Variceal Bleeding and Portal Hypertension: New Lights on Old Horizon

Abstract

New clinical, endoscopic, and imaging modalities for diagnosing varices and predicting bleeding are being investigated. Transnasal endoscopy and ultrathin battery-powered esophagoscopes are being used to improve patient comfort and compliance. Patients who respond to portal pressure-reducing drugs not only have a reduced risk of bleeding, but also a reduced risk of developing other complications, with improved survival. Nitrates have been shown to have no definite role in primary prophylaxis against variceal bleeding. The hemodynamic response to treatment has an independent prognostic value for the risk of variceal bleeding. Newer drugs have been investigated for reducing the hepatic venous pressure gradient, but with little success. Survival after bleeding has increased due to improved patient care and technological advances. Combined radiographic and endoscopic management of gastric varices is evolving and appears to be promising. Nonvariceal bleeding from portal hypertensive gastropathy is increasingly being recognized as a potential cause of bleeding in patients with portal hypertension, and pharmacotherapy with octreotide appears to be promising for the treatment of this condition. Variceal band ligation in children has been found to be as safe and effective as in adults.

Predictive Factors for Rebleeding and Death in Alcoholic Cirrhotic Patients with Acute Variceal Bleeding: A Multivariate Analysis

“…Several previous studies have sought to identify prognostic indicators associated with early variceal rebleeding. In these studies multivariate analyses have demonstrated that the following features have been reported as independent prognostic factors for early rebleeding and significant predictors of risk for 5-day failure: active bleeding at emergency endoscopy [20,[23][24][25][26], variceal size [27], Child-Pugh grade [20,21,25,27,28], Child-Pugh score [23,25,29,30], hematocrit level [20,29], bacterial infection [25,29,31,32], encephalopathy [23], portal vein thrombosis [20], platelet count [23], hepatocellular carcinoma [27,29], continued alcohol abuse [23,27,29], hypoalbuminemia [25], and a hepatic venous pressure gradient [20 mmHg measured shortly after hospital admission [29,[33][34][35]. The aggregate conclusions of these studies are, however, discordant, and the predictive value of the combined results is difficult to assess from the data.…”

“…Although several prognostic models have been proposed to predict mortality in patients with cirrhosis [5,21,30,38,45,47], the Child-Pugh score remains the most widely used scoring system both in clinical practice and in clinical research [51], and it is superior to any other predictive factor in determining mortality within the first 6 weeks after a major variceal bleed [26,28,[52][53][54]. In a systematic review of 118 studies of cirrhotic patients, the most common independent predictor of death was the overall Child-Pugh score, followed by each of the five components of the Child-Pugh score [51].…”

“…Several studies have evaluated the clinical factors associated with early mortality after endoscopic intervention for acute variceal bleeding. Previous investigators have shown that the severity of the bleeding episode (shock on admission to the hospital) and the Child‐Pugh grade [21] are independent predictors of short‐term mortality, whereas others have reported that a Child‐Pugh score >9, orthostatic hypotension, systolic blood pressure <100 mmHg, diastolic pressure of <60 mmHg, failure to control bleeding, placement of a Minnesota tube, airway intubation, transfusion requirement >5 units, and aspiration pneumonia were associated with an increased in‐hospital mortality [5, 30]. In a retrospective study of 124 cirrhotic patients with variceal bleeding, Le Moine et al found that of 24 variables studied, encephalopathy, prothrombin time, and the number of blood units transfused within 72 h had independent prognostic value [38].…”

Histopathological study of vascular changes after intra‐arterial and intravenous injection of N‐butyl‐2‐cyanoacrylate

“…This polymerization reaction results in immediate occlusion of varices on injection. Since then, cyanoacrylate compounds have been used in embolization of aneurysms, arteriovenous malformations and fistulae, and vascular lacerations 6 . N‐butyl‐2‐cyanoacrylate (Histoacryl) is the most commonly used cyanoacrylate glue, and another N‐butyl‐2‐cyanoacrylate, Glubran (GEM, Viareggio, Italy), has also been approved recently for endoscopic use in Europe.…”

Endoscopic Treatment of Gastrointestinal Bleedings

“…Almost all patients have fever, transient dysphagia and chest pain. Other possible complications are chest pain, aspiration pneumonia, pleural effusions and mediastinitis [10,11]. Frequency of complications depends on the experience of the operator and is proportional to the amount of sclerosant injected; and mortality induced complications are between 2-5%.…”