 years). Overall 5-year survival in these 24 patients was 62.5%.

Conclusions

The modified Sugiura procedure remains an effective rescue therapy for patients with bleeding esophageal varices when alternative treatments fail or are not indicated. Moreover, it can be a life-saving procedure in patients with anatomy unsuitable for shunt surgery or for patients treated in nonspecialized centers where surgical expertise for a shunt operation is not available.

Gluing gastric varices in 2012: lessons learnt over 25 years

Bleeding from gastric varices (GV) continues to pose a challenge to the endoscopist and no consensus has been reached on the best way for treating these patients. Gastric variceal obturation (GVO) with the tissue adhesive, N-2-butyl-cyanoacrylate (NBC), is considered the treatment of first-choice for this condition in most parts of the world. The liquid monomer polymerizes into a solid cast, obturating the vessel within 10-20 s of coming in contact with ionic solutions such as blood. Gastric variceal obturation achieves hemostasis in over 90% of patients with active bleeding, eradicates GV in over 80% of these patients, and re-bleeding occurs in 3-30%. These results are comparable with those of transjugular intrahepatic portosystemic shunting (TIPS; over 90% hemostasis in acute bleeding with re-bleeding in 15-30%). Though, there has been no direct comparison with GVO, balloon-occluded retrograde transvenous obliteration of GV (BRTO) achieves near 100% obliteration with recurrence in 0-10% and is superior to TIPS for hemostasis in active bleeding when used in combination with transcatheter sclerotherapy. Several complications have been described for GVO including thromboembolic complications which occur in 0.5-4.3% and may be devastating in some. Many of the complications and the variability in results of GVO can be attributed to variations in injection technique. The use of a standardized injection technique has been reported to achieve 100% hemostasis and obliteration with 6.9% re-bleeding and no embolic complications. Gastric variceal obturation with NBC continues to be the first-choice therapy for GV bleeding outside Japan. Adherence to a standard injection technique will maximize hemostasis and eradication of GV while minimizing complications of therapy.

The evaluation of liver dysfunction: when to suspect portal hypertension

Portal hypertension, as a result of cirrhosis or other cause of liver dysfunction, is a life-threatening disease process. The risk of bleeding varices is high. Treatment options have much better outcomes when administered early on. The role of the PA in treating portal hypertension centers on recognizing the complications and understanding the medical management of those problems. Familiarity with the available treatment options can facilitate initiation of the most appropriate therapy for each patient. The best plan of action is to stabilize the patient and refer him or her to a tertiary center with clinicians who have experience in managing this uncommon problem.

Advances in research on portal hypertensive enteropathy

Portal hypertensive enteropathy, whose fundamental pathologic change is a vasculopathy characterized histopathologically by mucosal and submucosal vessel dilatation, oedema and congestion, mainly results from a combination of increased intrahepatic vascular resistance and increased blood flow through the portal venous system. Though portal hypertensive enteropathy usually has non-specific clinical manifestations, it is a major cause of lower gastrointestinal bleeding. Up to now, there has been no standard for the diagnosis and grading of portal hypertensive enteropathy. Unfortunately, the experience of treatment for portal hypertensive enteropathy only comes from some small-sample trials. For these reasons, an in-depth study of portal hypertensive enteropathy is still necessary. In this article, we will review the advances in research on portal hypertensive enteropathy.

Management of gastric fundal varices without gastro-renal shunt in 15 patients

AIM: To examine the portal hemodynamics of gastric fundal varices (GV) without gastro-renal shunt (GRS), and to retrospectively investigate the effects of various kinds of treatment on eradication.

METHODS: Ninety-four liver cirrhosis patients at high-risk of GV were treated in our hospital and enrolled in this study. We retrospectively examined their characteristics, liver function, and portal hemodynamics of GV. We performed balloon-occluded retrograde transvenous obliteration (BRTO) at first. If it was not technically possible to perform BRTO, endoscopic injection sclerotherapy using α-cyanoacrylate glue (CA) or percutaneous transhepatic obliteration (PTO) was performed.

