Hemodynamic Factors Involved in the Development and Rupture of Esophageal Varices: A Pathophysiologic Approach to Treatment

Polio, John; Groszmann, Roberto J.

doi:10.1055/s-2008-1040614

Cited by 213 publications

(86 citation statements)

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“…That VP plays a major role in the occurrence of a variceal bleeding is not surprising. From a mathematical point of view, as expressed by the wall-tension formula, 22 variceal bleeding and rupture are indeed closely related to the degree of the transmural pressure; our study confirms this statement. Previous studies have shown that patients with large varices and/or red color signs on the varices run a higher risk of variceal bleeding, 4,5,15,23 and this was confirmed in the present study.…”

Section: Discussionsupporting

confidence: 85%

Variceal pressure is a factor predicting the risk of a first variceal bleeding: A prospective cohort study in cirrhotic patients

Nevens¹,

Bustami²,

Scheys³

et al. 1998

Hepatology

114

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Predictive criteria for a first variceal hemorrhage lack substantial accuracy. Cross-sectional studies suggest a close relationship between variceal pressure (VP) and the occurrence of variceal bleeding. In the present prospective cohort study, the significance of VP measurement for prediction of a first variceal bleed was assessed. Eighty-seven patients with cirrhosis and large esophageal varices who had never developed variceal bleeding were followed for 12 months. The endpoint of the study was the presentation or not of a variceal hemorrhage. Thirty-four patients (39%) were in Child's class A, 37 in class B (43%), and 16 in class C (18%). The median interval between endoscopic diagnosis of varices and the beginning of the study was 15 months. Twenty-eight patients (32%) developed a variceal hemorrhage with a bleeding-related mortality of 18% (n‫.)5؍‬ The 1-year mortality overall was 16% (n‫.)41؍‬ Variables predictive of a first bleed identified by Cox proportional hazards regression model were: the level of VP, the North Italian Endoscopic Club (NIEC) score, and the interval between the diagnosis of varices and the start of the study. By adding VP to NIEC, a significant gain in prognostic accuracy was obtained (P ‫؍‬ .003). In conclusion, the present study provides evidence that the level of VP is a major predictive factor for variceal hemorrhage, and that it provides further prognostic information in addition to the NIEC index. (HEPATOLOGY 1998;27:15-19.)

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Section: Discussionsupporting

confidence: 85%

Variceal pressure is a factor predicting the risk of a first variceal bleeding: A prospective cohort study in cirrhotic patients

Nevens¹,

Bustami²,

Scheys³

et al. 1998

Hepatology

114

View full text Add to dashboard Cite

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“…The predictive value of a 20% or more decrease in variceal pressure is likely to be related to the fact that it determines a marked fall in variceal wall tension, which is a major determinant of bleeding. 7,9 In the current study, most patients also had repeated HVPG measurements, which allowed comparison of the prognostic accuracy of the variceal pressure response with continued propranolol therapy with that of the HVPG response. Our results in the present series confirmed our previous findings indicating that reducing the HVPG by 20% or more was associated with a very low risk of bleeding, only 7% at 3 years of follow-up and of 0% when the final HVPG was less than 12 mm Hg.…”

Section: Discussionmentioning

confidence: 99%

“…This inconvenience is only relative because small varices have little risk of bleeding and do not strictly require treatment. 7,8 Second, endoscopic measurements are not exactly noninvasive, though certainly less than HVPG measurements. Our current results indicate that if used carefully by gastroenterologists familiar with the technique and its limitations, the method may provide a new way of monitoring the response to pharmacological therapy for portal hypertension.…”

Section: Discussionmentioning

confidence: 99%

“…1,7,8 These are some of the main determinants of variceal wall tension, 7 which is believed to play a key role in determining variceal rupture. 7,9 According to Laplace' s law, variceal wall tension is directly related to the radius of the varix and inversely related with its wall thickness. 7 Therefore, an increased size and decreased wall thickness will increase the tension exerted by the variceal wall and, consequently, the risk of bleeding.…”

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confidence: 99%

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Predictive value of the variceal pressure response to continued pharmacological therapy in patients with cirrhosis and portal hypertension

