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{{CMG}}
{{Portal hypertension}}
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==Overview==
==Overview==
Treatment with a non-selective [[beta blocker]] is often commenced once [[portal hypertension]] has been diagnosed, and almost always if there has already been bleeding from esophageal varices. Typically, this is done with either [[propranolol]] or [[nadolol]]. The addition of a [[nitrate]], such as [[isosorbide mononitrate]], to the [[beta blocker]] is more effective than using beta blockers alone and may be the preferred regimen in those people with portal [[hypertension]] who have already experienced variceal bleeding. In acute or severe complications of the [[hypertension]], such as bleeding varices, intravenous [[octreotide]] (a [[somatostatin]] analogue) or intravenous [[terlipressin]] (an [[antidiuretic hormone]] analogue) is commenced to decrease the portal pressure.
Pharmacological medical therapy is recommended among patients with [[cirrhosis]] and portal hypertension without [[esophageal varices]], with [[esophageal varices]] but not yet [[bleeding]], with [[esophageal varices]] that is [[bleeding]], and with [[esophageal varices]] that has already bled. Pharmacological medical therapies for portal hypertension include [[Beta blockers|non-selective beta blockers (NSBB)]], analogues of [[Nitric oxide|nitric oxide (NO)]], and [[Vasoactive amine|vasoactive agents]].
 
