Management of variceal hemorrhage: current concepts

Abstract

IntroductionThe treatment of portal hypertension is complex and the the best strategy depends on the underlying disease (cirrhosis vs. schistosomiasis), patient's clinical condition and time on it is performed (during an acute episode of variceal bleeding or electively, as pre-primary, primary or secondary prophylaxis). With the advent of new pharmacological options and technical development of endoscopy and interventional radiology treatment of portal hypertension has changed in recent decades.AimTo review the strategies employed in elective and emergency treatment of variceal bleeding in cirrhotic and schistosomotic patients.MethodsSurvey of publications in PubMed, Embase, Lilacs, SciELO and Cochrane databases through June 2013, using the headings: portal hypertension, esophageal and gastric varices, variceal bleeding, liver cirrhosis, schistosomiasis mansoni, surgical treatment, pharmacological treatment, secondary prophylaxis, primary prophylaxis, pre-primary prophylaxis.ConclusionPre-primary prophylaxis doesn't have specific treatment strategies; the best recommendation is treatment of the underlying disease. Primary prophylaxis should be performed in cirrhotic patients with beta-blockers or endoscopic variceal ligation. There is controversy regarding the effectiveness of primary prophylaxis in patients with schistosomiasis; when indicated, it is done with beta-blockers or endoscopic therapy in high-risk varices. Treatment of acute variceal bleeding is systematized in the literature, combination of vasoconstrictor drugs and endoscopic therapy, provided significant decline in mortality over the last decades. TIPS and surgical treatment are options as rescue therapy. Secondary prophylaxis plays a fundamental role in the reduction of recurrent bleeding, the best option in cirrhotic patients is the combination of pharmacological therapy with beta-blockers and endoscopic band ligation. TIPS or surgical treatment, are options for controlling rebleeding on failure of secondary prophylaxis. Despite the increasing evidence of the effectiveness of pharmacological and endoscopic treatment in schistosomotic patients, surgical therapy still plays an important role in secondary prophylaxis.

Morbidity and Mortality Due to Schistosoma mansoni Related Periportal Fibrosis: Could Early Diagnosis of Varices Improve the Outcome Following Available Treatment Modalities in Sub Saharan Africa? A Scoping Review

“…Non-selective B-blockers among PPF patients with varices have been reported elsewhere as a potential pharmacological measure for primary and secondary prevention of variceal bleeding [43]. The NSBB could be combined with variceal ligation (EVL) among those with large varices either with or without prior bleeding [44][45][46]. In the current body of literature in SSA, no report was available on the use and effect of NSBB on primary prevention of variceal bleeding.…”

Hemorragia digestiva alta diagnóstico e tratamento

“…Atendimento inicial É fundamental no manejo: a reposição volêmica, controle do sangramento com terapêutica farmacológica e/ou endoscópica e o controle de infecções 10 .…”

Avaliação da média de ressangramento em pacientes pediátricos com trombose da veia porta que fizeram uso de profilaxia endoscópica e/ou medicamentosa

“…Qualquer intervenção tomada para prevenir o primeiro episódio de sangramento consiste na profilaxia primária 8,9,10 . Já a profilaxia secundária se refere a prevenção de ressangramento e deve ser realizado em torno de 2 semanas após o primeiro episódio de sangramento 8,10,11,12 .…”