RESULTS: Among the 94 patients, a GRS was present in 79 (84.0%), and absent in the remaining 15 (16.0%). The subphrenic vein was connected to the inferior vena cava as the drainage vein in 13 (86.7%) out of the 15 cases without GRS. We performed BRTO in 6 patients, CA in 4 patients and PTO in 5 patients. The eradication rate was 100% for each procedure, but the rate of early recurrence within 6 mo was 16.7% for BRTO, 50.0% for CA and 40.0% for PTO, respectively.

CONCLUSION: We should examine the hemodynamics before treatment of GV irrespective of the existence of GRS. If this hemodynamic examination reveals that the drainage vein connects directly to the inferior vena cava in GV without GRS, BRTO may be an effective treatment for GV with GRS.

Prevention of the development of varices and first portal hypertensive bleeding episode

Variceal bleeding is a serious complication in patients with cirrhosis. Although bleeding related mortality rates have fallen recently, it continues to be amongst the leading causes of death. Cirrhotics should be screened for varices at diagnosis. Data on preventing formation/growth of oesophageal varices (pre-primary prophylaxis) are conflicting, with insufficient evidence to use beta-blockers. In order to prevent first bleeding, there is strong evidence in patients with medium/large size oesophageal varices that either non-selective beta-blockers or banding ligation can be used. Banding is superior with respect to bleeding but mortality is similar. Non-selective beta-blockers should remain first line treatment being effective, cheap and without serious complications. In contrast banding ligation is more expensive, requires specialised staff, cannot prevent bleeding from portal hypertensive gastropathy and can cause iatrogenic bleeding. Patients with small varices, particularly if they have progressive liver disease also benefit from beta-blockers, but fewer studies confirm this therapeutic approach.

Transabdominal modified devascularization procedure with or without esophageal stapler transection--an operation adequate for effective control of a variceal bleed. Is esophageal stapler transection necessary?

BACKGROUND

In Japan, the original Sugiura procedure reported favorable results in non-cirrhotic patients but in the West, the modified Sugiura procedure is not widely accepted because of high rebleeding, morbidity, and mortality in cirrhotics. We retrospectively analyzed the efficacy of our modified Sugiura procedure i.e., devascularization with/without esophageal transection combined with salvage endotherapy and pharmacotherapy for control of a variceal bleed.

MATERIALS AND METHODS

Between January 1999 and December 2004, 912 patients with variceal bleeding were treated. Of these, 66 (7.2%) patients were subjected to surgery after failed endotherapy/propranolol. Among these 66 patients, 52 had transabdominal devascularization (16 emergency, 36 elective); 14 patients underwent devascularization with esophageal stapler transection (group I), and 38 patients had devascularization without esophageal stapler transection (group II). Another 14 patients underwent elective end-to-side proximal splenorenal shunt surgery.

RESULTS

Postoperative mortality was 7.1% in group I, 10.5% in group II (P>0.05). Mortality for emergency surgery was 31.2% (5/16) but there were no deaths in the elective surgery group. Overall morbidity was 57.1% in group I and 21.0% in group II (P<0.05). The rates of variceal rebleeding were 7.1% and 7.8%; residual varices were 30.7% and 32.3%; recurrent varices were 7.6% and 5.8% following the group I and group II procedures, respectively, over a mean follow-up period of 39.9 (7-2) months. Esophageal transection-related morbidity (leak, stricture, and bleeding) was 21.4% (3/14) in group I.

CONCLUSIONS

Devascularization without esophageal stapler transection is a safe and effective procedure for adequate (urgent and long-term) control of variceal bleeding with similar results and less morbidity when compared to devascularization with esophageal transection in cirrhotic patients, as well as non-cirrhotic patients.

Vaginal bleeding complicating portal hypertension: a particular entity - report of two cases and review of the literature

Vaginal haemorrhage arising from varices is an exceptional complication of portal hypertension. Two cases successfully treated by transjugular intrahepatic portosystemic stent shunt are presented here. Both these patients previously had a total hysterectomy as did three out of four cases reported in the literature. Clinicians should be aware of 'vaginal bleeding' in the context of both hysterectomy and chronic liver disease in order to adopt the correct diagnostic and therapeutic approach. Definitive treatment can be obtained only if the underlying portal hypertension is adequately taken into consideration.

