Sustained rise of portal pressure after sclerotherapy, but not band ligation, in acute variceal bleeding in cirrhosis

Abstract

During variceal bleeding, several factors may increase portal pressure, which in turn may precipitate further bleeding. This study investigates the early effects of endoscopic injection sclerotherapy (EIS) and endoscopic band ligation (EBL) on hepatic venous pressure gradient (HVPG) during acute bleeding and the possible influence in outcome. In 50 cirrhotic patients with bleeding esophageal varices treated with EIS (n ‫؍‬ 25) or EBL (n ‫؍‬ 25), we performed repeated HVPG measurements before and immediately after endoscopic treatment (time 0) and every 24 hours for a 5-day period. Endotherapy was continued until the varices were too small for further treatment. Both groups were comparable with regard to age, gender, Child-Turcotte-Pugh grade, and HVPG. In the EBL and EIS groups, a significant (P < .0001) increase was observed in mean portal pressure (20.7 mm Hg ؎ 4.4 SD and 21.5 mm Hg ؎ 4.5 SD, respectively) immediately after treatment (time 0) as compared with pretreatment (18.1 ؎ 4.5 and 18.1 ؎ 4.0). However, HVPG in the EBL group returned to baseline values within 48 hours after treatment, while in the EIS group it remained high during the 120-hour study period (P < .0001). Bleeding stopped in all patients after endotherapy. During the 42-day follow-up period, the rebleeding rate over time was lower in the EBL group compared with the EIS group (P ‫؍‬ .024). Patients with an initial HVPG greater than 16 mm Hg had, despite endoscopic treatment, a significantly higher likelihood of rebleeding (P ‫؍‬ .05) and death (P ‫؍‬ .024) and overall failure (P ‫؍‬ .037). In conclusion, during acute variceal bleeding EIS, but not EBL, causes a sustained increase in HVPG, which is followed by a higher rebleeding

Clinical trial: the effect of somatostatin vs. octreotide in preventing post‐endoscopic increase in hepatic venous pressure gradient in cirrhotics with bleeding varices

“…death. 5 Importantly, in our study, HVPG value after endoscopy was the only independent prognostic factor of failure, highlighting the need for prevention of postendoscopy increase in HVPG. It may be postulated that the presence of blood in the gut or blood volume restitution could affect HVPG.…”

“…of HVPG changes in both groups. 5 Using a two-tailed paired Student's t-test, 16 patients in each arm were required to obtain this effect with an a-error of 0.05 and b-error of 0.8. Categorical data were analysed using the chi-squared test with Yate's correction or Fisher's exact test as appropriate.…”

“…3,4 However, previous studies showed that portal pressure, as evaluated by hepatic venous pressure gradient (HVPG), increases significantly after endoscopic therapy. [5][6][7] HVPG is the major factor determining variceal rupture 8 and patients with a higher HVPG have a greater risk of further bleeding and death. 5,9 Somatostatin (SST) is widely used in the treatment of variceal bleeding because it decreases the portal pressure and the collateral blood flow without significant adverse effects on systemic circulation.…”

“…[5][6][7] HVPG is the major factor determining variceal rupture 8 and patients with a higher HVPG have a greater risk of further bleeding and death. 5,9 Somatostatin (SST) is widely used in the treatment of variceal bleeding because it decreases the portal pressure and the collateral blood flow without significant adverse effects on systemic circulation. 10,11 However, haemodynamic and clinical data are not so consistent when other agents such as octreotide (OCT) are used.…”

Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis

“…62 In addition, one of the studies included in the meta-analysis showed that although HVPG increased significantly immediately after both EVL and sclerotherapy, it remained elevated for the duration of the study (5 days) in the sclerotherapy group while HVPG had decreased to baseline levels by 48 hours after EVL. 104 Therefore, by consensus, EVL is the preferred form of endoscopic therapy for acute esophageal variceal bleeding, although sclerotherapy is recommended in patients in whom EVL is not technically feasible. 7 Combination of pharmacological therapy and endoscopic therapy is the most rational approach in the treatment of acute variceal hemorrhage.…”