==Medical Therapy==
*Pharmacological medical therapy is recommended among patients with [[cirrhosis]] and portal hypertension:
**Without [[esophageal varices]]
**With [[esophageal varices]] but not yet [[bleeding]]
**With [[esophageal varices]] which is [[bleeding]]
**With [[esophageal varices]] which has already bled
*Pharmacological medical therapies for portal hypertension include [[Beta blockers|non-selective beta blockers (NSBB)]], analogues of [[Nitric oxide|nitric oxide (NO)]], and [[Vasoactive amine|vasoactive agents]].
===Portal hypertension===
*'''1 Stage 1 - Without esophageal varices'''
**No need to treat portal hypertension.<ref name="pmid16306522">{{cite journal |vauthors=Groszmann RJ, Garcia-Tsao G, Bosch J, Grace ND, Burroughs AK, Planas R, Escorsell A, Garcia-Pagan JC, Patch D, Matloff DS, Gao H, Makuch R |title=Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis |journal=N. Engl. J. Med. |volume=353 |issue=21 |pages=2254–61 |year=2005 |pmid=16306522 |doi=10.1056/NEJMoa044456 |url=}}</ref>
**Treat underlying causes of [[cirrhosis]], such as:
***[[Hepatitis C/Medical Therapy|Hepatitis C]]
***[[Hepatitis B/Medical Therapy|Hepatitis B]]
***[[Non-alcoholic fatty liver disease medical therapy|Non-alcoholic fatty liver disease]]
*'''2 Stage 2 - With esophageal varices but not yet bleeding'''
**2.1 '''Low-risk small varices'''<ref name="pmid15300580">{{cite journal |vauthors=Merkel C, Marin R, Angeli P, Zanella P, Felder M, Bernardinello E, Cavallarin G, Bolognesi M, Donada C, Bellini B, Torboli P, Gatta A |title=A placebo-controlled clinical trial of nadolol in the prophylaxis of growth of small esophageal varices in cirrhosis |journal=Gastroenterology |volume=127 |issue=2 |pages=476–84 |year=2004 |pmid=15300580 |doi= |url=}}</ref>
***2.1.1 '''Adult'''
****Preferred regimen (1): Conservative management
****Alternative regimen (1):
*****Starting dose: [[Propranolol]] 20 mg [[Per os|PO]] q12h; adjust every 2-3 days to achieve final goal; not exceed 320 mg daily.
*****Therapeutic goals: Maximal tolerating dose; resting [[heart rate]] of 50-55 [[beats per minute]].
*****Maintenance and follow up: Continue indefinitely without need to follow up [[endoscopy]].
****Alternative regimen (2):
*****Starting dose: [[Nadolol]] 40 mg [[Per os|PO]] daily; adjust every 2-3 days to achieve final goal; not exceed 160 mg daily.
*****Therapeutic goals: Maximal tolerating dose; resting [[heart rate]] of 50-55 [[beats per minute]].
*****Maintenance and follow up: Continue indefinitely without need to follow up [[endoscopy]].
**2.2 '''Medium risk large varices'''<ref name="pmid18042114">{{cite journal |vauthors=Gluud LL, Klingenberg S, Nikolova D, Gluud C |title=Banding ligation versus beta-blockers as primary prophylaxis in esophageal varices: systematic review of randomized trials |journal=Am. J. Gastroenterol. |volume=102 |issue=12 |pages=2842–8; quiz 2841, 2849 |year=2007 |pmid=18042114 |doi=10.1111/j.1572-0241.2007.01564.x |url=}}</ref><ref name="pmid18293274">{{cite journal |vauthors=Bosch J, Abraldes JG, Berzigotti A, Garcia-Pagan JC |title=Portal hypertension and gastrointestinal bleeding |journal=Semin. Liver Dis. |volume=28 |issue=1 |pages=3–25 |year=2008 |pmid=18293274 |doi=10.1055/s-2008-1040318 |url=}}</ref>
*** 2.2.1 '''Adult'''
****Preferred regimen (1):
*****Starting dose: [[Propranolol]] 20 mg [[Per os|PO]] q12h; adjust every 2-3 days to achieve final goal; not exceed 320 mg daily.
*****Therapeutic goals: Maximal tolerating dose; resting [[heart rate]] of 50-55 [[beats per minute]].
*****Maintenance and follow up: Continue indefinitely without need to follow up [[endoscopy]].
****Preferred regimen (2):
*****Starting dose: [[Nadolol]] 40 mg [[Per os|PO]] daily; adjust every 2-3 days to achieve final goal; not exceed 160 mg daily.
*****Therapeutic goals: Maximal tolerating dose; resting [[heart rate]] of 50-55 [[beats per minute]].
*****Maintenance and follow up: Continue indefinitely without need to follow up [[endoscopy]].
****Preferred procedure (3): Endoscopic variceal ligation every 2-4 weeks. Only to used with [[Beta blockers|non-selective beta-blockers]].
****Alternative regimen (1):
*****Starting dose: [[Isosorbide mononitrate|Isosorbide-5-mononitrate]] 10 mg [[Per os|PO]] at night daily; adjust every 2-3 days by adding 10 mg to morning and then evening; not exceed 20 mg q12h.
*****Therapeutic goals: Maximal tolerating dose; [[systolic blood pressure]] remains more than 95 mmHg.
*****Maintenance and follow up: Continue indefinitely.
**2.3 '''High risk small varices'''
*** 2.3.1 '''Adult'''
****Preferred regimen (1):
*****Starting dose: [[Propranolol]] 20 mg [[Per os|PO]] q12h; adjust every 2-3 days to achieve final goal; not exceed 320 mg daily.
