Sclerotherapy of Bleeding Oesophageal Varices by Means of Endoscopy

Paquet, K. J.; Oberhammer, E

doi:10.1055/s-0028-1098252

Cited by 214 publications

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“…At the end of the present study, 16 patients with severe and 10 patients with moderate hypertension treated with losartan agreed to participate in a long-term investigation and thus 20 Esophageal varices at upper gastrointestinal endoscopy were graded according to the classification of Paquet et al 21 continued losartan treatment. According to the follow-up schedule of that long-term study, 6 months after the baseline measurements, determination of the hemodynamic parameters was repeated.…”

Section: Resultsmentioning

confidence: 99%

Effect of losartan, an Angiotensin II receptor antagonist, on portal pressure in cirrhosis

1999

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The primary objective of drug therapy in portal hypertension is the prevention of variceal bleeding. The use of nonselective ␤-blockers that reduce portal pressure by lowering splanchnic blood inflow 1 has proved effective in this indication. Treatment with propranolol or nadolol reduces the risk of first hemorrhage 2 as well as that of further bleeding episodes in patients with a history of variceal bleeding. 3 However, the average reduction in portal pressure by 15% achieved with ␤-blockers is moderate, 4 and no relevant decrease is observed in more than 30% of patients despite adequate dosage. 5 To enhance the pressure-lowering effect on portal hypertension, ␤-blockers are combined with isosorbide-5 mononitrate, 6 an agent that reduces portal pressure in cirrhosis because of its vasodilator properties. 7 One study demonstrated a mean reduction in portal pressure of 19% during therapy with the combination of propranolol and isosorbide-5 mononitrate. 6 In patients with sodium retention and ascites, however, serious deterioration of renal function was observed with the combination of ␤-blockers and nitrates. 8 The limited effect on portal pressure, the incidence of adverse effects-15% for nonselective ␤-blockers alone, 9 16% for nadolol plus isosorbide-5 mononitrate 10 -and the timeconsuming dose-finding are a stimulant for the search for new antihypertensive substances.Angiotensin II is considered a potential mediator of intrahepatic portal hypertension, because its plasma level is elevated in cirrhosis 11 and its administration induces a rise in portal pressure. 12 Enhancement of the adrenergic vasoconstrictor influence on the portal systems, 13 direct contractile influence on stellate cells, 14 which serve as regulators of the sinusoidal blood flow, 15,16 and sodium and fluid retention induced by the stimulation of aldosterone secretion 17 may be mechanisms that contribute to the portal hypertensive effect of angiotensin II. Losartan is an angiotensin II receptor antagonist with dilatory effects on arteries and veins. 18 The substance has recently been approved for the treatment of arterial hypertension. As yet, its influence on portal hypertension has not been investigated. The aim of this study was to determine the antihypertensive effects of losartan on portal pressure with particular attention paid to potential side effects. PATIENTS AND METHODSPatients. In patients with cirrhosis and esophageal varices, portal hypertension was evaluated by the determination of hepatic venous pressure gradient (HVPG). Thirty consecutive patients with HVPG Ն 20 mm Hg (severe portal hypertension) were assigned to losartan treatment according to the below-mentioned protocol. In accordance with Armonis et al., 19 our preliminary investigations had shown a variability of Ϯ 1 mm Hg in the measurement of HVPG independent from the height of the values. Therefore, this initial selection of patients with high HVPG values was performed to reduce the influence of variability on the percentage change in HVPG caused by losartan. Later,...

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Section: Resultsmentioning

confidence: 99%

Effect of losartan, an Angiotensin II receptor antagonist, on portal pressure in cirrhosis

1999

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“…[1][2][3][4][5] Control of variceal bleeding is achieved with drugs, endoscopic therapy, emergency surgery, and transjugular intrahepatic portosystemic shunt. 1,[6][7][8][9] Drug therapy would appear to offer an optimal method of treatment, because sophisticated equipment is not required and it can be given immediately upon admission. 1 Because variceal hemorrhage occurs when varices rupture under excessive tension exerted by increased intravascular pressure and blood flow, the rationale for effective drug treatment of variceal bleeding is that agents might reduce pressure and blood flow at the esophageal varices.…”

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confidence: 99%

Effects of F-180, a new selective vasoconstrictor peptide, compared with terlipressin and vasopressin on systemic and splanchnic hemodynamics in a rat model of portal hypertension

