Novel Approaches to Reducing the Risk of Variceal Hemorrhage

Abstract

Background: Complications of advanced liver disease occur at the moment of clinical significant portal hypertension. Nitric oxide (NO) dysfunction and fibrosis play an important role in the pathophysiology of PH, but other mechanisms are also involved. Non-selective beta blockers (NSBB) stay the cornerstone in the primary and secondary prevention of variceal bleeding, but their safety in advanced cirrhosis has been recently debated and new drugs are under investigation. Transjugular intrahepatic portosystemic shunt and balloon tamponade are the standard therapy in case of refractory variceal bleeding, but both interventions have drawbacks. Key Message: Transelastography under certain conditions and the presence of collateral circulation on imaging allow to rule-in CSPH, which makes patients open at risk for variceal hemorrhage. FXR agonists are intrahepatic NO donors; they reduce fibrosis and prevent bacterial translocation, which make them promising drugs for the treatment of PH. NSBB should be used with caution in patients with refractory ascites and certainly in those with hepatorenal syndrome. Preliminary clinical data suggest that simvastatin and enoxaparin improve the prognosis of patients with cirrhosis. Finally, covered esophageal metallic stents are safer and more effective than balloon tamponade in the case of refactory variceal bleeding. Conclusions: Liver stiffness measurements enable the selection of patients for endoscopic screening for esophageal varices. In the case of tense ascites, the dose of NSBB should be adapted to the hemodynamic condition of the patient. Self-expanding, covered esophageal metallic stents replace balloon tamponade in the treatment of massive variceal hemorrhage.

Recommendations on the Diagnosis and Initial Management of Acute Variceal Bleeding and Hepatorenal Syndrome in Patients with Cirrhosis

“…Acute variceal bleeding can be fatal and remains a major public health problem. In the early 1980s, in-house mortality after variceal hemorrhage was around 40% [10]; however, in recent years, in-hospital mortality has fallen steadily to 10-20%, due to new knowledge on the pathophysiology of acute variceal bleeding and advances in therapy [11][12][13]. Although mortality has decreased, bleeding esophageal varices (BEV) still remain of significant clinical importance.…”