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Prevention and Management of Esophageal Variceal and Portal Hypertensive Hemorrhage

Thomas Hargrave, M.D. March 24, 2012

Gastroesophageal Variceal Hemorrhage


Gastroesophageal variceal hemorrhage is one of the major complications of portal hypertension from cirrhosis Variceal hemorrhage occurs in 25-35% of cirrhotics and accounts for 70-80% of UGIB in these patients. Aprroximately 50% of cirrhotics will have varices at the time of diagnosis 7-8% develop de novo varices each year

PREVALENCE AND SIZE OF ESOPHAGEAL VARICES IN PATIENTS WITH NEWLY DIAGNOSED CIRRHOSIS

Prevalence and Size of Esophageal Varices in Patients with Newly-Diagnosed Cirrhosis


100 80

Large

60

Patients with varices 40


20
0

Medium

Small

Overall
n=494

Child A
n=346

Child B
n=114

Child C
n=34

Pagliaro et al., In: Portal Hypertension: Pathophysiology and Management, 1994: 72

Gastroesophageal Variceal Hemorrhage


The 1-year risk of a first variceal hemorrhage is approximately 12% (5% for small varices and 15% for large varices). The 6-week mortality with each episode of variceal hemorrhage is approximately 15 -20%,
From 0% among patients with Child class A disease to 30% among patients with Child class C disease.

The 1-year rate of recurrent variceal hemorrhage is approximately 60%.

Pathophysiology
Portal Venous Anatomy

Hepatic/Portal Blood Flow


Blood accounts for 25-30% of the volume of the liver Total Hepatic Blood Flow: Hepatic arterial and portal venous blood flow
Approximately 25% of the cardiac output Males: 1860 cc/min Females: 1550 cc/min

Portal venous blood flow averages 1500 cc/min Normal portal venous pressure is 4-8 mmHg

Hepatic Lobular Anatomy

Pathophysiology
Gastroesophageal varices are a direct consequence of portal hypertension that, in cirrhosis, results from Increased resistance to portal flow
Structural (distortion of liver vascular architecture by fibrosis and regenerative nodules) and Dynamic (increased hepatic vascular tone due to endothelial dysfunction and decreased nitric oxide bioavailability).

Increased portal venous blood inflow.

Intracellular Spaces (of Disse) in the Portal Sinusoids Large Enough for Chylomicroms to Pass

Garcia-Tsao G, Bosch J. N Engl J Med 2010;362:823-832.

A THRESHOLD PORTAL PRESSURE OF ~12 mmHg IS NECESSARY FOR VARICES TO FORM

A Threshold Portal Pressure of ~12 mmHg is Necessary for Esophageal Varices to Form
Varices Present
(n=72) 35 30

Varices Absent
(n=15)

Hepatic Venous Pressure Gradient (mmHg)

25 20 P<0.01

15

12
10 5

Garcia-Tsao et. al., Hepatology 1985; 5:419

Venous Layers of the Esophagus

VARICES INCREASE IN DIAMETER PROGRESSIVELY

Varices Increase in Diameter Progressively

No varices

Small varices
7-8%/year 7-8%/year

Large varices

Merli et al. J Hepatol 2003;38:266

Grade II Varices

Grade III Varices

LARGE VARICES ARE MORE LIKELY TO RUPTURE

Large Varices Are More Likely To Rupture


100

No Varices

Small Varices
75

p<0.01 *

%
Patients without bleeding
50
25

Large Varices * *
2-year probability of first bleed: Small varices: 7% Large varices: 30%
0 12 24 12 Time (months) 36 24 36

*Merli et al., Hepatol 2003; 38:266, **Conn et al., Hepatology 1991; 13:902

Punctum

Variceal hemorrhage

Varix with red wale sign

Management of Variceal Bleeding


Primary Prophylaxis
Pharmacologic Endoscopic

Acute Variceal Hemorrhage


Pharmacologic Endoscopic TIPS

Secondary Prophylaxis
Pharmcologic Endoscopic TIPS

Primary Prophylaxis
In view of the relatively high rate of bleeding from esophageal varices and the high associated mortality, an important goal of management of patients with cirrhosis is the primary prevention of variceal hemorrhage. As a result, all patients with cirrhosis should undergo diagnostic endoscopy to document the presence of varices and to determine their risk for variceal hemorrhage.

