Gastrointestinal varices secondary prevention: Difference between revisions
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==Secondary Prevention== | ==Secondary Prevention== | ||
Secondary prevention of gastrointestinal varices involves prevention of rebleeding. The following options are available: | Secondary prevention of gastrointestinal varices involves prevention of rebleeding. The following options are available, according to the condition of the patient: | ||
'''Time to start secondary prophylaxis''' | '''Time to start secondary prophylaxis''' | ||
*Secondary prophylaxis should start as soon as possible from day 6 of the index variceal bleeding episode | *Secondary prophylaxis should start as soon as possible from day 6 of the index variceal bleeding episode | ||
*The | *The time of initiation of secondary prophylaxis should be recorded. | ||
'''Patients with cirrhosis who have not received primary prophylaxis''' | '''Patients with cirrhosis who have not received primary prophylaxis''' | ||
* | *In these patients, a combination of beta blockers and endoscopic band ligation may be used as a measure for secondary prophylaxis | ||
* | *Rebledding risk may be predicted by using the patient's response to pharmacological therapy as a prognostic factor | ||
'''Patients with cirrhosis who are on beta blockers for primary prevention and bleed''' | '''Patients with cirrhosis who are on beta blockers for primary prevention and bleed''' | ||
*Band ligation should be | *Band ligation should be considered in addition to beta blockers | ||
'''Patients who have contraindications or intolerance to beta blockers''' | '''Patients who have contraindications or intolerance to beta blockers''' | ||
*Band ligation is the | *Band ligation is the treatment of choice for prevention of rebleeding | ||
'''Patients who fail endoscopic and pharmacological treatment for prevention of rebleeding''' | '''Patients who fail endoscopic and pharmacological treatment for prevention of rebleeding''' | ||
*TIPS or surgical shunts (distal splenorenal shunt or 8 mm H-graft) are effective for those with Child class A/B cirrhosis | *TIPS or surgical shunts (distal splenorenal shunt or 8 mm H-graft) are effective for those with Child class A/B cirrhosis | ||
*In non-surgical candidates, TIPS is the | *In non-surgical candidates, TIPS is the sole option available | ||
*Transplantation | *Transplantation is associated with good long-term outcomes in Child class B/C cirrhosis and should be considered | ||
*TIPS serves as a bridge to transplantation | |||
'''Patients who have bled from isolated gastric varices, type 1 (IGV1) or gastro-oesophageal varices, type 2 (GOV 2)''' | '''Patients who have bled from isolated gastric varices, type 1 (IGV1) or gastro-oesophageal varices, type 2 (GOV 2)''' | ||
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'''Patients who have bled from gastro-esophageal varices, type 1 (GOV 1)''' | '''Patients who have bled from gastro-esophageal varices, type 1 (GOV 1)''' | ||
*May be treated | *May be treated via band ligation of oesophageal varices with cyanoacrylate or beta blockers | ||
'''Patients who have bled from portal hypertensive gastropathy''' | '''Patients who have bled from portal hypertensive gastropathy''' | ||
*Beta blockers | *Beta blockers to prevent recurrent bleeding | ||
'''Patients in whom beta blockers are contraindicated or fail and who cannot be managed by non-shunt therapy''' | '''Patients in whom beta blockers are contraindicated or fail and who cannot be managed by non-shunt therapy''' |
Revision as of 15:43, 7 December 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
Secondary Prevention
Secondary prevention of gastrointestinal varices involves prevention of rebleeding. The following options are available, according to the condition of the patient:
Time to start secondary prophylaxis
- Secondary prophylaxis should start as soon as possible from day 6 of the index variceal bleeding episode
- The time of initiation of secondary prophylaxis should be recorded.
Patients with cirrhosis who have not received primary prophylaxis
- In these patients, a combination of beta blockers and endoscopic band ligation may be used as a measure for secondary prophylaxis
- Rebledding risk may be predicted by using the patient's response to pharmacological therapy as a prognostic factor
Patients with cirrhosis who are on beta blockers for primary prevention and bleed
- Band ligation should be considered in addition to beta blockers
Patients who have contraindications or intolerance to beta blockers
- Band ligation is the treatment of choice for prevention of rebleeding
Patients who fail endoscopic and pharmacological treatment for prevention of rebleeding
- TIPS or surgical shunts (distal splenorenal shunt or 8 mm H-graft) are effective for those with Child class A/B cirrhosis
- In non-surgical candidates, TIPS is the sole option available
- Transplantation is associated with good long-term outcomes in Child class B/C cirrhosis and should be considered
- TIPS serves as a bridge to transplantation
Patients who have bled from isolated gastric varices, type 1 (IGV1) or gastro-oesophageal varices, type 2 (GOV 2)
- N-butyl-cyanoacrylate
- TIPS
- Beta blockers
Patients who have bled from gastro-esophageal varices, type 1 (GOV 1)
- May be treated via band ligation of oesophageal varices with cyanoacrylate or beta blockers
Patients who have bled from portal hypertensive gastropathy
- Beta blockers to prevent recurrent bleeding
Patients in whom beta blockers are contraindicated or fail and who cannot be managed by non-shunt therapy
- TIPS
- Surgical shunts