The treatment of portal hypertension: A meta-analytic review

D’Amico, Gennaro; Pagliaro, Luigi; Bosch, Jaime

doi:10.1002/hep.1840220145

Cited by 856 publications

(787 citation statements)

References 173 publications

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“…Approximately one-third of cirrhosis patients with esophageal varices bleed and the mortality rate associated with first bleed may reach 50%, although it has decreased in recent years. [1][2] To manage varices with potential risks of rupture, both endoscopic methods and pharmacologic therapy have been tried with some success. Endoscopic injection sclerotherapy (EIS) has been a well-established method in the management of acute bleeding from esophageal varices as well as in the prevention of rebleeding.…”

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confidence: 99%

Controlled Trial of Ligation Plus Nadolol Versus Nadolol Alone for the Prevention of First Variceal Bleeding

Chen

Wang

et al. 2010

Hepatology

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Both nadolol and ligation have proved to be effective in the prophylaxis of first variceal bleeding. This study was conducted to evaluate the effects and safety of combining nadolol with ligation. Cirrhotic patients with high-risk esophageal varices but without a bleeding history were considered for enrolment. Eligible patients were randomized to receive band ligation plus nadolol (Combined group, 70 patients) or nadolol alone (Nadolol group, 70 patients). In the Combined group multiligators were applied. Patients received regular ligation treatment at an interval of 4 weeks until variceal obliteration. Nadolol was administered at a dose to reduce 25% of the pulse rate in both the Combined group and the Nadolol group. Both groups were comparable in baseline data. In the Combined group 50 patients (71%) achieved variceal obliteration. The mean dose of nadolol was 52 ± 16 mg in the Combined group and 56 ± 19 mg in the Nadolol group. During a median follow-up of 26 months, 18 patients (26%) in the Combined group and 13 patients (18%) in the Nadolol group experienced upper gastrointestinal bleeding ( P = NS). Esophageal variceal bleeding occurred in 10 patients (14%) in the Combined group and nine patients (13%) in the Nadolol group ( P = NS). Adverse events were noted in 48 patients (68%) in the Combined group and 28 patients (40%) in the Nadolol group ( P = 0.06). Sixteen patients in each group died. Conclusion: The addition of ligation to nadolol may increase adverse events and did not enhance effectiveness in the prophylaxis of first variceal bleeding. (Hepatology 2010)

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Controlled Trial of Ligation Plus Nadolol Versus Nadolol Alone for the Prevention of First Variceal Bleeding

Chen

Wang

et al. 2010

Hepatology

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“…4 This has been thereafter confirmed by other studies, 6 emphasizing the concept that pharmacological treatment represents the optimal therapy in the subgroup of patients achieving such a pronounced decrease in HVPG. [1][2][3][4] Unfortunately, there is no adequate noninvasive way of assessing the HVPG response to treatment, which calls for repeated invasive hemodynamic studies.Several endoscopic findings, such as the size of the varices and the presence of red color signs (which are thought to reflect a reduced thickness of variceal wall) show a significant correlation with the risk of bleeding. 1,7,8 These are some of the main determinants of variceal wall tension, 7 which is believed to play a key role in determining variceal rupture.…”

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Predictive value of the variceal pressure response to continued pharmacological therapy in patients with cirrhosis and portal hypertension

et al. 2000

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Noninvasive measurements of variceal pressure adequately reflect the hemodynamic effects of propranolol on portal hypertension. However, the prognostic value of variceal pressure responses during continued propranolol therapy has not been evaluated, and it is unclear whether this may substitute invasive measurements of portal pressure response. Fifty-five portal hypertensive patients with cirrhosis were studied before and at 4 months of continued propranolol therapy. Variceal pressure was measured using an endoscopic pressure gauge. Portal pressure was evaluated as the hepatic venous pressure gradient (HVPG). Over a 28 ؎ 11 month follow-up, 16 patients experienced variceal bleeding. Baseline characteristics were similar in bleeders and nonbleeders. At 4 months, reduction in variceal pressure was less marked in bleeders than in nonbleeders (5% ؎ 20% vs. ؊15% ؎ 24%; P ‫؍‬ .03). A fall in variceal pressure 20% or greater of baseline was an independent predictor of absence of variceal bleeding; which occurred in 5% of patients with a 20% or greater fall in variceal pressure versus 42% of patients with less than a 20% reduction (P ‫؍‬ .004). The HVPG response had similar independent prognostic value (decrease H20%: 6% bleeding; decrease F20%: 45% bleeding; P ‫؍‬ .004) but identified different patients. Achieving a 20% decrease in either variceal pressure or HVPG was highly sensitive (85%) and specific ( Variceal bleeding is the most frequent and severe complication of portal hypertension in patients with cirrhosis. 1 Several treatment options are available to prevent recurrent variceal bleeding, including pharmacological therapy, endoscopic banding ligation, and surgical or transjugular intrahepatic portosystemic shunts (TIPS). 1,2 It has been recently shown that pharmacological treatment with propranolol offers almost optimal protection from bleeding and rebleeding when the portal venous pressure (estimated by the hepatic venous pressure gradient [HVPG]), achieves a target reduction. 3,4 The risk of bleeding or rebleeding is virtually abolished when the HVPG decreases to 12 mm Hg or below, 3-5 and the actuarial risk of rebleeding at 2 years is only 9% when the HVPG is reduced by at least 20% of the baseline value. 4 This has been thereafter confirmed by other studies, 6 emphasizing the concept that pharmacological treatment represents the optimal therapy in the subgroup of patients achieving such a pronounced decrease in HVPG. [1][2][3][4] Unfortunately, there is no adequate noninvasive way of assessing the HVPG response to treatment, which calls for repeated invasive hemodynamic studies.Several endoscopic findings, such as the size of the varices and the presence of red color signs (which are thought to reflect a reduced thickness of variceal wall) show a significant correlation with the risk of bleeding. 1,7,8 These are some of the main determinants of variceal wall tension, 7 which is believed to play a key role in determining variceal rupture. 7,9 According to Laplace' s law, variceal wall tension is directly re...

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“…To date, there is no reported randomized controlled trial of pharmacologic therapy for primary prophylaxis of bleeding from gastric varices. Nonetheless, it may be acceptable practice to use nonselective b-blockers for primary prophylaxis in patients with gastric varices because it would be logical to assume that reduction in HVPG should have beneficial effects [82].…”

Section: Recommendationsmentioning

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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The treatment of portal hypertension: A meta-analytic review

Cited by 856 publications

References 173 publications

Controlled Trial of Ligation Plus Nadolol Versus Nadolol Alone for the Prevention of First Variceal Bleeding

Controlled Trial of Ligation Plus Nadolol Versus Nadolol Alone for the Prevention of First Variceal Bleeding

Predictive value of the variceal pressure response to continued pharmacological therapy in patients with cirrhosis and portal hypertension

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

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