MANAGEMENT OF PATIENTS WITHOUT VARICES

Treatment of Varices / Variceal Hemorrhage


No varices Can we prevent formation of varices ?

Varices No hemorrhage Variceal hemorrhage Recurrent hemorrhage

NON-SELECTIVE BETA BLOCKERS DO NOT PREVENT DEVELOPMENT OF VARICES

Prevention of Esophageal Varices w/ Beta-Blockers?


Multicenter, randomized, placebo-controlled trial of timolol (non-selective beta-blocker) vs. placebo in patients

Beta-blockers did not prevent the development of varices and were associated with a higher rate of serious adverse events

In patients without varices, treatment with nonselective beta-blockers is not recommended


Groszmann, et al., Hepatology 2003;38 (suppl 1):206A

MANAGEMENT OF PATIENTS WITHOUT VARICES

Treatment of Varices / Variceal Hemorrhage


No varices

No specific therapy Repeat endoscopy in 2-3 yrs*

Varices No hemorrhage Variceal hemorrhage Recurrent hemorrhage * Sooner with cirrhosis decompensation

PREVENTION OF FIRST VARICEAL HEMORRHAGE

Treatment of Varices / Variceal Hemorrhage


No varices

Varices No hemorrhage Variceal hemorrhage Recurrent hemorrhage

Prevention of first variceal hemorrhage

Primary Prophylaxis for Variceal Hemorrhage


Pharmacologic Therapy
Beta Blockers Nitrates

Endoscopic Therapies
Band Ligation Sclerotherapy (historican interest only)

DECREASE IN HEPATIC VENOUS PRESSURE GRADIENT (HVPG) REDUCES THE RISK OF VARICEAL BLEEDING

Decrease In Hepatic Venous Pressure Gradient (HVPG) Reduces Risk of Variceal Bleeding
100
80 46-65% 60

Rebleeding 40
20 0% 0 HVPG decrease to < 12 mmHg HVPG decrease > 20% from baseline No change in HVPG 7-13%

Bosch and Garca-Pagn, Lancet 2003; 361:952

Primary Prophylaxis for Variceal Hemorrhage: Beta Blockers


Non-selective beta-blockers preferred
Beta-1 antagonism: reduced cardiac output Beta-2 antagonism: splanchnic vasoconstriction

Goal of therapy to reduce portal pressure by 20% or below 12 mm Hg Dose titrated to a resting HR of 55, or a 25% reduction in baseline Initial dose propranolol 40 mg bid, Average dose 160 mg/day Up to 1/3 intolerant to side effects resulting in discontinuation

NON-SELECTIVE BETA-BLOCKERS PREVENT FIRST VARICEAL HEMORRHAGE

Non-Selective Beta-Blockers Prevent First Variceal Hemorrhage: 11 Trials


Bleeding rate
(~2 year)

Control 25%
(n=600)

Beta-blocker 15%
(n=590)

Absolute rate difference -10%


(-16 to -5)

All varices
(11 trials)

Large varices
(8 trials)

30%
(n=411)

14%
(n=400)

-16%
(-24 to -8)

Small varices
(3 trials)

7%
(n=100)

2%
(n=91)

-5%
(-11 to 2)

DAmico et al., Sem Liv Dis 1999; 19:475

Primary Prophylaxis against Variceal Hemorrhage.

Garcia-Tsao G, Bosch J. N Engl J Med 2010;362:823-832.

THE RISK OF FIRST VARICEAL HEMORRHAGE IS NOT REDUCED BY ADDING ISOSORBIDE MONONITRATE (ISMN) TO BETA-BLOCKERS

The Risk of First Bleeding is Not Reduced by Adding Isosorbide Mononitrate (ISMN) to b-blockers
Free of a first variceal bleeding
100 100

Survival

75

ns

ns 75

50 25 0 1 2 Propranolol + ISMN Propranolol + placebo

50

25 0

Propranolol + ISMN Propranolol + placebo

Years

Years
Garca-Pagn et al., Hepatology 2003; 37:1260

ENDOSCOPIC VARICEAL BAND LIGATION

Endoscopic Variceal Band Ligation

Primary Prophylaxis for Variceal Hemorrhage


3 randomized controlled trials published comparing band ligation to no treatment, showing lower bleeding rates and mortality. Meta-analysis of 8 trial show banding superior to beta blockers but no difference in survival One trial of band ligation and beta blockers: no benefit Prophylactic sclerotherapy definitely of no proven benefit, probably harmful.

