Gastrointestinal varices medical therapy: Difference between revisions
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=== Goal-directed management === | === Goal-directed management === | ||
The management of gastrointestinal varices is aimed at optimizing the following: | The management of gastrointestinal varices is aimed at optimizing the following:<ref name="pmid3301517">{{cite journal |vauthors=Blei AT, Garcia-Tsao G, Groszmann RJ, Kahrilas P, Ganger D, Morse S, Fung HL |title=Hemodynamic evaluation of isosorbide dinitrate in alcoholic cirrhosis. Pharmacokinetic-hemodynamic interactions |journal=Gastroenterology |volume=93 |issue=3 |pages=576–83 |year=1987 |pmid=3301517 |doi= |url=}}</ref><ref name="pmid3734100">{{cite journal |vauthors=Reichen J, Le M |title=Verapamil favorably influences hepatic microvascular exchange and function in rats with cirrhosis of the liver |journal=J. Clin. Invest. |volume=78 |issue=2 |pages=448–55 |year=1986 |pmid=3734100 |pmc=423578 |doi=10.1172/JCI112596 |url=}}</ref> | ||
* Portal venous inflow | * Portal venous inflow | ||
* Portal resistance | * Portal resistance | ||
* Portal pressure | * Portal pressure | ||
This is achieved through the following pharmacological therapies: | This is achieved through the following pharmacological therapies:<ref name="pmid23864788">{{cite journal |vauthors=Kong DR, Ma C, Wang M, Wang JG, Chen C, Zhang L, Hao JH, Li P, Xu JM |title=Effects of propranolol or propranolol plus isosorbide-5-mononitrate on variceal pressure in schistosomiasis |journal=World J. Gastroenterol. |volume=19 |issue=26 |pages=4228–33 |year=2013 |pmid=23864788 |pmc=3710427 |doi=10.3748/wjg.v19.i26.4228 |url=}}</ref><ref name="pmid3301517">{{cite journal |vauthors=Blei AT, Garcia-Tsao G, Groszmann RJ, Kahrilas P, Ganger D, Morse S, Fung HL |title=Hemodynamic evaluation of isosorbide dinitrate in alcoholic cirrhosis. Pharmacokinetic-hemodynamic interactions |journal=Gastroenterology |volume=93 |issue=3 |pages=576–83 |year=1987 |pmid=3301517 |doi= |url=}}</ref> | ||
* Splanchnic vasoconstrictors: | * Splanchnic vasoconstrictors: | ||
** Vasopressin and analogues | ** Vasopressin and analogues | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
Medical Therapy
General considerations and disease stratification
The management of gastrointestinal varices in chronic liver disease should be tailored according to the clinical stage of liver disease and cirrhosis. The following table outlines the key stages of chronic liver disease and the treatement goals for the respective stage:
| Disease stage | HPVG | Varices | Complications of portal hypertension | Management goals |
|---|---|---|---|---|
| Compensated liver disease | Less than 10 mmHg | - | - | |
| Greater than equal to 10 mmHg | - | - | Prevent decompensation | |
| Greater than equal to 10 mmHg | + | - | Prevent decompensation | |
| Decompensated liver disease | Greater than equal to 12 mmHg | + | Acute variceal bleed | Control bleeding, prevent early rebleeding and death |
| Greater than equal to 12 mmHg | + | Previous variceal hemorrhage without ascites or encephelopathy | Prevent further decompensation (further bleeding, ascites and encephelopathy) | |
| Greater than equal to 12 mmHg | + | Prior variceal hemorrhage with ascites and/or encehelopathy | Prevent further decompensation and death |
Goal-directed management
The management of gastrointestinal varices is aimed at optimizing the following:[1][2]
- Portal venous inflow
- Portal resistance
- Portal pressure
This is achieved through the following pharmacological therapies:[3][1]
- Splanchnic vasoconstrictors:
- Vasopressin and analogues
- Somatostatin and analogues
- Nonselective β-blockers
- Venodilators:
- Nitrates
The following table shows the major mechanism affected by the various pharmacological therapies used in the management of varices:
| Major pharmacological therapy | Portal flow | Portal resistance | Portal pressure |
|---|---|---|---|
| Vasoconstrictors (e.g. β-blockers) | ↓↓ | ↑ | ↓ |
| Venodilators (e.g. nitrates) | ↓ | ↓ | ↓ |
| Endoscopic therapy | – | – | – |
| TIPS/Shunt therapy | ↑ | ↓↓↓ | ↓↓↓ |
References
- ↑ 1.0 1.1 Blei AT, Garcia-Tsao G, Groszmann RJ, Kahrilas P, Ganger D, Morse S, Fung HL (1987). "Hemodynamic evaluation of isosorbide dinitrate in alcoholic cirrhosis. Pharmacokinetic-hemodynamic interactions". Gastroenterology. 93 (3): 576–83. PMID 3301517.
- ↑ Reichen J, Le M (1986). "Verapamil favorably influences hepatic microvascular exchange and function in rats with cirrhosis of the liver". J. Clin. Invest. 78 (2): 448–55. doi:10.1172/JCI112596. PMC 423578. PMID 3734100.
- ↑ Kong DR, Ma C, Wang M, Wang JG, Chen C, Zhang L, Hao JH, Li P, Xu JM (2013). "Effects of propranolol or propranolol plus isosorbide-5-mononitrate on variceal pressure in schistosomiasis". World J. Gastroenterol. 19 (26): 4228–33. doi:10.3748/wjg.v19.i26.4228. PMC 3710427. PMID 23864788.