Precision medicine in variceal bleeding: Are we there yet?

Abstract

Variceal bleeding is one of the most feared complications of portal hypertension in patients with cirrhosis because of its deleterious impact on prognosis. Adequate management of patients at risk of developing variceal bleeding includes the prevention of the first episode of variceal bleeding and rebleeding, and is crucial in modifying prognosis. The presence of clinically significant portal hypertension is the main factor determining the risk of development of varices and other liver-related decompensations; therefore, it should be carefully screened for and monitored. Treating patients with clinically significant portal hypertension based on their individual risk of portal hypertension-related bleeding undoubtedly improves prognosis. The evaluation of liver haemodynamics and liver function can stratify patients according to their risk of bleeding and are no question useful tools to guide therapy in an individualised manner. That said, recent data support the idea that tailoring therapy to patient characteristics may effectively impact on prognosis and increase survival in all clinical scenarios. This review will focus on evaluating the available evidence supporting the use of individual risk characteristics for clinical decision-making and their impact on clinical outcome and survival. In primary prophylaxis, identification and treatment of patients with clinically significant portal hypertension improves decompensation-free survival. In the setting of acute variceal bleeding, the risk of failure and rebleeding can be easily predicted, allowing for early escalation of treatment (i.e. pre-emptive transjugular intrahepatic portosystemic shunt) which can improve survival in appropriate candidates. Stratifying the risk of recurrent variceal bleeding based on liver function and haemodynamic response to non-selective betablockers allows for tailored treatment, thereby increasing survival and avoiding adverse events.

Recent Advances in the Management of Acute Variceal Hemorrhage

“…Patients with acute VH who are more likely to fail, despite initial control of hemorrhage by standard therapy, are those belonging to Child C class or those with HVPG > 20 mmHg [50,55]. It was, therefore, postulated that the placement of a TIPS before failure of standard therapy ("pre-emptive TIPS") could improve survival [56]. A first RCT in which 52 patients with HVPG > 20 mmHg was randomized to standard treatment vs. pre-emptive TIPS (uncovered) demonstrated significantly lower failure rates and all cause short-term mortality in the TIPS arm (12% vs. 50% and 17% vs. 38%, respectively) [57].…”

Efficacy and Safety of Treatments for Patients With Portal Hypertension and Cirrhosis: A Systematic Review and Bayesian Network Meta-Analysis

“…Abundant research has shown that variceal bleeding and rebleeding are among the most serious complications of portal hypertension in patients with cirrhosis because of a severe impact on prognosis (11,56). Treating patients based on their individual risk of portal hypertension-related bleeding undoubtedly affects the prognosis.…”

“…However, EVL has been shown to result in lower rebleeding, mortality and complication rates compared with EIS (8)(9)(10). Transjugular intrahepatic portosystemic shunt (TIPS) is a metal stent that connects the hepatic vein and intrahepatic portal vein to effectively decrease portal pressure and prevent ascites aggravation and rebleeding (11). It is ideal to maintain the portal pressure gradient of the portal and inferior vena cava between 10 and 12 mm Hg (5).…”

Estatinas e o Fígado: Mito ou Realidade

“…Ressaltamos que a recorrência do sangramento em um ano pode ser de até de 60% e que a mortalidade atual de cada sangramento varia de 15-20%. Também chamamos atenção de que pacientes com varizes de médio/grosso calibre tem risco de sangramento de 25-30% em dois anos 4 .…”