VARICEAL BAND LIGATION (VBL) VS. BETA-BLOCKERS (BB) IN THE PREVENTION OF FIRST VARICEAL HEMORRHAGE

Variceal Band Ligation (VBL) vs. Beta-Blockers (BB) in the Prevention of First Variceal Bleed
First hemorrhage
Chen 1998 Sarin 1999 De 1999 Jutabha 2000 De la Mora 2000 Lui 2002 Lo 2004 Schepke 2004 Total
Relative risk

Survival

10

10 40

Favors VBL

Favors BB

Favors VBL

Favors BB

Khuroo, et al., Aliment Pharmacol Ther 2005; 21:347

MANAGEMENT ALGORITHM FOR THE PROPHYLAXIS OF VARICEAL HEMORRHAGE - SUMMARY

Prophylaxis of Variceal Hemorrhage


Diagnosis of Cirrhosis
Endoscopy
No Varices
Follow-up EGD in 2-3 years*

Small Varices
Follow-up EGD in 1-2 years*

Medium/Large Varices Childs C or Stigmata

*EGD every year in decompensated cirrhosis Stepwise increase until maximally tolerated dose Continue beta-blocker (life-long) No role for repeated endoscopy!!

Beta-blocker therapy
No Contraindications Contraindications or Beta-blocker intolerance

Endoscopic Variceal Band Ligation

No role for sclerotherapy or nitrates

Primary Prophylaxis for Variceal Hemorrhage: Conclusions


Propranolol is the most cost-effective treatment for the prevention of initial variceal bleeding The documented benefits of prophylactic beta blockers may be lost if discontinued due to a rebound in bleeding/ mortality. Life-long beta blocker treatment is therefore indicated Non-compliant patients may be better served by band ligation therapy, although at substantially higher costs ($1425 vs $4284)
Hepatology 2001; 34(6):1096-02

Management of Variceal Bleeding


Primary Prophylaxis
Pharmacologic Endoscopic

Acute Variceal Hemorrhage


Pharmacologic Endoscopic TIPS

Secondary Prophylaxis
Pharmcologic Endoscopic TIPS

TREATMENT OF ACUTE VARICEAL HEMORRHAGE

Treatment of Acute Variceal Hemorrhage


General Management:
IV access and fluid resuscitation Antibiotic prophylaxis Correct coagulopathy Do not overtransfuse (hemoglobin ~ 7-8 g/dL) Empiric lactulose?

Specific therapy:
Pharmacological therapy: octreotide, vasopressin + nitroglycerin Early endoscopic therapy: band ligation Shunt therapy: TIPS, surgical shunt

Cautious Transfusion Improves Outcome in Cirrhotics with Variceal Hemorrhage


214 cirrhotics with UGIB randomized to restricted (Hgb 7-8 gm) or liberal transfusion (Hgb 9-10 gm) 69% esophageal variceal 7% gastric variceal 15% peptic ulcer 3% gastropathy Therapeutic failure occurred in 16% of restricted and 28% of liberal group (p<0.04) In subgroup with esophageal variceal bleed, the 6 week survival without therapeutic failure was better in restrictive group (84% vs 69%: p<0.02) 38% in restrictive group required no transfusion vs 9% in liberal group
Colomo A. et al , Abstract 232A (AASLD 2008)

Cautious Transfusion Improves Outcome in Cirrhotics with Variceal Hemorrhage


90%
80% 70% 60% 50% P= 0.04 69%
6-week survival in variceal bleeders who did not have therapeutic failure

84%

P= 0.02

40%
30% 20% 10% 0% 28%

16%

Treatment failure

6 week survival

HGB 7.0 (n= 109)

HGB 9.0 N=105)


Colomo A. et al , Abstract 232A (AASLD 2008)