et al. 2000

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Noninvasive measurements of variceal pressure adequately reflect the hemodynamic effects of propranolol on portal hypertension. However, the prognostic value of variceal pressure responses during continued propranolol therapy has not been evaluated, and it is unclear whether this may substitute invasive measurements of portal pressure response. Fifty-five portal hypertensive patients with cirrhosis were studied before and at 4 months of continued propranolol therapy. Variceal pressure was measured using an endoscopic pressure gauge. Portal pressure was evaluated as the hepatic venous pressure gradient (HVPG). Over a 28 ؎ 11 month follow-up, 16 patients experienced variceal bleeding. Baseline characteristics were similar in bleeders and nonbleeders. At 4 months, reduction in variceal pressure was less marked in bleeders than in nonbleeders (5% ؎ 20% vs. ؊15% ؎ 24%; P ‫؍‬ .03). A fall in variceal pressure 20% or greater of baseline was an independent predictor of absence of variceal bleeding; which occurred in 5% of patients with a 20% or greater fall in variceal pressure versus 42% of patients with less than a 20% reduction (P ‫؍‬ .004). The HVPG response had similar independent prognostic value (decrease H20%: 6% bleeding; decrease F20%: 45% bleeding; P ‫؍‬ .004) but identified different patients. Achieving a 20% decrease in either variceal pressure or HVPG was highly sensitive (85%) and specific ( Variceal bleeding is the most frequent and severe complication of portal hypertension in patients with cirrhosis. 1 Several treatment options are available to prevent recurrent variceal bleeding, including pharmacological therapy, endoscopic banding ligation, and surgical or transjugular intrahepatic portosystemic shunts (TIPS). 1,2 It has been recently shown that pharmacological treatment with propranolol offers almost optimal protection from bleeding and rebleeding when the portal venous pressure (estimated by the hepatic venous pressure gradient [HVPG]), achieves a target reduction. 3,4 The risk of bleeding or rebleeding is virtually abolished when the HVPG decreases to 12 mm Hg or below, 3-5 and the actuarial risk of rebleeding at 2 years is only 9% when the HVPG is reduced by at least 20% of the baseline value. 4 This has been thereafter confirmed by other studies, 6 emphasizing the concept that pharmacological treatment represents the optimal therapy in the subgroup of patients achieving such a pronounced decrease in HVPG. [1][2][3][4] Unfortunately, there is no adequate noninvasive way of assessing the HVPG response to treatment, which calls for repeated invasive hemodynamic studies.Several endoscopic findings, such as the size of the varices and the presence of red color signs (which are thought to reflect a reduced thickness of variceal wall) show a significant correlation with the risk of bleeding. 1,7,8 These are some of the main determinants of variceal wall tension, 7 which is believed to play a key role in determining variceal rupture. 7,9 According to Laplace' s law, variceal wall tension is directly re...

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“…Thus, the changes in HR and CO in the placebo group (HR: 53% Ϯ 6% and CO: 81% Ϯ 23%) were much higher than in the propranolol group (HR: 17% Ϯ 4% and CO: 35% Ϯ 4%; P Ͻ .05). 3,1998 Norepinephrine levels increased markedly during exercise, from 308 Ϯ 52 to 770 Ϯ 135 pg · mL -1 in the placebo group (P Ͻ .01) and from 347 Ϯ 62 to 1,193 Ϯ 239 pg · mL -1 in the propranolol group (P Ͻ .001).…”

Section: Effects Of Placebo or Propranolol Infusion On Hepatic And Symentioning

confidence: 99%

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

et al. 1998

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Physical exercise increases portal pressure (hepatic venous pressure gradient [HVPG]) in patients with cirrhosis.It is unknown if this deleterious effect is associated with changes in gastroesophageal collateral blood flow and if these can be prevented by propranolol administration. The aim of this study was to characterize the effects of propranolol on the splanchnic hemodynamic response to exercise in patients with cirrhosis. Twenty-three patients with cirrhosis and portal hypertension had hemodynamic measurements in baseline conditions, and during moderate cycling exercise (40 W) under double-blind propranolol or placebo administration. In patients receiving placebo, HVPG significantly increased during exercise (from 16.7 ؎ 0.9 to 19.0 ؎ 1.0 mm Hg; P F .01), hepatic blood flow (HBF) decreased (-18% ؎ 4%; P F .01), while azygos blood flow (AzBF) was unchanged (4% ؎ 12%; ns). In patients receiving propranolol, portal pressure did not increase during exercise, but decreased from 16.3 ؎ 1.0 to 12.9 ؎ 1.1 mm Hg (P F .01). The lack of increase in HVPG in response to exercise in patients receiving propranolol may be related to a more pronounced decrease in HBF, as compared with patients receiving placebo, and to a blunted increase in cardiac output (CO). Moderate physical exercise adversely influences the hepatic hemodynamics in patients with cirrhosis, causing a significant increase in portal pressure. This is effectively prevented by propranolol pretreatment. (HEPATOL-OGY 1998;28:677-682.)

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Hemodynamic Factors Involved in the Development and Rupture of Esophageal Varices: A Pathophysiologic Approach to Treatment

Cited by 213 publications

References 0 publications

Variceal pressure is a factor predicting the risk of a first variceal bleeding: A prospective cohort study in cirrhotic patients

Variceal pressure is a factor predicting the risk of a first variceal bleeding: A prospective cohort study in cirrhotic patients

Predictive value of the variceal pressure response to continued pharmacological therapy in patients with cirrhosis and portal hypertension

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

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