Effects of propranolol on the hepatic hemodynamic response to physical exercise in patients with cirrhosis

Bandi, Juan Carlos; García–Pagán, Joan Carles; Escorsell, Àngels; François, Erik; Moitinho, Eduardo; Rodés, Joan; Bosch, Jaume

doi:10.1002/hep.510280312

Cited by 70 publications

(38 citation statements)

References 28 publications

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“…However, the exact time of the development of hepatocelluar carcinoma cannot be clearly defi ned; therefore, the hepatocelluar carcinoma was also excluded to prevent bias. Further, isometric exercise may increase portal pressure, theoretically increase risk of EV bleeding ( 10,11 ); however, the potential risk of exercise on EV bleeding was, again, not assessed because it is diffi cult to translate and quantify daily activity to exercise amount.…”

Section: Liver Precipitating Factors Of Ev Bleedingmentioning

confidence: 99%

“…Large volume paracentesis demonstrates the benefi cial eff ect of relieving high intraabdominal pressure and reducing variceal pressure, which suggests that transient increase in intra-abdominal pressure could have a harmful eff ect on EV bleeding ( 8,9 ). Isometric exercise ( 10,11 ) and heavy alcohol binges ( 12 ) reportedly increase portal pressure. Ingestion of aspirin or other non-steroidal anti-infl ammatory drugs (NSAIDs) is also associated with EV bleeding ( 13,14 ).…”

Section: Introductionmentioning

confidence: 99%

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Potential Precipitating Factors of Esophageal Variceal Bleeding: A Case–Control Study

Liao

Hou

Chang

et al. 2011

American Journal of Gastroenterology

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Valsalva maneuver-associated activities such as straining during defecation, vomiting, and cough are believed to cause abrupt increase in variceal pressure. Whether these actions can precipitate rupture of esophageal varices (EV) is unknown. The association of EV bleeding with these activities and other potential risk factors such as ingestion of alcohol and non-steroidal anti-infl ammatory drugs was investigated. METHODS:Between January 2003 and May 2009, 240 patients with liver cirrhosis and acute EV bleeding (group A) and 240 matched patients with Child-Pugh ' s class and moderate size EV without bleeding (group B) were included. Each patient was questioned regarding constipation, vomiting, cough, and other potential risk factors in the week prior to index bleeding (group A) or endoscopy (group B) using a standard questionnaire. RESULTS:Group A had more patients with constipation ( n = 44 vs. n = 16, P < 0.001) and higher constipation scores (0.79 ± 1.67 vs. 0.25 ± 0.92, P < 0.001) than group B. Group A also had more patients with vomiting ( n = 60 vs. n = 33, P = 0.002) and higher vomiting scores (3.0 ± 0.86 vs. 1.85 ± 0.87, P < 0.001). No difference in cough existed between the two groups ( n = 77 group A vs. n = 73 group B); however, group A had higher cough scores (5.08 ± 2.70 vs. 3.19 ± 2.23, P < 0.001). Group A had more patients with excessive alcohol consumption in the week preceding inclusion in the study ( n = 58 vs. n = 5, P < 0.001). On multivariate analysis, constipation score and vomiting score and alcohol consumption were independent determinants of fi rst EV bleeding.CONCLUSIONS: Constipation, vomiting, severe coughing, and excessive consumption of alcohol may precipitate rupture of EV. A prospective cohort study is required to clarify the causal relationship between potential precipitating factors and EV bleeding.

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Section: Liver Precipitating Factors Of Ev Bleedingmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Potential Precipitating Factors of Esophageal Variceal Bleeding: A Case–Control Study

Liao

Hou

Chang

et al. 2011

American Journal of Gastroenterology

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“…In the light of our results, we can hypothesize that other physiologic situations known to transiently increase portal pressure and/or AzBF, such as moderate physical exercise 11,12 or meals, [13][14][15][16][17][18][19][20] may cause significant increases in variceal pressure. It is of interest to note that propranolol therapy has been shown to prevent the changes in HVPG associated with moderate exercise.…”