Prophylactic Antibiotics Improve Outcomes in Cirrhotic Patients with GI Hemorrhage


PROPHYLACTIC ANTIBIOTICS IMPROVE OUTCOMES IN CIRRHOTIC PATIENTS WITH GI HEMORRHAGE

The use of prophylactic antibiotics in cirrhotics with GI hemorrhage has been shown by metaanalysis to reduce infection, increase survival, and reduce recurrent hemorrhage (13 prospective trials) Recommended antibiotics include oral norfloxacin, ciprofloxin, ofloacin, and amoxicillin clavulanate, ceftriaxone IV
Scand J. Gastro 2003;38:193-200

PROPHYLACTIC ANTIBIOTICS IMPROVE OUTCOMES IN CIRRHOTIC PATIENTS WITH GI HEMORRHAGE

Prophylactic Antibiotics Improve Outcomes in Cirrhotic Patients with GI Hemorrhage


Control
(n=270)

Antibiotic
(n=264)

Absolute rate difference


(95% CI)

Infection SBP / Bacteremia Death

45% 27% 24%

14% 8% 15%

-32%
(-42 to 23)

-18%
(-26 to 11)

-9%
(-15 to 3)

Meta-analysis of 5 randomized trials

Bernard et al., Hepatology 1999; 29:1655

PROPHYLACTIC ANTIBIOTICS PREVENT EARLY VARICEAL REBLEEDING

Prophylactic Antibiotics Reduce Probability of Recurrent Variceal Hemorrhage


1.0

0.8

Prophylactic antibiotics (n=59)

0.6

No antibiotics (n=61)

%
free of 0.4 variceal hemorrhage
0.2

Greatest benefit in first 7 days

0 0 1 2 3 12 18 24 30

Follow-up (months)

Ofloxacin 200 mg iv q12 hr for 2 days, then oral 200 bid for 5 days

Hou M-C et al., Hepatology 2004; 39:746

Phamacologic Treatment for Acute Variceal Hemorrhage


Octreotide:
50 microgram bolus and 25-50 mcg/hr for up to 5 days (range 2-5 days) Too dangerous for empiric initial therapy Contiunuous infusion 0.2-0.4 U/min up to 1.0 U/min Recommended only in combination with i.v. TNG: 1050 mcg/min Titrate TNG infusion to maintain systolic BP >90 mmHg Continuous vasopressin> 24 hr not recommended

Vasopressin:

Prophylaxis of HSE in Acute Variceal Bleed

Lactulose 30 mL TID_QID until pts had non-melenic stools and then the dose was reduced so that patients had two to three semiformed stools per day

PROPHYLACTIC ANTIBIOTICS IMPROVE OUTCOMES IN CIRRHOTIC PATIENTS WITH GI HEMORRHAGE

Endoscopic Therapy Now Standard in the Management of Variceal Hemorrhage

Non-Pharmacologic Treatment of Acute Variceal Hemorrhage


Endoscopic Band Ligation Transjugular Intrahepatic Portalsystemic Shunting (TIPS) Mostly Historical Interest
Sengstaken-Blakemore Tube Embolization of varices Portacaval shunt surgery Injection Sclerotherapy

ENDOSCOPIC VARICEAL BAND LIGATION

Endoscopic Variceal Band Ligation


Bleeding controlled in 90%

Rebleeding rate 30%


Compared with sclerotherapy:

Less rebleeding Lower mortality Fewer complications Fewer treatment sessions

Erythromycin improves visibility during endoscopy for variceal bleeding


Study involved 90 patients with cirrhosis who had been vomiting blood due to variceal bleeding during the previous 12 hours. The 47 patients randomized to the intervention group received an intravenous bolus infusion of 125 mg erythromycin lactobionate in 50 mL normal saline. The other 43 patients received only the saline. (All patients also received octreotide, esmoprazole, and ceftriaxone.)
Gastrointest Endosc 2010.

Erythromycin improves visibility during endoscopy for variceal bleeding


On multivariate analysis, erythromycin was the only predictor of an empty stomach. As a result, the average time needed for endoscopy was also shorter after erythromycin (19 vs 26 min, p < 0.005). Physicians found that with erythromycin, they could control bleeding by band ligation more often (70% vs 49%, p < 0.04) and that hospital stays were shorter (3.4 vs 5.1 days, p < 0.002).
Gastrointest Endosc 2010.

