Variceal and other portal hypertension related bleeding

Turón, Fanny; Casu, Stefania; Hernández‐Gea, Virginia; García‐Pagán, Juan Carlos

doi:10.1016/j.bpg.2013.08.004

Cited by 55 publications

(35 citation statements)

References 115 publications

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“…Nonresponse to β-adrenergic receptor antagonists, defined as continued bleeding despite this therapy and transfusion-dependency despite iron replacement therapy, should prompt consideration of interventional therapies [214] . Nonspecific β-adrenergic receptor antagonists are a first line therapy for secondary prophylaxis of PHG bleeding [191,208] . Nadolol alone was as effective as nadolol with isosorbide mononitrate in preventing the first episode of PHG bleeding [226] .…”

Section: Pharmacotherapy For Phgmentioning

confidence: 99%

Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy

Gjeorgjievski¹

2016

WJH

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AIM:To describe the pathophysiology, clinical presentation, natural history, and therapy of portal hypertensive gastropathy (PHG) based on a systematic literature review. METHODS:Computerized search of the literature was performed via PubMed using the following medical subject headings or keywords: "portal" and "gastropathy"; or "portal" and "hypertensive"; or "congestive" and "gastropathy"; or "congestive" and "gastroenteropathy". The following criteria were applied for study inclusion: Publication in peer-reviewed journals, and publication since 1980. Articles were independently evaluated by each author and selected for inclusion by consensus after discussion based on the following criteria: Well-designed, prospective trials; recent studies; large study populations; and study emphasis on PHG. RESULTS:PHG is diagnosed by characteristic endoscopic findings of small polygonal areas of variable erythema surrounded by a pale, reticular border in a mosaic pattern in the gastric fundus/body in a patient with cirrhotic or non-cirrhotic portal hypertension. Histologic findings include capillary and venule dilatation, congestion, and tortuosity, without vascular fibrin thrombi or inflammatory cells in gastric submucosa. PHG is differentiated from gastric antral vascular ectasia by a different endoscopic appearance. The etiology of PHG is inadequately understood. Portal hypertension is necessary but insufficient to develop PHG because many patients have portal hypertension without PHG. Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy PHG increases in frequency with more severe portal hypertension, advanced liver disease, longer liver disease duration, presence of esophageal varices, and endoscopic variceal obliteration. PHG pathogenesis is related to a hyperdynamic circulation, induced by portal hypertension, characterized by increased intrahepatic resistance to flow, increased splanchnic flow, increased total gastric flow, and most likely decreased gastric mucosal flow. Gastric mucosa in PHG shows increased susceptibility to gastrotoxic chemicals and poor wound healing. Nitrous oxide, free radicals, tumor necrosis factor-alpha, and glucagon may contribute to PHG development. Acute and chronic gastrointestinal bleeding are the only clinical complications. Bleeding is typically mild-to-moderate. Endoscopic therapy is rarely useful because the bleeding is typically diffuse. Acute bleeding is primarily treated with octreotide, often with concomitant proton pump inhibitor therapy, or secondarily treated with vasopressin or terlipressin. Nonselective β-adrenergic receptor antagonists, particularly propranolol, are used to prevent bleeding after an acute episode or for chronic bleeding. Iron deficiency anemia from chronic bleeding may require iron replacement therapy. Transjugular-intrahepaticportosystemic-shunt and liver transplantation are highly successful ultimate therapies because they reduce the underlying portal hypertension. SYSTEMA...

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Section: Pharmacotherapy For Phgmentioning

confidence: 99%

Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy

Gjeorgjievski¹

2016

WJH

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“…However, with improved surgical techniques, the use of blood products was reduced to a large extent [7]. Bleeding at surgery in patients with cirrhosis is now attributed mainly to technical issues and to portal hypertension [8], not to an acquired coagulopathy. Indeed, patients with cirrhosis have a preserved capacity to generate thrombin in vitro, provided that platelet counts are above 60x10 9 /L [9].…”

Section: Coagulopathy In Cirrhosismentioning

confidence: 99%

Splanchnic and Extrasplanchnic Thrombosis in Cirrhosis: Prophylaxis vs Treatment

Nery

Valla

2014

Curr Hepatology Rep

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Venous thromboembolism (deep vein thrombosis and pulmonary embolism) and portal vein thrombosis (PVT) occur in up to 6.3 % and 15.9 % of patients with cirrhosis, respectively. There is recent evidence that a procoagulable prothrombotic state is related to cirrhosis despite the reduced levels of many coagulation factors, and decreased platelet counts. Indeed, (i) the combination of high levels of factor VIII, with low levels of protein C and antithrombin induces a procoagulant state in vitro; while (ii) increased levels of von Willebrand factor and decreased ADAMTS 13 activity can compensate for decreased platelet counts.

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“…Fluid resuscitation should be initiated as soon as possible aiming to maintain a systolic blood pressure around 90 to 100 mmHg. Prolonged periods of hypotension should be avoided to prevent complications such as infection and renal failure, which are associated with increased morbidity and mortality and a higher risk of rebleeding [35,36]. As with other forms of gastrointestinal bleeding, transfusion of blood should be performed cautiously using a restrictive strategy aiming to maintain the haemoglobin level between 7 and 8 g/dl; this is associated with significantly improved outcomes in patients with acute upper gastrointestinal bleeding [37].…”

Section: Assessment and Medical Managementmentioning

confidence: 99%

The Management of Bleeding from Anorectal Varices

Robertson

Thompson

Hayes

2017

Curr Hepatology Rep

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Purpose of Review The purpose of this review is to summarize available strategies for the diagnosis and management of bleeding anorectal varices. Recent Findings Interventional radiological procedures, including TIPS, BRTO and/or embolization, have been established as efficacious treatments, particularly in the setting of treatment failure. Summary Anorectal varices are prevalent in patients with portal hypertension. Acute bleeding is uncommon, but can be massive and life-threatening. Anorectal varices should be considered as a differential diagnosis in any patient with cirrhosis or portal hypertension who presents with lower gastrointestinal bleeding. No evidence-based guidelines exist to guide the management of bleeding anorectal varices, which typically requires a multidisciplinary team of endoscopists, hepatologists, surgeons and interventional radiologists. Administration of prophylactic antibiotics and vasoactive therapy is recommended based on efficacy in bleeding oesophageal varices. Urgent endoscopy should be performed in all patients. Endoscopic sclerotherapy has the greatest body of evidence and should be considered the first-line therapy; efficacy and safety may be increased if this is performed with endoscopic ultrasound. Endoscopic banding or obturation are alternative first-line treatments; all methods offer a technically simple and efficacious method of achieving haemostasis, and local expertise will determine which procedure is employed.

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Variceal and other portal hypertension related bleeding

Cited by 55 publications

References 115 publications

Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy

Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy

Splanchnic and Extrasplanchnic Thrombosis in Cirrhosis: Prophylaxis vs Treatment

The Management of Bleeding from Anorectal Varices

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