Section: Discussionmentioning

confidence: 96%

“…It is of interest to note that propranolol therapy has been shown to prevent the changes in HVPG associated with moderate exercise. 12 All the splanchnic and variceal hemodynamic parameters aggravated by increasing IAP reverse after releasing the high IAP. 4 Although in our study we assessed these changes over relatively short periods, it is likely that the reiteration of even transient increases in variceal pressure, size, and wall tension may contribute to the progressive dilatation of the esophageal varices that precedes its rupture when the elastic limit of variceal wall is exceeded.…”

Section: Discussionmentioning

confidence: 97%

Increasing intra-abdominal pressure increases pressure, volume, and wall tension in esophageal varices

et al. 2002

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Many daily activities cause acute elevations of intra-abdominal pressure (IAP). In portal hypertensive cirrhotic patients, increased IAP increases absolute portal pressure and azygos blood flow, suggesting that it may have detrimental consequences at the esophageal varices. The aim of this study was to investigate the effects of increased IAP on variceal pressure, size, and wall tension. Endosonography and a noninvasive endoscopic pressure gauge were used to measure variceal pressure, radius, wall tension, and volume in baseline conditions and after increasing IAP by 10 mm Hg using an inflatable girdle in 14 patients with cirrhosis and esophageal varices. Increasing IAP markedly increased variceal pressure (from 13.3 ؎ 4.2 to 17.4 ؎ 4.6 mm Hg; P ‫؍‬ .0001) and radius (from 2.9 ؎ 1.0 to 3.9 ؎ 1.1 mm; P ‫؍‬ .0001). Consequently, wall tension dramatically increased (from 38.7 ؎ 13.6 to 65.9 ؎ 23.8 mm Hg ⅐ mm, ؉78%; P ‫؍‬ .0001). Variceal volume increased significantly from 1,264 ؎ 759 to 2,025 ؎ 1,129 mm 3 (P ‫؍‬ .0001). In conclusion, in portal hypertensive cirrhotic patients, increases in IAP have deleterious effects on variceal hemodynamics, markedly increasing the volume, pressure, and wall tension of the varices. Increases in IAP may contribute to the progressive dilatation that precedes the rupture of the varices in portal hypertension. V ariceal wall tension is thought to represent the key factor determining variceal rupture. 1,2 Wall tension is the inwardly directed force that opposes the expanding force that the increased intravascular pressure and blood flow exert on the variceal wall. 1 It is calculated by Frank's modification of Laplace's law, as the transmural pressure at the varices (the difference between intravariceal and esophageal luminal pressures) times the radius of the varix, divided by the thickness of the variceal wall. 1 Several efforts have been made to obtain objective measurements of variceal wall tension. In that regard, we have previously shown that the combination of endosonography and endoscopic measurement of transmural variceal pressure allows a quantitative, objective, and reproducible estimation of variceal wall tension. 3 In addition, endosonography allows for estimation of variceal volume in the distal esophagus. 3 Elevations of intra-abdominal pressure (IAP) in cirrhotic patients have significant effects on both the systemic and the splanchnic circulation. A previous study from our laboratory showed that brief mechanical elevations of IAP increased azygos blood flow (AzBF), an index of gastroesophageal collateral blood flow, and the absolute portal pressure, estimated by the wedged hepatic venous pressure. 4 Therefore, an elevated IAP may be associated with acute increments of both variceal pressure and variceal blood flow.Moreover, Kravetz et al. 5 showed that in cirrhotic patients with ascites releasing an increased IAP by means of total volume paracentesis decreased intravariceal pressure. These effects of total volume paracentesis may be related to a significant decrease ...

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“…Propranolol therapy may protect from the deleterious effects of a moderate physical exercise on portal hemodynamics at the expense of reduction of liver perfusion in patients with cirrhosis [33,34].…”

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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Effects of propranolol on the hepatic hemodynamic response to physical exercise in patients with cirrhosis

Cited by 70 publications

References 28 publications

Potential Precipitating Factors of Esophageal Variceal Bleeding: A Case–Control Study

Potential Precipitating Factors of Esophageal Variceal Bleeding: A Case–Control Study

Increasing intra-abdominal pressure increases pressure, volume, and wall tension in esophageal varices

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

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