Prognostic value of early measurements of portal pressure in acute variceal bleeding

Moitinho, Eduardo; Escorsell, Àngels; Bandi, Juan Carlos; Salmerón, Joan–Manuel; García-Pagán, J.C.; Rodés, Juan; Bosch, Jaime

doi:10.1016/s0016-5085(99)70455-5

Cited by 433 publications

(271 citation statements)

References 22 publications

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“…[30][31][32] Patients with an HVPG Ͼ20 mmHg (measured within 24 hours of variceal hemorrhage) have been identified as being at a higher risk for early rebleeding (recurrent bleeding within the first week of admission) or failure to control bleeding (83% vs. 29%) and a higher 1-year mortality (64% vs. 20%) compared to those with lower pressure. 33,34 Late rebleeding occurs in approximately 60% of untreated patients, mostly within 1-2 years of the index hemorrhage. 35,36 Variceal wall tension is probably the main factor that determines variceal rupture.…”

Section: Natural History Of Varicesmentioning

confidence: 99%

“…An elevated HVPG Ͼ20 mmHg (measured within 24 hours of presentation) has been shown to be predictive of treatment failure. 33 Shunt therapy, either shunt surgery (in Child A patients) or TIPS, has proven clinical efficacy as salvage therapy for patients who fail to respond to endoscopic or pharmacological therapy. 106,107 A surgical group has reported almost universal control of bleeding and a low mortality with the performance of portocaval shunt within 8 hours of onset of bleeding in unselected cirrhotic patients collected over a 30-year period.…”

Section: Rescue Therapiesmentioning

confidence: 99%

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Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis

et al. 2007

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Section: Natural History Of Varicesmentioning

confidence: 99%

Section: Rescue Therapiesmentioning

confidence: 99%

Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis

et al. 2007

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“…Finally, it has also been suggested that monitoring of hepatic venous pressure gradient during the acute esophageal variceal bleeding episode can identify patients with a high risk of continued bleeding or early rebleeding. 31,32 This also seems to be the case in patients treated with SMT infusion, 33 suggesting that such an approach could perhaps limit more aggressive alternative therapies to the subgroup of patients with a poor response to pharmacological treatment. However, the value of all these considerations should be adequately assessed in future studies.…”

Section: Discussionmentioning

confidence: 98%

Somatostatin alone or combined with emergency sclerotherapy in the treatment of acute esophageal variceal bleeding: A prospective randomized trial

et al. 1999

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Recent trials have shown that somatostatin (SMT) is as effective as sclerotherapy in the treatment of acute variceal bleeding and that the combination of both treatments is more effective than sclerotherapy alone. To assess whether the addition of sclerotherapy improves the efficacy of SMT alone, all patients admitted to our unit with gastrointestinal bleeding and with suspected cirrhosis received a continuous infusion of SMT (250 g/h). Endoscopy was performed between 1 and 5 hours later, and patients with esophageal variceal bleeding were randomized to receive or not to receive sclerotherapy. In both groups, SMT infusion was continued for 5 days. Fifty patient admissions were allocated to each group. Therapeutic failure occurred in 21 cases of the SMT group and in 7 cases of the combinedtherapy group (P ‫؍‬ .002). Failure to control the acute episode occurred in 24% vs. 8% (P ‫؍‬ .03) and early rebleeding in 24% vs. 7% (P ‫؍‬ .03), respectively. Transfusional requirements were significantly higher in the SMT group, while the incidence of complications was lower (8% vs. 24%; P ‫؍‬ .029). In the multivariate analysis, the presence of shock at admission and active bleeding during endoscopy were the variables that better predicted the failure of therapy with SMT alone. Mortality at 6 weeks was similar. These data demonstrate that the addition of sclerotherapy significantly improves the efficacy of SMT alone for the treatment of acute variceal bleeding, although it also increases the rate of complications. Patients with shock and those with active bleeding are more likely to benefit from this combined therapy. (HEPATOLOGY 1999;30:384-389.)Despite recent therapeutic advances, acute esophageal variceal hemorrhage is still one of the leading causes of death in patients with cirrhosis. 1 Sclerotherapy is widely used as the main emergency treatment in most institutions. Randomized, controlled trials have shown that emergency sclerotherapy (EST) is effective for the control of acute esophageal variceal bleeding, 1 and meta-analysis of comparative studies has suggested that it fares better than balloon tamponade and vasopressin. 1 It has also been suggested that EST reduces the frequency of early rebleeding, 1 which is an important indicator of death risk. 2 However, EST is not always successful, it is associated with a non-negligible rate of serious complications, and it requires a skilled endoscopist, a necessity not always available. 3 Somatostatin (SMT) was introduced for the treatment of acute variceal hemorrhage because of its capacity to decrease portal pressure and collateral splanchnic blood flow, without the adverse effects of vasopressin on the systemic circulation. 4 One placebo-controlled trial failed to show any beneficial effect with SMT, 5 although the high spontaneous success rate observed with placebo suggests that some inadvertent bias could occur in this study. 5 Furthermore, several randomized, controlled trials have shown that SMT is more effective than placebo, 6 and as effective as vasopressin, 7,8 ...

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“…For definitions relative to prophylactic treatment of gastroesophageal varices, primary prophylaxis relates to offering treatment to prevent the first variceal bleed in patients who have never had any previous variceal hemorrhage [5]. Factors associated with the risk of bleeding from varices include size and wall thickness, the presence of endoscopic stigmata such as red signs (an area where the variceal wall is thin, and therefore weakened), the severity of the liver disease, and the portal pressure [8][9][10][11][12]. Several groups have described different classifications of esophageal varices by size, form, color, and stigmata.…”

Section: Definitions Of Varices and Variceal Bleed Prophylaxismentioning

confidence: 99%

Primary prophylaxis of gastroesophageal variceal bleeding: consensus recommendations of the Asian Pacific Association for the Study of the Liver

et al. 2008

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The Asian Pacific Association for the Study of the Liver (APASL) set up a Working Party on Portal Hypertension in 2002, with a mandate to develop consensus guidelines on various clinical aspects of portal hypertension relevant to disease patterns and clinical practice in the Asia-Pacific region. Variceal bleeding is a consequence of portal hypertension, which, in turn, is the major complication of liver cirrhosis. Primary prophylaxis to prevent the first bleed from varices is one of the most important strategies for reducing the mortality in cirrhotic patients. Experts predominantly from the Asia-Pacific region were requested to identify the different aspects of primary prophylaxis and develop the consensus guidelines. The APASL Working Party on Portal Hypertension evaluated the various therapies that have been used for the prevention of first variceal bleeding. A 2-day meeting was held on January 12 and 13, 2007, at New Delhi, India, to discuss and finalize the consensus statements. Only those statements that were unanimously approved by the experts were accepted. These statements were circulated to all the experts and were subsequently presented at the annual conference of the APASL at Kyoto, Japan, in March 2007.

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Prognostic value of early measurements of portal pressure in acute variceal bleeding

Cited by 433 publications

References 22 publications

Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis

Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis

Somatostatin alone or combined with emergency sclerotherapy in the treatment of acute esophageal variceal bleeding: A prospective randomized trial

Primary prophylaxis of gastroesophageal variceal bleeding: consensus recommendations of the Asian Pacific Association for the Study of the Liver

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