COMBINATION DRUG/ENDOSCOPIC THERAPY IS MORE EFFECTIVE THAN ENDOSCOPIC THERAPY ALONE

Combination Drug / Endoscopic Therapy is More Effective Than Endoscopic Therapy Alone in Achieving Five-Day Hemostasis
Sclero + Octreotide Ligation + Octreotide Sclero + Octreotide / ST Sclero + Octreotide Sclero + Octreotide Sclero + ST Sclero + Octreotide Sclero / ligation + Vapreotide TOTAL
0.8 1 1.2 1.4 1.6 1.8 2

Besson, 1995 Sung, 1995 Signorelli, 1996 Ceriani, 1997 Signorelli, 1997 Avgerinos, 1997 Zuberi, 2000 Cales, 2001
Relative Risk

Favors endoscopic therapy alone

Favors endoscopic plus drug therapy


Baares R et al., Hepatology 2002; 35:609

No Mortality Difference

THE TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT

Transjugular Intrahepatic Portosystemic Shunt


Hepatic vein

TIPS

Portal vein

Splenic vein Superior mesenteric vein

TIPS IN THE TREATMENT OF VARICEAL HEMORRHAGE

TIPS in the Treatment of Variceal Hemorrhage


TIPS is rescue therapy for recurrent variceal hemorrhage
(at second rebleed for esophageal varices, at first rebleed for gastric varices)

TIPS is indicated in patients who rebleed on combination endoscopic plus pharmacologic therapy (10-20%) In patients with Child A/B cirrhosis, the distal spleno-renal shunt is as effective as TIPS
(dependent on local expertise)

Early TIPS In Patients With Acute Variceal Hemorrhage and HVPG > 20 mmHg (High Risk) May Improve Survival

116 cirrhotics with acute variceal bleed Urgent assessment of wedged hepatic vein pressure 64 HVPG < 20 mmHg: routine therapy 52 HVPG > 20 mmHg randomized to TIPS vs routine therapy Early TIPS in patients with HVPG>20 associated with reduced transfusion, rebleed, in-hospital and 1 year mortality
Monescillo et al., Hepatology 2004; 40:793

EARLY TIPS IN PATIENTS WITH ACUTE VARICEAL HEMORRHAGE AND HVPG > 20 mmHg MAY IMPROVE SURVIVAL

Early TIPS In Patients With Acute Variceal Hemorrhage and HVPG > 20 mmHg (High Risk) May Improve Survival
1
HVPG <20 0.8 0.6 HVPG >20 - TIPS

Probability of survival

0.4 HVPG >20 No TIPS

0.2
0 0 3 6 9 12

Months
Monescillo et al., Hepatology 2004; 40:793

Early Use of TIPS in Patients with Cirrhosis and Variceal Bleeding


63 patients with cirrhosis and acute variceal bleeding who had been treated with vasoactive drugs plus endoscopic therapy Randomized to treatment with a polytetrafluoroethylenecovered stent within 72 hours after randomization (early-TIPS group, 32 patients) Vs continuation of vasoactive-drug therapy, followed after 3 to 5 days by treatment with propranolol or nadolol and long-term endoscopic band ligation (EBL), with insertion of a TIPS if needed as rescue therapy (pharmacotherapyEBL group, 31 patients).
Garca-Pagn JC et al. N Engl J Med 2010;362:2370-2379.

Early Use of TIPS in Patients with Cirrhosis and Variceal Bleeding

Garca-Pagn JC et al. N Engl J Med 2010;362:2370-2379.

Early Use of TIPS in Patients with Cirrhosis and Variceal Bleeding


During a median follow-up of 16 months, rebleeding or failure to control bleeding occurred in 14 patients in the pharmacotherapyEBL group as compared with 1 patient in the early-TIPS group (P=0.001). The 1-year actuarial probability of remaining free of this composite end point was 50% in the pharmacotherapyEBL group versus 97% in the early-TIPS group (P<0.001). Sixteen patients died (12 in the pharmacotherapyEBL group and 4 in the early-TIPS group, P=0.01). The 1-year actuarial survival was 61% in the pharmacotherapyEBL group versus 86% in the early-TIPS group (P<0.001)
Garca-Pagn JC et al. N Engl J Med 2010;362:2370-2379.

