Bleeding from varices – viewpoint on therapy after Baveno VI

Česká verzia

Authors: T. Fejfar; V. Jirkovský; Š. Šembera; T. Vaňásek; P. Hůlek
Authors place of work: II. interní gastroenterologická klinika LF UK a FN Hradec Králové
Published in the journal: Gastroent Hepatol 2016; 70(2): 125-132
Category: Hepatology: Review article
doi: https://doi.org/10.14735/amgh2016125

Summary

Variceal bleeding is the most severe life-threatening complication of portal hypertension. Currently, clear therapeutic algorithms are used, which include initial general management, fluid replacement, haemosubstitution, antibiotic prophylaxis, vasoactive medication and endoscopic intervention. A transjugular intrahepatic portosystemic shunt (TIPS) created using a PTFE-covered stent is recommended when these treatment regimens fail. A dedicated oesophageal metal stent or a balloon tamponade can be used as a bridge to the TIPS or in the case of TIPS contraindications. No selective β-blockers or endoscopic therapy is used in prophylaxis.

Key words:
portal hypertension – hemorrhage – therapy

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manuscript met the ICMJE „uniform requirements“ for biomedical papers.

Submitted:
24. 2. 2016

Accepted:
2. 4. 2016

Zdroje

1. De Franchis R et al. Portal hypertension IV. Proceedings of the Fourth Baveno International Consensus Workshop. London: Blackwell Publishing Ltd. 2006.

2. De Franchis R et al. Portal Hypertension V. Proceedings of the Fifth Baveno International Consensus Workshop. London: Blackwell Publishing Ltd. 2011.

3. North Italian Endoscopic Club for Study and Treatment of Esophageal Varices. Prediction of the first variceal haemorrhage in patiens with cirrhosis of the liver and esophageal varices. A prospective multicenter study. N Engl J Med 1988; 319(15): 983–989.

4. Carbonell N, Pauwels A, Sarfaty L et al. Improved survival after variceal bleeding in patients with cirrhosis over the past two decades. Hepatology 2004; 40(3): 652–659.

5. De Franchis R. Baveno VI Faculty. Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63(3): 743–752. doi: 10.1016/j.jhep.2015.05.022.

6. Villanueva C, Colomo A, Bosch A et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013; 368(1): 11–21. doi: 10.1056/NEJMoa 1211801.

7. Bosch J, Thabut D, Albillos A et al. Recombinant factor VIIa for variceal bleeding in patients with advanced cirrhosis: a randomised, controlled trial. Hepatology 2008; 47(5): 1604–1614. doi: 10.1002/hep.22216.

8. Bendtsen F, D’Amico G, Rusch E et al. Effect of recombinant Factor VIIa on outcome of acute variceal bleeding: an individual patient based meta-analysis of two controlled trials. J Hepatol 2014; 61(2): 252–259. doi: 10.1016/j.jhep.2014.03.035.

9. Goulis J, Armonis A, Patch D et al. Bacterial infection is independently associated with failure to control bleeding in cirrhotic patients with gastrointestinal hemorrhage. Hepatology 1998; 27(5): 1207– 1212.

10. Bernard B, Grangé JD, Khac EN et al. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology 1999; 29(6): 1655– 1661.

11. Soares-Weiser K, Brezis M, Tur-Kaspa Ret al. Antibiotic prophylaxis for cirrhotic patients with gastrointestinal bleeding. Cochrane Database Syst Rev 2002; 9(2): CD002907.

12. Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila FI et al. Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding. Cochrane Database Syst Rev 2010; 8(9): CD002907. doi: 10.1002/14651858.CD002907.pub2.

13. Tandon P, Abraldes JG, Keough A et al. Risk of bacterial infection in patients with cirrhosis and acute variceal hemorrhage, based on Child-Pugh class, and effects of antibiotics. Clin Gastroenterol Hepatol 2015; 13(6): 1189–1196. doi: 10.1016/j.cgh.2014.11.019.

14. American Association for the Study of Liver Diseases; European Association for the Study of the Liver. Hepatic encephalopathy in chronic liver disease: 2014. Practice guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases. J Hepatol 2014; 61(3): 642–659. doi: 10.1016/j.jhep.2014.05.042.

