JOURNAL READING

MANAGEMENT OF VARICES & VARICEAL HEMORRHAGE IN CIRRHOSIS

THE NEW ENGLAND JOURNAL OF MEDICINE

Oleh Winda Septia Khairunnisa I11108031

BACKGROUND
Variceal hemorrhage lethal complication of

cirrhosis Management of varices and variceal hemorrhage in cirrhosis

primary prophylaxis
treatment of the acute bleeding episode secondary prophylaxis

NATURAL HISTORY AND EPIDEMIOLOGY

Gastroesophageal varices >50% patients with cirrhosis at the time of diagnosis (<<Child class B or C)
1 Year Rate First Variceal Bleeding

Small Varices

Large Varices

5%

15%

1 Year Rate Reccurent Bleeding 6 Weeks Mortality

60 %

15-20%

Child Pugh A

0%

Child Pugh C

30%

PATOPHYSIOLOGY

PHYSIOLOGY OF BLOOD FLOW FROM VENA PORTA

PORTAL HYPERTENSION

THERAPIES
DRUGS
Sphlancnic Vasoconstriction
Vasopressin & somatostatin Nonselective betaadrenergic blockers Nitrates & simvastatin Adrenergic blockers

Reduction of Cardiac Output delivery of NO to intrahepatic circulation Intrahepatic Vasodilator

THERAPIES THAT REDUCE PORTAL PRESSURE

Angiotensin blockers

SHUNT
TIPS (Transjugular Intrahepatic Portosystemic Shunt) Surgical Shunt

THERAPIES

TIPS...

THERAPIES
LONG TERM
Variceal Ligation

LOCAL THERAPIES WITHOUT PORTAL PRESSUREREDUCING EFFECTS

Variceal Sclerotherapy Variceal Obturation

SHORT TERM
Balloon Tamponade Expandable Esophageal Stents

THERAPIES

Figure 1. Endoscopic variceal sclerotheraphy & Endoscopic variceal ligation

Figure 2. Endoscopic variceal obturation

Risk Stratification for Patients with Portal Hypertension

Gastroesophageal varices
Esophagogastroduodenoscopy

COMPENSATED CIRRHOSIS

Capsule endoscopy A ratio of platelet count to spleen size

>5 mm Hg Portal hypertension >10 mm Hg predictor for development of varices, clinical decompensation & hepatocellular carcinoma

DECOMPENSATED CIRRHOSIS

Portal Pressure (HVPG)

No Varices Variceal Hemorrhage

20 mm Hg Poor outcome <12 mm Hg or a reduction >20% risk of variceal hemorrhage and survival

Risk Stratification for Patients with Portal Hypertension

CHILD-PUGH Classificationstratify risk for Compensated & Decompensated Cirrhosis

Class A: 5-6; B: 7-9; C: 10-15. Patient with variceal Hemorrhage + CHILD Class C HVPG > 20 mmHg Poor Outcome

Risk Stratification for Patients with Portal Hypertension

Predict development of decompensation in patient without varices

Model for End Stage Liver Disease score (MELDs)

Predict 6-week mortality in patient with variceal Hemorrhage

Prevention of Varices & First Variceal Hemorrhage

VARICES

Treatment for varices

Yes

No

Bleeding

Low risk for bleeding & death No

Nonselective -blockers not recommended

Yes

Treatment for acute bleeding

Prevention of Varices & First Variceal Hemorrhage

VARICES

Small

Medium/Large

Low risk of bleeding red wale marks (-) severe liver disease (-)

High risk of hemorrhage red wale marks (+) Child class B/C

Optional

Recommended
OR

Recommended

Nonselective blockers

Endoscopic Variceal Ligation

See Table 2...

Red Wale Marks

Advantages & Disavantages of Treatment

THERAPHY Advantages Disadvantages Contraindications & side effects (fatigue and shortness of breath) Nonselective - Cost is low blockers Expertise is not required Reduce portal pressureprevent other complications Endoscopic Variceal Ligation Can be performed at the time of screening endoscopy Side effects

Need specific expertise Potential for lethal hemorrhage from postprocedure ulcers

Treatment of Acute Variceal Hemorrhage

VARICEAL HEMORRHAGE

Standard Theraphy:
Vasoconstrictor + endoscopic therapy + short-term prophylactic antibiotics

Surgery

Child Class A/B

Child class C + HVPG > 20 MMhG Recommended in 2448 hours

Endoscopic Variceal Ligation

Endoscopic Variceal Obturation Best for acute bleeding

Fails

TIPS

If there is no expertise

See Table 3...

TREATMENT OF ACUTE VARICEAL HEMORRHAGE

Table 3. First-Line Management of Acute Esophageal Variceal Hemorrhage

TREATMENT OF ACUTE VARICEAL HEMORRHAGE

Prevention of Recurrent Variceal Hemorrhage

PREVENT VARICEAL HEMORRHAGE

Alternative Theraphy
those who are not candidates for endoscopic theraphy

Recommended Theraphy
Significantly lower rate of variceal rebleeding

Drugs
Non selective -blocker + nitrates

Endoscopic Theraphy
Variceal ligation

TIPS or Surgical Shunt

Fails

Most effective for preventing recurrent hemorrhage

See Table 4...

PREVENTION OF RECURRENT VARICEAL HEMORRHAGE

Special Situations for which There Is Limited or No Evidence

A. Portal Hypertensive Gastropathy portal hypertensionrelated gastrointestinal mucosal lesion ectatic gastric mucosal vessels (fundus and body of the stomach) Prediction of portal hypertensive gastropathy the presence of gastroesophageal varices and the Child class Development or its progression from mild to severe Child class Incicence >> patients who have undergone endoscopic therapy (sclerotherapy or endoscopic variceal ligation) The most common presentation chronic, slow hemorrhage anemia The initial management iron supplementation + nonselective -blockers failsshunt therapy ( TIPS or shunt surgery)

Special Situations for which There Is Limited or No Evidence

B. Associated Portal-Vein Thrombosis
The development of portal-vein thrombosis important event in

the natural history of advanced cirrhosis associated with worsening liver function, ascites, and variceal hemorrhage. The incidence 16% per year in patients with advanced liver disease Treatment for portal-vein thrombosis in these patients (e.g., with anticoagulation, thrombolysis, or placement of a transjugular intrahepatic portosystemic shunt) is currently determined on a case by-case basis.

T E R I M A

K A S I H