Actuarial Probability of the Primary Composite End Point and of Survival, According to Treatment Group.

No significant differences were observed between the two treatment groups with respect to serious adverse events.
Garca-Pagn JC et al. N Engl J Med 2010;362:2370-2379.

Early Use of TIPS in Patients with Cirrhosis and Variceal Bleeding


TIPS
40% 33% 28%

Standard RX

15.60%

6%
2.50% 0%

6%

HSE

> Ascites

SBP

HRS

MANAGEMENT ALGORITHM IN ACUTE ESOPHAGEAL VARICEAL HEMORRHAGE

Management of Acute Variceal Hemorrhage


Variceal Hemorrhage Suspected
Initial Management Acute Hemorrhage Controlled?
NO YES

Balloon Tamponade
YES

Early rebleeding?
NO

Rescue TIPS/Shunt surgery


Further bleeding

2nd Endoscopy

Prophylaxis against recurrent hemorrhage

Management of Variceal Bleeding


Primary Prophylaxis
Pharmacologic Endoscopic

Acute Variceal Hemorrhage


Pharmacologic Endoscopic TIPS

Secondary Prophylaxis
Pharmcologic Endoscopic TIPS

LOWEST REBLEEDING RATES ARE OBTAINED IN HVPG RESPONDERS AND IN PATIENTS TREATED WITH VARICEAL BAND LIGATION + BETA-BLOCKERS

Lowest Rebleeding Rates are Obtained in HVPG Responders and With Ligation + b-Blockers
80

60

%
Rebleeding

40

20

Untreated b-blockers

Sclerotherapy

b -blockers + ISMN (6 trials)

(19 trials) (26 trials) (54 trials)

HVPGLigation Responders* + b-blockers (18 trials) (6 trials) (2 trials)

Ligation

Bosch and Garca-Pagn, Lancet 2003; 361:952

* HVPG <12 mmHg or >20% from baseline

MANAGEMENT ALGORITHM FOR THE PREVENTION OF RECURRENT VARICEAL HEMORRHAGE

Prophylaxis of Recurrent Variceal Hemorrhage


Control of Acute Variceal Hemorrhage Prophylactic Pharmacotherapy and/or Endoscopic Variceal Band Ligation Recurrent Hemorrhage
NO YES

Surveillance Endoscopy and/or Life-long Pharmacotherapy

Is patient on EVL + Pharmacotherapy?


NO YES

Initiate combination Rx

TIPS/Shunt Surgery

Further bleeding

SUMMARY OF MANAGEMENT OF VARICES AND VARICEAL HEMORRHAGE

Evolution of Varices
Cirrhosis with no varices
Small varices No hemorrhage

Level of Intervention

Management Recommendations
Repeat endoscopy in 2-3 years No specific therapy Small varices Repeat endoscopy in 1-2 years No specific therapy ? beta-blocker to prevent enlargement

Pre-primary prophylaxis

Medium / large varices No hemorrhage

Primary prophylaxis

Medium/Large varices Non-selective beta-blockers EVL in those intolerant to drugs Endoscopic/pharmacologic therapy Antibiotics in all patients TIPS or shunt surgery as rescue therapy

Variceal hemorrhage

Secondary prophylaxis Recurrent variceal hemorrhage

Beta-blockers + nitrates or EVL Beta-blockers + EVL ? TIPS or shunt surgery as rescue therapy

GASTRIC VARICES

Gastric Varices
10-15% of variceal bleeding episodes Limited data from controlled trials

Optimal therapy not known


Vasoactive drugs used, but not studied Endoscopic cyanoacrylate injection: 90% control of bleeding Balloon tamponade with Linton-Nachlas tube TIPS: 90% control of bleeding

CLASSIFICATION OF GASTRIC VARICES

Classification of Gastric Varices


GOV 2

GOV 1

IGV 1

IGV 2

Sarin et al, Am J Gastro 1989; 84:1244

MANAGEMENT ALGORITHM FOR PATIENTS BLEEDING FROM GASTRIC VARICES

Management of Acute Gastric (Fundal) Variceal Bleeding


Variceal Hemorrhage Suspected
Initial Management Variceal obturation possible?
NO YES