15. Vilstrup H, Amodio P, Bajaj J et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for theStudy of Liver Diseases and the European Association for the Study of the Liver. Hepatology 2014; 60(2): 715–735. doi: 10.1002/hep.27210.

16. Hůlek P, Krajina A (eds). Current Practice of TIPS. Hradec Králové: Olga Štambergová 2001.

17. Merkel C, Gatta A, Bolognesi M et al. Hemodynamic changes of systemic, hepatic and splenic circulation following triglycyl-lysin-vasopressin administration in alcoholic cirrhosis. Dig Dis Sci 1988; 33(9): 1103–1109.

18. Møller S, Hansen EF, Becker U et al. Central and systemic haemodynamic effect of terlipressin in portal hypertensive patients. Liver 2000; 20(1): 51– 59.

19. Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 2003; 1: CD002147.

20. Wells M, Chande N, Adams P. Meta-analysis: vasoactive medications for the management of acute variceal bleeds. Aliment Pharmacol Ther 2012; 35(11): 1267– 1278. doi: 10.1111/j.1365-2036.2012.05088.x.

21. Yim SY, Seo YS, Jung CH et al. Risk factors for developing hyponatremia during terlipressin treatment: a retrospective analyses in variceal bleeding. J Clin Gastroenterol 2015; 49(7): 607–712. doi: 10.1097/MCG.0000000000000217.

22. Moitinho E, Planas R, Banares R et al. Multicenter randomised controlled trial comparing different schedules of somatostatin in the treatment of acute variceal bleeding. J Hepatol 2001; 35(6): 712–718.

23. Vilanueva C, Planella M, Arycil C et al. Hemodynamic effects of terlipressin and high somatostatin dose during acute variceal bleeding in nonresponders to the usual somatostatin dose. Am J Gastroenterol 2005; 100(3): 624–630.

24. Seo YS, Park SY, Kim MY et al. Lack of difference among terlipressin, somatostatin, and octreotide in the control of acute gastroesophageal variceal hemorrhage. Hepatology 2014; 60(3): 954–963. doi: 10.1002/hep.27006.

25. D’Amico G, Pietrosi G, Tarantino I et al. Emergency sclerotherapy versus vasoactive drugs for variceal bleeding in cirrhosis: a Cochrane meta-analysis. Gastroenterology 2003; 124(5): 1277–1291.

26. D’Amico G, Pagliaro L, Pietrosi G et al. Emergency sclerotherapy versus vasoactive drugs for variceal bleeding in cirrhotic patients. Cochrane Database Syst Rev 2010; 3: CD002233. doi: 10.1002/14651858.CD002233.pub2.

27. Bai Y, Guo JF, Li ZS. Meta-analysis: erythromycin before endoscopy for acute upper gastrointestinal bleeding. Aliment Pharmacol Ther 2011; 34(2): 166–171. doi: 10.1111/j.1365-2036.2011.04708.x.

28. Theivanayagam S, Lim RG, Cobell WJet al. Administration of erythromycinbefore endoscopy in upper gastrointestinal bleeding: a meta-analysis of randomized controlled trials. Saudi J Gastroenterol 2013; 19(5): 205–210. doi: 10.4103/1319-3767.118120.

29. Lo GH, Lai KH, Cheng JS et al. Emergency banding ligation versus sclerotherapy for the control of active bleeding from esophageal varices. Hepatology 1997; 25(5): 1101–1104.

30. Villanueva C, Piqueras M, Aracil C at al. A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding. J Hepatol 2006; 45(4): 560–567.

31. Bañares R, Albilos A, Rincon D et al. Endoscopoc treatment versus endoscopic plus pharmacologic treatment for acute variceal bleeding:a meta-analysis. Hepatology 2002; 35(3): 609–615.

32. Abraldes JG, Villanueva C, Bañares R et al. Hepatic venous pressure gradient and prognosis in patients with acute variceal bleeding treated with pharmacologic and endoscopic therapy. J Hepatol 2008; 48(2): 229–236.

33. D’Amico G, De Franchis R. Upper digestive bleeding in cirrhosis. Posttherapeutic outcome and prognostic indicators. Hepatology 2003; 38(3): 599–612.