Bernadich

Bandi

Melin³

et al. 1998

Hepatology

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The present study is aimed at characterizing the portal, splanchnic, and systemic circulatory effects of F-180, a new long-acting analog of vasopressin (VP) with selective effect on the vascular (V 1 ) receptor, both in normal rats and in portal-hypertensive animals. In preliminary vasopressor tests, F-180 was 18 times more potent than terlipressin (TP) (164 ؎ 10 IU ؋ mmol ؊1 vs. 9.2 ؎ 1.2 IU ؋ mmol ؊1 ) and four times less potent than arginine VP (614 ؎ 25 IU ؋ mmol ؊1 ). F-180 had negligible antidiuretic potency, resulting in vascular selectivity (V 1 /V 2 ) of 858 compared with 1.0 for VP and 2.2 for TP. In portal-hypertensive rats with partial portal vein ligation (PPVL), the vasopressor effect of F-180 was 19 times that of TP on a molar basis (ED 50 F-180: 0.54 vs. TP: 10.02 nmol ؋ kg ؊1 ). At low doses (0.405 nmol ؋ kg ؊1 ), F-180 significantly reduced portal pressure (PP) (؊13.8% ؎ 6.7%) and superior mesenteric artery blood flow (SMABF) (؊25.6% ؎ 4.5%), whereas TP at 8.10 nmol ؋ kg ؊1 was required to achieve comparable splanchnic effects; however, this dose caused a significantly greater increase in mean arterial pressure (MAP) than F-180 at 0.405 nmol ؋ kg ؊1 (28.2% ؎ 2.7% vs. 8.9% ؎ 2.7% at 20 minutes; P F .05). F-180 at 0.405 nmol ؋ kg ؊1 had effects on PP and SMABF similar to a 30-minute intravenous infusion of VP at 10 mU ؋ kg ؊1 in PPVL rats, but VP caused a significantly greater elevation in systemic vascular resistance (SVR) and MAP, and more pronounced reduction in cardiac index (P F .05). (HEPATOLOGY 1998;27:351-356.)

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“…5 Also, mortality associated with gastric variceal hemorrhage is much higher (45-55%) 1 as compared to mortality rate associated with esophageal variceal hemorrhage (6-15%). 6,7 Endotherapy for esophageal varices has high rate of technical success (87-100%) and a lower incidence of major complications. 8 Ruptured GV have a high rate of rebleeding post-therapy 7-65%).…”

Section: Discussionmentioning

confidence: 99%

Balloon-Occluded Retrograde Transvenous Obliteration (BRTO): A Novel Method of Control of Bleeding from Post-Glue Ulcer over Gastric Varices. Report of Two Cases and Review of Literature

Prajapati

Ranjan

Gupta

et al. 2016

Journal of Clinical and Experimental Hepatology

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Bleeding gastric varices (GV) are managed by cyanoacrylate glue injection with transjugular intrahepatic portosystemic shunt (TIPSS) as modality for treatment failure. Ulcer can form at the site of glue injection over GV and it can cause bleeding. Treatment approach for such bleed is not well described. Balloon-occluded retrograde transvenous obliteration (BRTO), TIPSS, and devascularization remain the treatment options in this scenario. BRTO is an endovascular procedure where a balloon catheter is inserted into a draining vein of GV, and the sclerosant can be injected into the varices through the catheter during balloon occlusion. BRTO has the benefit of increasing portal hepatic blood flow and can also be useful in patients who may not tolerate TIPSS. We report two cases where BRTO was done for control of bleeding from ulcers formed over previously injected GV. 1 Treatment modalities for bleeding GV are cyanoacrylate glue injection and transjugular intrahepatic portosystemic shunt (TIPSS). Balloon-occluded retrograde transvenous obliteration (BRTO) has been used as a primary treatment for acute bleeding GV. Ulcer can form at the site of glue injection over GV and it can cause bleeding. The exact prevalence of such bleeding and treatment options is not well established. BRTO has been proposed as a possible treatment option in such situation. TIPSS and devascularization remain other therapeutic options in this scenario.BRTO is an endovascular procedure where a balloon catheter is inserted into a draining vein of GV, and the sclerosant can be injected into the varices through the catheter during balloon occlusion. BRTO has been used for active GV hemorrhage, which was transiently treated by either endoscopic sclerotherapy or Sengstaken-Blakemore tubes, recent bleeding, and preventive GV obliteration in patients who had never bled.2 Reports of refractory variceal bleed treated with BRTO are rare. 2 We report two cases where BRTO was done for control of bleeding from ulcers formed over previously injected GV. CASE 1A 44-year-old male with Child-Pugh class B cirrhosis presented with UGI bleed. He had past history of glue injection for gastric variceal bleeding one month ago. At admission, the patient had tachycardia (pulse 116/min) and hypotension (BP 86/50 mmHg) pallor. He was resuscitated with crystalloid infusion and blood transfusion and terlipressin infusion was started. After hemodynamic stabilization, he underwent emergent UGI endoscopy which showed small esophageal varices with no stigmata of bleed with large deep white based ulcer over GV at the site of previous glue injection (Figure 1). There was no unsolidified area in the varices for further glue injection. There was ongoing bleeding as indicated by persistent tachycardia and requirement of blood transfusion. Options of TIPSS or BRTO were considered and CT angiography abdomen was done to assess patency of portal vein, hepatic veins, splenic vein, and presence of gastrorenal shunt. CT showed patent portal and splenic veins and a large gastrorenal shunt d...

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Sclerotherapy of Bleeding Oesophageal Varices by Means of Endoscopy

Cited by 214 publications

References 0 publications

Effect of losartan, an Angiotensin II receptor antagonist, on portal pressure in cirrhosis

Effect of losartan, an Angiotensin II receptor antagonist, on portal pressure in cirrhosis

Effects of F-180, a new selective vasoconstrictor peptide, compared with terlipressin and vasopressin on systemic and splanchnic hemodynamics in a rat model of portal hypertension

Balloon-Occluded Retrograde Transvenous Obliteration (BRTO): A Novel Method of Control of Bleeding from Post-Glue Ulcer over Gastric Varices. Report of Two Cases and Review of Literature

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