Portosystemic shunts versus endoscopic therapy for variceal rebleeding in patients with cirrhosis

Khan, SA; Williamson, Paul; Sutton, R.; Tudur, C

doi:10.1002/14651858.cd000553

Cited by 29 publications

(37 citation statements)

References 14 publications

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“…However, this does not translate into a survival advantage and the better rebleeding prophylaxis occurs at the expense of a higher rate of overt encephalopathy [31,45,46]. Hepatic encephalopathy is lowered with the placement of covered small lumen stents [31,47].…”

Section: Prevention Of Rebleeding Depending On Stage and Aetiology Ofmentioning

confidence: 99%

Treatment of Oesophageal Varices in Liver Cirrhosis

Sauerbruch

2018

Digestion

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Background: The development of cirrhosis with resultant portal hypertension can lead to oesophageal varices at a rate of 7% per annum. Bleeding from varices happens when the portal pressure is ≥12 mm Hg and can threaten life. Summary: Eliminating the aetiology of cirrhosis is a pivotal step to prevent the formation of varices. In patients with established varices, primary prophylaxis with non-selective beta blockers (NSBB) may slow down the progression of varices and prevent the first variceal bleed. NSBB, similar to other agents such as renin/angiotensin blockers, statins, and rifaximin, may have the additional advantage of blunting inflammatory stimuli, which can contribute to the progression of varices. Variceal band ligation is an alternative for primary bleeding prophylaxis with excellent results. Any acute variceal bleed should be managed with band ligation after careful resuscitation. Early pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) in decompensated cirrhotic patients is very effective in controlling the bleeding and improves survival. Secondary prophylaxis against further variceal bleeding using NSBB and band ligation is recommended in most other patients. TIPS may be considered in appropriate patients as a secondary prophylaxis against recurrent variceal bleed. Future research should be directed towards the prevention of varices and targeting inflammation to reduce cirrhotic complications. Key Messages: Treatment strategies depend on the stage the patient is at along the natural history of varices: NSBB or band ligation for primary prophylaxis; band ligation or early TIPS for acute bleed; and a combination of NSBB + band ligation or TIPS for secondary prophylaxis (Fig. 1).

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Section: Prevention Of Rebleeding Depending On Stage and Aetiology Ofmentioning

confidence: 99%

Treatment of Oesophageal Varices in Liver Cirrhosis

Sauerbruch

2018

Digestion

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“…A meta-analysis of all randomized clinical trials comparing total shunts, DSRS, or TIPS with endoscopic therapy in patients who had recovered from an episode of variceal hemorrhage and were known to be cirrhotic included 22 trials evaluating 1,409 patients [63]. Shunt therapy compared with endoscopic therapy demonstrated significantly less rebleeding (OR 0.24, 95% CI: 0.18-0.30), but at the cost of significantly increased acute hepatic encephalopathy (OR 2.07, 95% CI: 1.59-2.69), and chronic encephalopathy (OR 2.09, 95% CI: 1.20-3.62).…”

Section: Role Of Surgery For Secondary Prophylaxis In Cirrhosismentioning

confidence: 99%

“…There were no significant differences regarding mortality and duration of in-patient stay. The proportion of patients with shunt occlusion or dysfunction was 3.1% (95% CI: 0.4-10.7) following TS (two trials), 7.8% (95% CI: 3.8-13.9) following DSRS (four trials), and 59% (range: 18-72%) following TIPS (14 trials) [63]. The meta-analysis concluded that all portosystemic shunts resulted in a significantly lower rebleeding rate at the expense of a higher incidence of encephalopathy and TIPS was complicated by a high incidence of shunt dysfunction.…”