34. Cárdenas A, Ginès P, Uritz J et al. Renal failure after upper gastrointestinal bleeding in cirrhosis: incidence, clinical course, predictive factors and short-term prognosis. Hepatology 2001; 34 (4 Pt 1): 671–676.

35. Avgerinos A, Armonis A. Balloon tamponade technique and efficacy in variceal haemorrhage. Scand J Gastroenterol Suppl 1994; 207: 11–16.

36. Zehetner J, Shamiyeh A, Wayand W et al. Results of a new method to stop acute bleeding from esophageal varices: implantation of a self-expanding stent. Surg Endosc 2008; 22(10): 2149–2152. doi: 10.1007/s00464-008-0009-7.

37. Wright G, Lewis H, Hogan B et al. A self-expanding metal stent for complicated variceal hemorrhage: experience at a single center. Gastrointest Endosc 2010; 71(1): 71–78. doi: 10.1016/j.gie.2009.07.028.

38. Fejfar T, Šafka V, Jirkovský V et al. Danišův jícnový stent v terapii varikózního krvácení. Gastroent Hepatol 2013; 67(2): 98–103.

39. Sanyal AJ, Freedman AM, Luketic VA et al. Transjuglar intrahepatic portosystemic shunts for patients with active variceal hemorrhage unresponsive to sclerotherapy. Gastroenterology 1996; 111(1): 138–146.

40. Chau TN, Patch D, Chan YW et al. “Salvage“ transjugular intrahepatic portosystemic shunts: gastric fundal compared with esophageal variceal bleeding. Gastroenterology 1998; 114(5): 981–987.

41. Krajina A, Hulek P, Fejfar T et al. Quality improvement guidelines for Transjugular Intrahepatic Portosystemic shunt (TIPS). Cardiovasc Intervent Radiol 2012; 35(6): 1295–1300. doi: 10.1007/s00270-012-0493-y.

42. Gluud LL, Krag A. Banding ligation versus beta-blockers for primary prevention of oesophageal verices in adults. Cochrane Database Syst Rev 2012; 8: CD004544. doi: 10.1002/14651858.CD004544.pub2.

43. Tripathi D, Hayes PC. Beta-blockers in portal hypertension: new developments and controversies. Liv Intern 2014; 34(5): 655–667. doi: 10.1111/liv.12360.

44. Ohnishi K, Nakayama T, Saito M et al. Effects of propranolol on portal hemodynamics in patients with chronic liver disease. Am J Gastroenterol 1985; 80(2): 132–135.

45. Mastai R, Bosch J, Navasa M et al. Effects of alpha-adrenergic stimulation and beta-adrenergic blockade on azygos blood flow and splanchnic haemodynamics in patients with cirrhosis. J Hepatol 1987; 4(1): 71–79.

46. Sinagra E, Perricone G, D’Amico M et al. Systematic review with meta-analysis: the haemodynamic effects of carvedilol compared with propranolol for portal hypertension in cirrhosis. Aliment Pharmacol Ther 2014; 39(6): 557–568. doi: 10.1111/apt.12634.

47. Akbas H, Ozden M, Kanko M et al. Protective antioxidant effects of carvedilol in a rat model of ischaemia-reperfusion injury. J Int Med Res 2005; 33(5): 528–536.

48. Hamdy N, El-Demerdash E. New therapeutic aspect for carvedilol: antifibrotic effects of carvedilol in chronic carbon tetrachloride-induced liver damage. Toxicol Appl Pharmacol 2012; 261(3): 292–299. doi: 10.1016/j.taap.2012.04.012.

49. Bakris GL, Fonseca V, Katholi RE et al. Metabolic effects of carvedilol vs metoprolol in patients with type 2 diabetes mellitus and hypertension: a randomized controlled trial. JAMA 2004; 292(18): 2227–2236.

50. Bruha R, Vitek L, Petrtyl J et al. Effect of carvedilol on portal hypertension depends on the degree of endothelial activation and inflammatory changes. Scand J Gastroenterol 2006; 41(12): 1454–1463.

51. Lo GH, Chen WC, Wang HM et al. Randomized, controlled trial of carvedilol versus nadolol plus isosorbide mononitrate for the prevention of variceal rebleeding. J Gastroentol Hepatol 2012; 27(11): 1681– 1687. doi: 10.1111/j.1440-1746.2012.07244.x.