*****Therapeutic goals: Maximal tolerating dose; resting [[heart rate]] of 50-55 [[beats per minute]].
*****Maintenance and follow up: Continue indefinitely without need to follow up [[endoscopy]].
****Preferred regimen (2):
*****Starting dose: [[Nadolol]] 40 mg [[Per os|PO]] daily; adjust every 2-3 days to achieve final goal; not exceed 160 mg daily.
*****Therapeutic goals: Maximal tolerating dose; resting [[heart rate]] of 50-55 [[beats per minute]].
*****Maintenance and follow up: Continue indefinitely without need to follow up [[endoscopy]].
****Alternative procedure (1): Endoscopic [[Esophageal varices|variceal]] [[ligation]] every 2-4 weeks. Only to used with [[Beta blockers|non-selective beta-blockers]].
****Alternative regimen (2):
*****Starting dose: [[Isosorbide mononitrate|Isosorbide-5-mononitrate]] 10 mg [[Per os|PO]] at night daily; adjust every 2-3 days by adding 10 mg to morning and then evening; not exceed 20 mg q12h.
*****Therapeutic goals: Maximal tolerating dose; [[systolic blood pressure]] remains more than 95 mmHg.
*****Maintenance and follow up: Continue indefinitely.
* '''3 Stage 3 - With esophageal varices which is bleeding'''
** 3.1 '''Basic Medical conditions'''
*** 3.1.1 [[Airway]], [[breathing]], and [[circulation]] stabilization
** 3.2 '''Advance cirrhosis'''
*** 3.2.1 [[Antibiotic]] prophylaxis<ref name="pmid17030175">{{cite journal |vauthors=Fernández J, Ruiz del Arbol L, Gómez C, Durandez R, Serradilla R, Guarner C, Planas R, Arroyo V, Navasa M |title=Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage |journal=Gastroenterology |volume=131 |issue=4 |pages=1049–56; quiz 1285 |year=2006 |pmid=17030175 |doi=10.1053/j.gastro.2006.07.010 |url=}}</ref>
**** Preferred regimen (1): [[Ceftriaxone|Ceftriaxon]] 1 g [[Intravenous therapy|IV]] q12h
**** Alternative regimen (1): [[Norfloxacin]] 400 mg [[Intravenous therapy|IV]] q12h
*** 3.2.2 '''Vasoactive agents'''
**** Preferred regimen (1): [[Somatostatin]] 250 μg [[Intravenous therapy|IV]] [[Bolus (medicine)|bolus]], then 250-500 μg/h [[maintenance dose]]; for 5 days
**** Preferred regimen (2): [[Octreotide]] 50 μg [[Intravenous therapy|IV]] [[bolus]], then 50 μg/h [[maintenance dose]]; for 5 days
**** Preferred regimen (3): [[Vapreotide]] 50 μg [[Intravenous therapy|IV]] [[Bolus (medicine)|bolus]], then 50 μg/h [[maintenance dose]]; for 5 days
**** Alternative regimen (1): [[Vasopressin]] 0.2-0.4 units/min [[Intravenous therapy|IV]] [[infusion]], always use with [[Nitroglycerin|nitroglycerine]]; until 24 hours
**** Alternative regimen (2): [[Terlipressin]] 2 mg [[Intravenous therapy|IV]] q4h until control of bleeding, then 1 mg IV q4h for prevention of rebleeding; for 5 days
* '''4 Stage 4 - With esophageal varices which has already bled'''
** 4.1 '''Patients with transjugular intrahepatic portosystemic shunt (TIPS)'''
*** No need to treat portal hypertension anymore
*** Check the [[Shunt (medical)|shunt]] patency every 6 months
** 4.1 '''Patients without''' '''transjugular intrahepatic portosystemic shunt''' '''(TIPS)'''<ref name="pmid8985266">{{cite journal |vauthors=Bernard B, Lebrec D, Mathurin P, Opolon P, Poynard T |title=Beta-adrenergic antagonists in the prevention of gastrointestinal rebleeding in patients with cirrhosis: a meta-analysis |journal=Hepatology |volume=25 |issue=1 |pages=63–70 |year=1997 |pmid=8985266 |doi=10.1053/jhep.1997.v25.pm0008985266 |url=}}</ref>
*** 4.1.1 '''Adults'''
****Preferred regimen (1):
*****Starting dose: [[Propranolol]] 20 mg [[Per os|PO]] q12h; adjust every 2-3 days to achieve final goal; not exceed 320 mg daily.
*****Therapeutic goals: Maximal tolerating dose; resting [[heart rate]] of 50-55 [[beats per minute]].
*****Maintenance and follow up: Continue indefinitely without need to follow up [[endoscopy]].
****Preferred regimen (2):
*****Starting dose: [[Nadolol]] 40 mg [[Per os|PO]] daily; adjust every 2-3 days to achieve final goal; not exceed 160 mg daily.
*****Therapeutic goals: Maximal tolerating dose; resting [[heart rate]] of 50-55 [[beats per minute]].
*****Maintenance and follow up: Continue indefinitely without need to follow up [[endoscopy]].
****Alternative regimen (1):
*****Starting dose: [[Isosorbide mononitrate|Isosorbide-5-mononitrate]] 10 mg [[Per os|PO]] at night daily; adjust every 2-3 days by adding 10 mg to morning and then evening; not exceed 20 mg q12h.
*****Therapeutic goals: Maximal tolerating dose; [[systolic blood pressure]] remains more than 95 mmHg.
*****Maintenance and follow up: Continue indefinitely.
 