Transfuse to hemoglobin ~8 g/dL Early pharmacotherapy Antibiotic prophylaxis

Bleeding controlled?
NO YES

TIPS*

Variceal obliteration +beta-blockers


Not possible or rebleed

*Surgical shunt may be considered for Childs Class A

MANAGEMENT OF GASTRIC VARICES

Management of Gastric Varices


Gastric varices that are continuous with esophageal varices and extend along the lesser curve (GOV1) should be treated in the same way as esophageal varices In patients with isolated fundal varices (IGV1), splenic vein thrombosis should be investigated. If present, treatment consists of splenectomy
Cirrhotic patients bleeding from gastric fundal varices require specific treatment

ENDOSCOPIC IMAGES OF GASTRIC VARICES

Gastric Varices

Pretreatment cyanoacrylate

Post-treatment cyanoacrylate

PORTAL HYPERTENSIVE GASTROPATHY

Portal Hypertensive Gastropathy


Endoscopic changes seen in most patients with portal hypertension Characterized by a cobblestone appearance of the mucosa and red signs on endoscopy

Often confused with:


Gastric Antral Vascular Estasia (GAVE) Watermelon Stomach

May be associated with chronic occult bleeding, anemia, and occasionally cause of acute UGI hemorrhage

SEVERE PORTAL HYPERTENSIVE GASTROPATHY MAY BE DIFFICULT TO DISTINGUISH FROM DIFFUSE GAVE

Severe Portal Hypertensive Gastropathy May be Difficult to Distinguish from Diffuse GAVE

Severe PHG

Diffuse GAVE

ENDOSCOPIC IMAGES OF THE TWO TYPES OF GASTRIC ANTRAL VASCULAR ECTASIA

Types of Gastric Antral Vascular Ectasia

Typical GAVE watermelon stomach

Diffuse GAVE

GASTRIC ANTRAL VASCULAR ECTASIA

Gastric Antral Vascular Ectasia (GAVE)


Endoscopic findings:
Red spots without background mosaic pattern Linear aggregates in antrum: watermelon stomach Diffuse lesions in proximal and distal stomach

May be difficult to differentiate from portal hypertensive gastropathy (PHG)


Ideal therapy not known

Argon Plasma Coagulation for GAVE

Band Ligation for GAVE

VARICEAL WALL TENSION IS A MAJOR DETERMINANT OF VARICEAL RUPTURE

Variceal Wall Tension (T) is a Major Determinant of Variceal Rupture


Esophagus

Wall thickness (w)

Radius (r)

Transmural pressure (tp)

Varix

Tension (T)

r T = tp x w
Groszmann, Gastroenterology 1984; 80:1611

MANAGEMENT OF PATIENTS WITHOUT VARICES

Treatment of Varices / Variceal Hemorrhage


No varices Prevent Formation of Varices ?

Varices No hemorrhage Variceal hemorrhage Recurrent hemorrhage

Prevent First Variceal Hemorrhage Control Bleeding: Reduce Mortality

Prevent Recurrent Hemorrhage

Endoscopic Findings

Which is the best option? 1) Start atenolol 2) Start propranolol 3) Variceal band ligation 4) Propranol and isosorbide mononitrate 5) Band ligation and beta blockers

Bleeding controlled with band ligation, antibiotics an octreotide No bleeding for 5 days Child score 10. MELD 15 MAP 90 mmHg Which is the best discharge regiment? 1) Beta blockers and nitrates 2) Serial ligation alone 3) Ligation and beta blockers 4) TIPS 5) Portacaval shunt

Prevention of Recurrent Bleeding TIPS vs. Drug Therapy


91 Childs-Pugh class B/C cirrhotic patients who survived first variceal hemorrhage Randomized to TIPS(47) vs propranolol plus isosorbide-5-mononitrate(44) Followed for 2 years Assess hepatic encephalopathy, recurrent variceal hemorrhage, costs, number of medical interventions, and survival
Hepatology 2002;35:385-92