52. Groszmann RJ, Garcia-Tsao G, Bosch Jet al. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis. N Engl J Med 2005; 353(21): 2254–2261.

53. Vlachogiannakos J, Goulis J, Patch D et al. Review article: primary prophylaxis for portal hypertensive bleeding in cirrhosis. Aliment Pharmacol Ther 2000; 14(7): 851–860.

54. Tripathi D, Hayes PC. Review article: a drug therapy for the prevention of variceal haemorrhage. Aliment Pharmacol Ther 2001; 15(3): 291–310.

55. Imperiale T, Chalasani N. A meta-analysis of endoscopic variceal ligation for primary prophylaxis of esophageal variceal bleeding. Hepatology 2001; 33(4): 802–807.

56. Grace N, Lo GH, Nevens F et al. Preventing rebleeding in 2010. In: De Franchis R et al. Portal Hypertension V. Proceedings of the Fifth Baveno International Consensus Workshop. London: Blackwell Publishing Ltd. 2011.

57. Monescillo A, Martínez-Lagares F, Ruiz-del-Arbol L et al. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology 2004; 40(4): 793–801.

58. García-Pagán JC, Caca K, Bureau C et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 2010; 362(25): 2370–2379. doi: 10.1056/NEJMoa0910102.

59. Garcia-Pagán JC, Di Pascoli M, Caca Ket al. Use of early-TIPS for high-risk variceal bleeding: results of a post-RCT surveillance study. J Hepatol 2013; 58(1): 45–50. doi: 10.1016/j.jhep.2012.08.020.

60. Lo GH, Lai KW, Cheng JS et al. Endoscopic variceal ligation plus nadolol and sucralfate compared with ligation alone for the prevention of variceal rebleeding: a prospective, randomised trial. Hepatology 2000; 32(3): 462–465.

61. de la Peña J, Brullet E, Sanchez-Hernández E et al. Variceal ligation plus nadolol compared with ligation for prophyla for prophylaxis of variceal rebleeding: a multicenter trial. Hepatology 2005; 41(3): 572–578.

62. Sersté T, Francoz C, Durand F et al. Beta-blockers cause paracentesis-induced circulatory dysfunction in patients with cirrhosis and refraktory ascites: a crossover study. J Hepatol 2011; 55(4): 794–799. doi: 10.1016/j.jhep.2011.01.034.

63. Sersté T, Melot C, Francoz C et al. Deleterious effect of beta-blockers on survival in patients with cirrhosis and refractory ascites. Hepatology 2010; 52(3): 1017–1022. doi: 10.1002/ hep.23775.

64. Krag A, Wiest R, Albillos A et al. The window hypothesis: haemodynamic and non-haemodynamic effect of beta-blockers improve survival of patients with cirrhosis during a window in the disease. Gut 2012; 61(7): 967–969. doi: 10.1136/gutjnl-2011-301348.

65. Ge PS, Runyon BA. The changing role of beta-blocker therapy in patients with cirrhosis. J Hepatol 2014; 60(3): 643–653. doi: 10.1016/j.jhep.2013.09.016.

66. Garcia-Tsao, Sanyal AJ, Grace ND et al. Prevention and managament of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007; 46(3): 922–938.

67. Ryan BM, Stockbrugger RW, Ryan JM. A pathophysiologic, gastroenterologic and radiologic approach to the managament of gastric varices. Gastroenterology 2004; 126(4): 1175–1189.

68. Sarin SK, Kumar A. Gastric varices: profile, classification and management. Am J Gastroenterol 1989; 84(10): 1244–1249.

69. Lo GH, Lai KH, Cheng JS et al. A prospective randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices. Hepatology 2001; 33(5): 1060–1064.

70. Tan PC, Hou MC, Lin HC et al. A randomized trial of endoscopic treatment of acute gastric variceal haemorrhage: N-butyl-2-cyanoacrylate injection versus band ligation. Hepatology 2006; 43(4): 690–697.

71. Tripathi D, Therapondos G, Jackson E et al. The role of the transjugular intrahepatic portosystemic stent shunt (TIPSS) in the management of bleeding gastric varices: clinical and haemodynamic correlations. Gut 2002; 51(2): 270–274.