Liver transplantation as ultimate tool to treat portal hypertension

Portal hypertension is a complication of liver cirrhosis that may itself cause complications such as variceal bleeding, ascites and hepatorenal syndrome. There are several options for symptomatic treatment including drug therapy, endoscopy, transjugular intrahepatic portosystemic shunt (TIPS), and various surgical procedures, notably liver transplantation, the only causal treatment. The indication for liver transplantation has to be defined carefully. Progression of the primary disease, evaluation of comorbidity and overall prognosis have to be considered. Conservative symptomatic treatment is used for bridging purposes until liver transplantation can be provided to cure portal hypertension and the underlying primary disease. Careful timing of the transplantation is necessary as well as reorganization of the waiting lists by introducing new priority systems as the Model for End-Stage Liver Disease (MELD) in order to reduce mortality. Furthermore, living donor liver transplantation and split liver transplantation are methods to enlarge the donor pool, and thus accessibility of transplantation to a greater number of patients. This review evaluates the indication of liver transplantation in the treatment of portal hypertension.

Management of acute variceal bleeding

Portal hypertension as a consequence of liver cirrhosis is responsible for its most common complications: ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, hepatic encephalopathy and the most important one--variceal hemorrhage. Variceal bleeding results in considerable morbidity and mortality. This review covers all areas of importance in the therapy of acute variceal hemorrhage--endoscopic and pharmacological treatment, transjugular intrahepatic portosystemic shunt, surgery and balloon tamponade. Indications and limitations of these therapeutic modalities are widely discussed.

Portal Hypertension

Portal hypertension is a serious condition that is most commonly a result of cirrhosis. It is defined as an increase in portal venous pressure that impedes blood flow into the liver. This review describes portal hypertension and its typical etiologies. Twodimensional and Doppler sonography play important roles in the diagnosis and surveillance of patients with portal hypertension.

Primary prophylaxis of variceal bleeding in cirrhosis

Variceal bleeding is the result of portal hypertension, which is a major complication of liver cirrhosis and carries a high mortality rate. Because of the mortality associated with variceal bleeding, strategies for prevention of the first bleed is important. Risk stratification is important in determining those at risk of bleeding from varices and current data suggest that patients with large varices with red signs, severe underlying liver disease and those who have a hepatic venous pressure gradient of greater than 12 mmHg are at high risk of bleeding. Surveillance for varices in patients with cirrhosis is therefore important. The current review evaluates the role of various treatments in the primary prophylaxis of variceal bleeding. The current first choice treatment is non-selective beta-blockers; which is cheap, easy to administer, and reduces the risk of first variceal haemorrhage significantly. Combination of beta-blockers and nitrates looks promising but needs further evaluation. Endoscopic variceal band ligation compares favourably with non-selective beta-blockers in preventing the first bleeding episode in cirrhotic patients and may be an alternative for patients who cannot tolerate, or have contraindications to beta-blockers. The role of monitoring the hepatic venous pressure gradient in those being treated with pharmacological agents, the role of newer drugs such as non-selective beta-blockers with intrinsic alpha-adrenergic activity and angiotensin receptor blockers require further evaluation.

Massive esophageal variceal hemorrhage triggered by complicated endotracheal intubation

Esophageal variceal hemorrhage is frequently a catastrophic event. The specific events that trigger variceal rupture are not well understood. Acute elevations in systemic blood pressure and increased splanchnic blood flow, however, may lead to increased intravariceal pressure followed by variceal rupture and hemorrhage. This report describes a strong temporal association between complicated endotracheal intubation and abrupt onset of life-threatening variceal hemorrhage. A 52-year-old man with a history of portal hypertension was intubated emergently for airway protection because of respiratory insufficiency due to sepsis. Intubation was complicated by initial inadvertent esophageal intubation and by a peak mean arterial blood pressure of 155 mmHg. At the conclusion of the procedure, the patient sustained large volume hematemesis due to esophageal variceal rupture. This case suggests a risk of triggering variceal hemorrhage as a result of intubation-induced increase in blood pressure. A number of agents, including fentanyl, have been shown to be effective in attenuating the cardiovascular response to intubation. This case report provides strong evidence in support of administering fentanyl, or a suitable alternative adjunctive medication, before intubation of patients with documented portal hypertension and a history of esophageal variceal hemorrhage.