Prophylactic sclerotherapy in high-risk cirrhotics selected by endoscopic criteria

Franchis, Roberto de; Primignani, Massimo; Arcidiacono, Paolo Giorgio; Rizzi, Paolo; Vitagliano, P.; Vazzoler, Maria C.; Arcidiacono, R; Rossi, Alfredo; Zambelli, A.; Cosentino, F.; Caletti, Giancarlo; Brunati, Sergio; Battaglia, Giorgio; Gerunda, Giorgio Enrico

doi:10.1016/0016-5085(91)90738-7

Cited by 56 publications

(17 citation statements)

References 22 publications

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“…This index was prospectively validated in a study by Prada and colleagues 20. Using the same variables the NIEC index was simplified by De Franchis and colleagues21 and shown to correlate with the original index. Further studies showed that the HVPG and intravariceal pressure were also independent predictors of first variceal haemorrhage when analysed in conjunction with the NIEC index 22…”

Section: 0 Natural History Of Varices In Cirrhosismentioning

confidence: 99%

UK guidelines on the management of variceal haemorrhage in cirrhotic patients

Jalan

Hayes²

2000

Gut

177

164

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Section: 0 Natural History Of Varices In Cirrhosismentioning

confidence: 99%

UK guidelines on the management of variceal haemorrhage in cirrhotic patients

Jalan

Hayes²

2000

Gut

177

164

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“…2,3 Reduction of PVP minimizes the risk of bleeding from varices, the likelihood of hepatic encephalopathy and problems relating to first pass uptake of drugs. 4 Reduced portal pressure also decreases intestinal venous congestion and could increase blood flow through the hepatic parenchyma and hence increase liver function.…”

mentioning

confidence: 99%

The effect of mechanically enhancing portal venous inflow on hepatic oxygenation, microcirculation, and function in a rabbit model with extensive hepatic fibrosis

et al. 1999

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Enhancing the portal venous blood flow (PVBF) has been shown to reduce portal pressure and intrahepatic vascular resistance and to improve liver function in isolated cirrhotic rodent livers in vitro. The aim of this study was to assess the short-term effect of mechanically pumping the portal inflow on hepatic microcirculation (HM), oxygenation, and function in an animal model of extensive hepatic fibrosis. New Zealand white rabbits underwent laparotomy and exposure of the liver: group 1 (n ‫؍‬ 7) were normal controls; group 2 (n ‫؍‬ 7) had hepatic fibrosis. Total hepatic blood flow (THBF) and HM was measured along with continuous monitoring of intrahepatic tissue oxygenation using near infrared spectroscopy (NIRS). Baseline hepatic hemodynamics and liver function were measured in both groups. PVBF was then increased by 50% over a 3-hour period in the hepatic fibrosis group using a miniature portal pump designed for human implantation, and the hemodynamics were monitored continuously. Liver function tests were repeated after portal pumping. In comparison with normal controls, animals with hepatic fibrosis had a higher portal pressure (13.0 ؎ 3.6 vs. 3.7 ؎ 1.4 mm Hg, P F .001, mean ؎ SD vs. controls), reduced PVBF (52.4 ؎ 24.6 vs. 96.9 ؎ 21.1 mL/min, P ‫؍‬ .003), and increased portal vascular resistance (P ‫؍‬ .001). THBF and flow in the HM was lower than in controls, and liver function tests were abnormal. After a 3-hour period of enhanced portal flow in animals with hepatic fibrosis, the portal pressure greatly reduced (13.0 ؎ 3.6 to 2.5 ؎ 1.1 mm Hg, P F .001) as did the intrahepatic portal resistance ( Current aims in the management of portal hypertension are to reduce portal venous pressure (PVP), to increase blood flow through hepatic parenchyma, 1 and to decompress esophageal and gastric varices. 2,3 Reduction of PVP minimizes the risk of bleeding from varices, the likelihood of hepatic encephalopathy and problems relating to first pass uptake of drugs. 4 Reduced portal pressure also decreases intestinal venous congestion and could increase blood flow through the hepatic parenchyma and hence increase liver function. 5 In 1991, Habib et al. 6 first introduced the concept of mechanical pumping of portal blood to enhance hepatic portal inflow. Since then, we have seen a number of publications in this field. 7-10 Cardoso et al. [7][8][9] showed that augmenting portal inflow to isolated perfused cirrhotic rat and human livers decreased intrahepatic resistance without a change in intrahepatic shunting and resulted in liver function improvement. Bernadich et al. 10 found that in rats with portal hypertension owing to portal vein stenosis, mechanical portal pumping decreased portal pressure and portal-systemic shunting without having a significant effect on systemic hemodynamics. In cirrhosis, several early studies provided evidence that it was vasoactive mediators coupled with the extensive destruction of hepatocytes and nodular regeneration that contributed to the pathogenesis of portal hypertension. [11][12][13]...

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“…Mortality is apparently reduced by reducing the rate of first variceal bleeds, which decreases the death rate due to variceal bleeding [26]. The more recent randomized trials have overcome the methodological problems of the earliest trials and have suggested either a benefit for prophylactic sclerotherapy [1,8,12,16,18] or no treatment effect [23,25]. The most discouraging ''Veterans Affairs'' study [24], abandoned after preliminary results, is subject to two principal criticisms: the choice of sodium tetradecyl sulfate as sclerosant when it is known to induce a high incidence of esophageal ulceration, and the minimal experience (20 sclerotherapy procedures) criterion for investigators.…”

Section: Discussionmentioning

confidence: 99%

“…Prophylactic endoscopic sclerotherapy (PES) has been investigated in several randomized controlled trials, and results have been quite contradictory. Some studies have shown remarkable benefit [8,12,13,29], and others [1,14,16,18,23,25] have shown no benefit. In one study a significantly higher bleeding rate in the sclerotherapy group was observed [17].…”

mentioning

confidence: 98%