Section: Role Of Surgery For Secondary Prophylaxis In Cirrhosismentioning

confidence: 99%

Current Role of Surgery in Portal Hypertension

Pal

2011

Indian J Surg

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Treatment for portal hypertension (PHT) has evolved from surgery being the only option during the 1970s to the wide range of options currently available. Surgery has not vanished from the therapeutic armamentarium, but its role has changed and is constantly evolving. The present review primarily focuses on the role of surgery in tackling patients with PHT and varices with regard to the Indian scenario and also looks at its relevance, given the availability of a host of other therapeutic options.Keywords Portal hypertension . Portosystemic shunt . Surgery . Variceal haemorrhage Pathophysiology of PHTFor understanding how surgery can help modify the natural course in patients with PHT, it is necessary to understand its pathophysiology and the natural history of varices in such patients. PHT is usually the consequence of increased resistance to portal blood flow coupled with increased blood flow through the splanchnic circulation because of a hyperdynamic circulatory state that exists both in cirrhotics and to some extent in noncirrhotic etiologies (large congested splenomegaly) as well. Traditionally, at the ultrastructural level, PHT has been classified into presinusoidal, sinusoidal, and postsinusoidal. It is for the sinusoidal and postsinusoidal blocks that there is an accurate but invasive way of monitoring the portal pressure by using the method to estimate the hepatic venous pressure gradient (HVPG) in the vascular/hemodynamic lab [1][2][3]. In cirrhotic patients, as about a third to half of them will actually have PHT; HVPG >5 mmHg indicates PHT. PHT becomes clinically significant when the HVPG is ≥10 mmHg [1][2][3]. This is the pressure threshold when PHT leads to the formation of esophagogastric varices, retroperitoneal and periportal collaterals, hypersplenism, low serum albuminascitic albumin gradient ascites, spontaneous bacterial peritonitis, etc. Varices rupture and bleed only when the HVPG >12 mmHg [1][2][3]. Natural History of PHTIt has been estimated that varices are present in about 30-40% of compensated cirrhotics and nearly two-thirds of the decompensated patients. In cirrhotic patients without varices on the first endoscopy, the annual incidence of new varices is between 5% and 10% [1,4]. Once developed, the progression of varices from small to large depends on the deterioration of liver function and continued hepatic insult (virus-, alcohol-, metabolic-, drug-induced, etc.). The overall annual incidence of bleeding is about 4% and this increases to 15% per year in those with large varices, red signs, and poor Child's status [1,[4][5][6]. About a third of the cirrhotic patients with varices will bleed and the mortality following each episode of bleeding is about 20% (maybe higher) in experienced tertiary health centers. Early mortality (within 6 weeks) following an acute episode of variceal bleeding depends on the etiology of PHT, the severity of underlying liver disease (Child's C, model for end-stage liver disease [MELD] >18), actively bleeding varices, bleeding gastric varices (GV...

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“…Bleeding esophageal varices (BEV) is a common and highly lethal complication of cirrhosis of the liver (Graham & Smith, 1981;Smith & Graham, 1982;Burroughs et al, 1989;Bornman et al, 1994;Khan et al, 2006;Orloff et al, 1977;Mikkelsen, 1974;Terblanche et al, 1989;& D'Amico et al, 1995) The mortality rate associated with BEV is highest during the period surrounding the episode of acute bleeding. If the varices remain untreated after recovery from a bout of acute bleeding, we ( Orloff et al, 1977) and others observed a 95% incidence of recurrent bleeding, and death within 2 to 5 years in 90% to 100% of the patients.…”

Section: Introductionmentioning

confidence: 99%

Portal-Systemic Encephalopathy in Emergency Treatment of Cirrhosis and Bleeding Esophageal Varices

Orloff¹

2012

Miscellanea on Encephalopathies - A Second Look

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Portosystemic shunts versus endoscopic therapy for variceal rebleeding in patients with cirrhosis

Cited by 29 publications

References 14 publications

Treatment of Oesophageal Varices in Liver Cirrhosis

Treatment of Oesophageal Varices in Liver Cirrhosis

Current Role of Surgery in Portal Hypertension

Portal-Systemic Encephalopathy in Emergency Treatment of Cirrhosis and Bleeding Esophageal Varices

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