·
Risk for death
from bleeding is mainly related to the underlying hepatic functional reserve.
Risk
for death µ __________1__________
Hepatic functional reserve
·
The greatest risk
for rebleeding from varices is within the first few days after the onset of
hemorrhage.
·
Pathogenesis-
·
Treatment
Ä
Nonoperative
treatments are generally preferred for acutely bleeding patients because they
are often high operative risks because of decompensated hepatic function.
Ä
Treatment of the acutely bleeding episode
§
Points to be kept
in mind-
✯ Patients with acute variceal bleeding are at high risk
for emergency surgical intervention due to decompensated hepatic function.
✯ Emergency treatment should be nonoperative [Endoscopic
treatment (sclerosis or ligation)] whenever possible.
✯ Before endoscopy, the patient should be
hemodynamically stabilized and the stomach evacuated of blood clots with a
large-bore lavage tube.
§
Resuscitation-
✯ Restoration of circulating blood volume with isotonic
crystalloid solutions & blood.
✯ Monitoring of blood volume status through central
venous pressure measurements, urinary output & Swan-Ganz pulmonary artery
catheter.
✯ If Prothrombin time > 3 sec, then give FFP .
✯ If Platelet count < 50,000/mm3, then
infuse platelets.
✯ Prophylactic antibiotics to be initiated.
§
Treatment plan-
✯ If a bleeding esophageal varix is observed or
suspected because of an overlying clot, sclerotherapy or variceal ligation is
performed.
✯ Bleeding from gastric varices or from Portal
hypertensive gastropathy (PHG )
should be treated initially with pharmacotherapy.
§ Pharmacotherapy
✯ Vasopressin
§
Causes
hypertension, bradycardia, i cardiac output &
coronary vasoconstriction.
§
Nitroglycerin is
simultaneously infused to reduce systemic A/E.
✯ Somatostatin Analogues
§ Somatostatin- 250 mg IV bolus, followed
by continuous infusion of 250 mg/hour IV for 2-4 days.
§ Octreotide (long acting)- 50 mg IV bolus, followed by continuous infusion of 25-50 mg/hour IV for 2-4 days.
§ Ballon tamponade
✯
Done using Sengstaken-Blakemore
tube
✯
Adv- immediate cessation of bleeding
✯
Diasadv- frequent
recurrent hemorrhage
✯
Complications-
§ Esophageal perforation secondary to
intraesophageal inflation of the gastric balloon
§ Ischemic necrosis of the esophagus
secondary to overinflation of the esophageal balloon
§ Aspiration
✯
Indications-
§ When
exsanguinating hemorrhage prevents acute endoscopic treatment
§ In
patients in whom sclerotherapy has failed
§ In
patients who do not respond to pharmacotherapy
§ Endoscopic treatment
✯ Variceal Sclerosis
§
Both intravariceal and paravariceal techniques
used.
§
Sclerosants- sodium morrhuate and sodium
tetradecyl sulfate.
§
Each varix is usually injected with 1 to 2 mL of
sclerosant just above the esophagogastric junction and 5 cm proximal to it.
§
Complications of sclerotherapy- 1retrosternal chest pain, 2esophageal ulceration, 3fever, 4esophageal perforation, 5worsening of variceal hemorrhage, and 6aspiration pneumonitis
✯ Band Ligation- variceal ligation with rubber band.
✯ A
parenchymal tract between hepatic and major intrahepatic portal venous branch
is created with a balloon catheter, and a 10-mm expandable metal stent is
inserted, thereby creating the shunt.
✯ Not
recommended as initial therapy for acute variceal hemorrhage
✯ Used
only after less invasive treatments, such as endoscopic therapy and
pharmacotherapy, have failed to control bleeding.
✯ Absolute
contraindications-
§
Right-sided heart failure
§
Polycystic liver disease
✯ Relative
contraindications
§ Portal
vein thrombosis
§ Hypervascular
liver tumors
§ Encephalopathy
§
Emergency surgery
✯ Portacaval
shunt
Ä Prevention of Recurrent Hemorrhage
§
Options available for definitive treatment
include pharmacotherapy, chronic endoscopic treatment, TIPS, three hemodynamic
types of shunt operations (nonselective, selective, and partial), a variety of
nonshunt procedures, and hepatic transplantation. The most effective treatment
regimen usually uses two or more of these therapies in sequence.
§
Pharmacotherapy
✯ Objective-
to reduce the HVWP (Hepatic Venous Wedge Pressure) below 12 mm Hg.
✯ Combination
of a β-blocker and a long-acting nitrate (isosorbide
5-mononitrate) is used.
§
Endoscopic therapy
✯ Objective-
to eradicate esophageal varices
✯ After
eradication is achieved, diagnostic endoscopy is performed at 6-month to 1-year
intervals because varices do recur and can bleed (also, through gastric varices
& PHG )
✯ Variceal
ligation more efficacious than sclerotherapy.
✯ combination
of variceal ligation and pharmacotherapy with nonselective β-blockade is more
effective.
§
TIPS
✯ TIPS,
when it effectively decompresses varices, is a nonselective shunt and
completely diverts portal flow.
✯ Major
limitations- 1Shunt
stenosis, 2 h encephalopathy, 3 shunt thrombosis
§
Portosystemic shunts
✯ Nonselective
shunts
§
End-to-side portacaval shunt (Eck fistula)
§
Side-to-side portacaval shunt
§
Large-diameter interposition shunts
§
Conventional splenorenal shunt
✯ Selective
shunts
§
The distal
splenorenal shunt- anastomosis of the distal end of the splenic vein to the
left renal vein and interruption of all collateral vessels, such as the coronary
and gastroepiploic veins, connecting the superior mesenteric and gastrosplenic
components of the splanchnic venous circulation.
✯ Partial
shunts
§
Small-diameter interposition portacaval shunt
using a polytetrafluoroethylene graft, combined with ligation of the coronary
vein and other collateral vessels
§
objectives of partial and selective shunts-
✯
Preservation of hepatic
portal perfusion
✯
Maintenance of some
residual portal hypertension
§ Non-shunt operations
§
Hepatic transplantation
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