==References==
==References==
{{reflist|2}}
{{reflist|2}}
{{WH}}
{{WS}}


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Latest revision as of 14:18, 7 December 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Overview

Pharmacological medical therapy is recommended among patients with cirrhosis and portal hypertension without esophageal varices, with esophageal varices but not yet bleeding, with esophageal varices that is bleeding, and with esophageal varices that has already bled. Pharmacological medical therapies for portal hypertension include non-selective beta blockers (NSBB), analogues of nitric oxide (NO), and vasoactive agents.

Medical Therapy

Portal hypertension

  • 1 Stage 1 - Without esophageal varices
  • 2 Stage 2 - With esophageal varices but not yet bleeding
    • 2.1 Low-risk small varices[2]
      • 2.1.1 Adult
        • Preferred regimen (1): Conservative management
        • Alternative regimen (1):
          • Starting dose: Propranolol 20 mg PO q12h; adjust every 2-3 days to achieve final goal; not exceed 320 mg daily.
          • Therapeutic goals: Maximal tolerating dose; resting heart rate of 50-55 beats per minute.
          • Maintenance and follow up: Continue indefinitely without need to follow up endoscopy.
        • Alternative regimen (2):
          • Starting dose: Nadolol 40 mg PO daily; adjust every 2-3 days to achieve final goal; not exceed 160 mg daily.
          • Therapeutic goals: Maximal tolerating dose; resting heart rate of 50-55 beats per minute.
          • Maintenance and follow up: Continue indefinitely without need to follow up endoscopy.
    • 2.2 Medium risk large varices[3][4]
      • 2.2.1 Adult
        • Preferred regimen (1):
          • Starting dose: Propranolol 20 mg PO q12h; adjust every 2-3 days to achieve final goal; not exceed 320 mg daily.
          • Therapeutic goals: Maximal tolerating dose; resting heart rate of 50-55 beats per minute.
          • Maintenance and follow up: Continue indefinitely without need to follow up endoscopy.
        • Preferred regimen (2):
          • Starting dose: Nadolol 40 mg PO daily; adjust every 2-3 days to achieve final goal; not exceed 160 mg daily.
          • Therapeutic goals: Maximal tolerating dose; resting heart rate of 50-55 beats per minute.
          • Maintenance and follow up: Continue indefinitely without need to follow up endoscopy.
        • Preferred procedure (3): Endoscopic variceal ligation every 2-4 weeks. Only to used with non-selective beta-blockers.
        • Alternative regimen (1):
          • Starting dose: Isosorbide-5-mononitrate 10 mg PO at night daily; adjust every 2-3 days by adding 10 mg to morning and then evening; not exceed 20 mg q12h.
          • Therapeutic goals: Maximal tolerating dose; systolic blood pressure remains more than 95 mmHg.
          • Maintenance and follow up: Continue indefinitely.
    • 2.3 High risk small varices
      • 2.3.1 Adult
        • Preferred regimen (1):
          • Starting dose: Propranolol 20 mg PO q12h; adjust every 2-3 days to achieve final goal; not exceed 320 mg daily.
          • Therapeutic goals: Maximal tolerating dose; resting heart rate of 50-55 beats per minute.
          • Maintenance and follow up: Continue indefinitely without need to follow up endoscopy.
        • Preferred regimen (2):
          • Starting dose: Nadolol 40 mg PO daily; adjust every 2-3 days to achieve final goal; not exceed 160 mg daily.
          • Therapeutic goals: Maximal tolerating dose; resting heart rate of 50-55 beats per minute.
          • Maintenance and follow up: Continue indefinitely without need to follow up endoscopy.
        • Alternative procedure (1): Endoscopic variceal ligation every 2-4 weeks. Only to used with non-selective beta-blockers.
        • Alternative regimen (2):
          • Starting dose: Isosorbide-5-mononitrate 10 mg PO at night daily; adjust every 2-3 days by adding 10 mg to morning and then evening; not exceed 20 mg q12h.
          • Therapeutic goals: Maximal tolerating dose; systolic blood pressure remains more than 95 mmHg.
          • Maintenance and follow up: Continue indefinitely.
  • 3 Stage 3 - With esophageal varices which is bleeding
  • 4 Stage 4 - With esophageal varices which has already bled
    • 4.1 Patients with transjugular intrahepatic portosystemic shunt (TIPS)
      • No need to treat portal hypertension anymore
      • Check the shunt patency every 6 months
    • 4.1 Patients without transjugular intrahepatic portosystemic shunt (TIPS)[6]
      • 4.1.1 Adults
        • Preferred regimen (1):
          • Starting dose: Propranolol 20 mg PO q12h; adjust every 2-3 days to achieve final goal; not exceed 320 mg daily.
          • Therapeutic goals: Maximal tolerating dose; resting heart rate of 50-55 beats per minute.
          • Maintenance and follow up: Continue indefinitely without need to follow up endoscopy.
        • Preferred regimen (2):
          • Starting dose: Nadolol 40 mg PO daily; adjust every 2-3 days to achieve final goal; not exceed 160 mg daily.
          • Therapeutic goals: Maximal tolerating dose; resting heart rate of 50-55 beats per minute.
          • Maintenance and follow up: Continue indefinitely without need to follow up endoscopy.
        • Alternative regimen (1):
          • Starting dose: Isosorbide-5-mononitrate 10 mg PO at night daily; adjust every 2-3 days by adding 10 mg to morning and then evening; not exceed 20 mg q12h.
          • Therapeutic goals: Maximal tolerating dose; systolic blood pressure remains more than 95 mmHg.
          • Maintenance and follow up: Continue indefinitely.

