Varices and Variceal Hemorrhage in Cirrhosis: A New View of an Old Problem

Abstract

The management of portal hypertension in cirrhosis has evolved over time leading to improvements in the care and survival of patients with varices and variceal hemorrhage, particularly in those who achieve a significant reduction in portal pressure. In addition to better treatment strategies and improved therapeutic options, the issue of risk stratification has become essential to identify different patient subpopulations that require a different treatment. We now recognize that the management of varices and variceal hemorrhage must be taken in the context of other complications of cirrhosis (ascites, encephalopathy, jaundice) and that the goals of therapy should be based on the presence of such complications. Evolving knowledge of the predominant pathophysiological mechanisms at each of the stages of cirrhosis has also evolved and will continue to lead to improvements in therapy. This review focuses on the management of varices and variceal hemorrhage vis-à-vis refinements in the risk stratification of patients with cirrhosis.

A randomized trial to assess whether portal pressure guided therapy to prevent variceal rebleeding improves survival in cirrhosis

“…Decompensated cirrhosis attributed to VB constitutes a high‐risk setting with greater mortality than while in the compensated stage . Mortality is even greater when, in addition to bleeding, patients develop further decompensation of cirrhosis . In keeping with previous uncontrolled studies, our results suggest that HVPG‐guided therapy may improve risk of developing further decompensation, thus contributing to improve survival.…”

CLIF-C ACLF score is a better mortality predictor than MELD, MELD-Na and CTP in patients with Acute on Chronic Liver Failure admitted to the ward

“…As those are frequently associated with ACLF, a higher prevalence of the syndrome could be expected in our cohort (3). In the same way, gastrointestinal hemorrhage was also more common in our ward but there was a trend for bleeding patients to develop ACLF less frequently, probably because they promptly seek medical care and there were major improvements in the management of this condition in recent years (15). The higher prevalence of identified precipitating factors may be related to different diagnostic procedures between the two studies, namely due to the collection of cultures, to the higher prevalence of SBP due to lower compliance to SBP prophylaxis (the most frequent infection) and to a less perfect guideline approach to variceal bleeding outside a randomized controlled trial.…”

The effect of variceal bleeding on T-cell subsets in patients with cirrhosis

“…Bacterial infections occur more frequently in cirrhotic patients admitted with gastrointestinal bleeding than for other causes [4,5]. During acute variceal hemorrhage, prophylactic antibiotics are mainstay of treatment [6]. That statement has been approved by our study, since we found significant reduction in T helper and NK cells during the episode of bleeding.…”