Portal hypertension: varices and bleeding

Question 1

What is the pathogenesis of portal hypertension and varices?

Answer 1

backward theory - increased resistance to outflow 
forward theory (increased flow)
pressure = flow x resistance

Question 2

What are the risk factors for bleeding/mortality?

Answer 2

endoscopic appearances = size, red signs,active bleeding
Wall tension = GV can bleed at lower pressures
portal pressure = HVPG 12, 20
alcohol= failure to abstain
liver cancer - risk of PVT

Question 3

What are the risks and treatments for patients with small varices?

Answer 3

bleeding risk is low until small varices progress
up to 15% risk at 4 years
carvedilol = promise in reducing progression of small varices

Question 4

How does carvedilol work?

Answer 4

non-selective beta- blokcer with vasodilating action (alpha 1 antagonism)
2-4 times greater beta blocking action of propranolol
additional effect of reducing intrahepatic resistance
greater portal hypotensive effect than propranolol

Question 5

What are the general MOA of non-selective beta blockers??

Answer 5

Beta 1 = reduce CO
beta 2 = reduce splanchnic flow (unopposed alpha1 action)
reduced portal flow = reduced portal pressure
reduction in bleeding by 50% and mortality by 25-45% compared with placebo

Question 6

What is variceal band ligation?

Answer 6

reduced location complication over sclerotherapy and better outcomes
multibanders used and easy to get carried away
this method comes out sligthly better than beta blockers in pts with median/large variceals

Question 7

What is the aim of resuscitation and what factors need to be considered?

Answer 7

volume expansion - aim to preserve tissue perfusion
consider co-morbidities, age, haemodynamic status, ongoing bleeding
must correct hypovoleamia and promote tissue oxgenation

Question 8

Is it beneficial for cirrhotic patients to receive abx prophylaxis?

Answer 8

meta-analysis showed the patients with GI bleeding have reduced incidence of infection, rebleeding and mortality on prophylaxis

Question 9

What is terlipressin?

Answer 9

only vasoactive agent shown to improve survival
- early admin confers greatest effect
- continue after endoscopic haemostasis
have to balance side effects with efficacy
watch out for hyponatraemia

Question 10

What are the preparations for endoscopy?

Answer 10

elective ventilation - ongoing bleeding, assists endoscopy therapy, allow safe transfer
does not adversely affect outcomes
aim to scope within 24 hour of admission but adequate prep is crucial

Question 11

How effective is variceal band ligation ?

Answer 11

initial control of bleeding good but rebleeding up to 50%

best combined with vasoactive drugs = better control of bleeding, less rebleeds but no survival benefit

Question 12

What is balloon tamponade effective for?

Answer 12

good initial haemostasis
high rebleeding and rate of local complications
needs careful placement
- ideally endoscopicallys, important to chek CXR

Question 13

What are oesophageal stents?

Answer 13

removable stents
- case reports of successful haemostasis and no major complications
- RCT showed better control of bleeding and reduced need for TIPSS
mortality is similar

Question 14

What is TIPSS?

Answer 14

transjugular intrahepatic portosystemic shunt
- excellent haemostasis but high mortality
early or pre-emptive in selected pts showed reduced bleeding and improved survival
- low uptake worldwide and huge logistical issues