References

  1. ↑ Groszmann RJ, Garcia-Tsao G, Bosch J, Grace ND, Burroughs AK, Planas R, Escorsell A, Garcia-Pagan JC, Patch D, Matloff DS, Gao H, Makuch R (2005). "Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis". N. Engl. J. Med. 353 (21): 2254–61. doi:10.1056/NEJMoa044456. PMID 16306522.
  2. ↑ Merkel C, Marin R, Angeli P, Zanella P, Felder M, Bernardinello E, Cavallarin G, Bolognesi M, Donada C, Bellini B, Torboli P, Gatta A (2004). "A placebo-controlled clinical trial of nadolol in the prophylaxis of growth of small esophageal varices in cirrhosis". Gastroenterology. 127 (2): 476–84. PMID 15300580.
  3. ↑ Gluud LL, Klingenberg S, Nikolova D, Gluud C (2007). "Banding ligation versus beta-blockers as primary prophylaxis in esophageal varices: systematic review of randomized trials". Am. J. Gastroenterol. 102 (12): 2842–8, quiz 2841, 2849. doi:10.1111/j.1572-0241.2007.01564.x. PMID 18042114.
  4. ↑ Bosch J, Abraldes JG, Berzigotti A, Garcia-Pagan JC (2008). "Portal hypertension and gastrointestinal bleeding". Semin. Liver Dis. 28 (1): 3–25. doi:10.1055/s-2008-1040318. PMID 18293274.
  5. ↑ Fernández J, Ruiz del Arbol L, Gómez C, Durandez R, Serradilla R, Guarner C, Planas R, Arroyo V, Navasa M (2006). "Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage". Gastroenterology. 131 (4): 1049–56, quiz 1285. doi:10.1053/j.gastro.2006.07.010. PMID 17030175.
  6. ↑ Bernard B, Lebrec D, Mathurin P, Opolon P, Poynard T (1997). "Beta-adrenergic antagonists in the prevention of gastrointestinal rebleeding in patients with cirrhosis: a meta-analysis". Hepatology. 25 (1): 63–70. doi:10.1053/jhep.1997.v25.pm0008985266. PMID 8985266.

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