Hemodynamic response–guided therapy for prevention of variceal rebleeding

Abstract

The clinical usefulness of assessing hemodynamic response to drug therapy in the prophylaxis of variceal rebleeding is unknown. An open-labeled, uncontrolled pilot trial was performed to evaluate the feasibility and efficacy of using the hemodynamic response to pharmacological treatment to guide therapy in this setting. Fifty patients with acute variceal bleeding underwent a hepatic venous pressure gradient (HVPG) measurement 5 days after the episode. Nadolol and nitrates were initiated, and a second HVPG was measured 15 days later. Responder patients (>20% decrease in HVPG from baseline) were maintained on drugs, partial responders (>10% and <20%) had banding ligation added to the drugs, and nonresponders (<10%) received a transjugular intrahepatic portal-systemic shunt (TIPS). Mean follow-up was 22 months. Eight patients (16%) did not receive the second HVPG, 6 of them because of early variceal rebleeding. Of the other 42 patients, 24 were classified as responders (57%); 10 as partial responders (24%), who had banding added; and 8 as nonresponders (19%), who received a TIPS. Patients with cirrhosis of viral etiology compared to alcoholic cirrhosis tended to present more early rebleedings, less response to drugs and needed more TIPS. Variceal rebleeding occurred in 22% of all patients but only in 12% of patients whose hemodynamic response was assessed. The 3 therapeutic groups were not different. In conclusion, using hemodynamic response to pharmacological treatment to guide therapy in secondary prophylaxis to prevent variceal bleeding is feasible and effectively protects patients from rebleeding. In this context, viral cirrhosis seems to present a worse outcome than alcoholic cirrhosis. (HEPATOLOGY 2006;44:806-812.)

Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis

“…19,36 In patients who are HVPG responders, it would not be rational to use endoscopic therapy. As suggested recently, perhaps the most rational therapy would be to adapt the different therapies to prevent variceal rebleeding in the context of HVPG response 125,126 ; however, this would require standardization of the HVPG technique, including the best timing to perform the repeat HVPG measurement. Existing studies have performed the second HVPG measurement a median of 90 days after the first measurement (range 19-159 days), and there is evidence suggesting that the predictive value of the change in HVPG is reduced with increasing time between measurements.…”

Prevention and Management of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis

“…In patients who are HVPG responders, it would not be rational to use endoscopic therapy. As suggested recently, perhaps the most rational therapy would be to adapt the different therapies to prevent variceal rebleeding in the context of HVPG response (125,126); however, this would require standardization of the HVPG technique, including the best timing to perform the repeat HVPG measurement. Existing studies have performed the second HVPG measurement a median of 90 days after the first measurement (range 19-159 days), and there is evidence suggesting that the predictive value of the change in HVPG is reduced with increasing time between measurements (19).…”

Management of variceal and nonvariceal upper gastrointestinal bleeding in patients with cirrhosis

“…Patients with a reduction in HVPG to less than 12 mmHg or a reduction in HVPG by more than 20% have the lowest rate of variceal rebleeding, about 10% [D'Amico et al 2006;Bosch and Garcia-Pagán, 2003]. It has been suggested that such patients could be treated with pharmacological treatment alone without endoscopic variceal ligation until eradication [Bureau et al 2002;Gonzalez et al 2006]. However, HVPG measurements are made only in referral centres and cannot be used for clinical practice.…”