Abstract
Background
Acute variceal bleeding is the major cause of death in patients with chronic liver disease. This justifies the search for a more effective therapy to achieve rapid and definitive hemostasis in every patient. At present, the recommended standard treatment for acute variceal bleeding consists of immediate drug treatment with terlipressin or octreotide together with early endoscopic band ligation or sclerotherapy. In the case of ectopic varices terlipressin and cyanoacrylate embolization (if varices can be reached by endoscope) are in use.
Focus
The treatment is considered to have failed when bleeding continues or significant bleeding recurs within 48 h. This indicates the need for emergency transjugular intrahepatic portosystemic shunting (TIPS) which has been regarded as rescue treatment of choice when standard treatment fails. Although randomized studies against supportive treatment are lacking, the high efficacy and relatively low mortality after TIPS implantation are convincing. It is reasonable that smaller shunts should be preferred (probably 8 mm in diameter) since most patients have an increased risk of liver failure. To increase the effect of the shunt with respect to acute hemostasis it should be combined with transjugular embolization of the varices.
Conclusion
Only strict adherence to the definition of failure of standard treatment and a generous indication to the TIPS implantation before multiorgan failure occurs may decrease the high mortality of acute variceal bleeding.
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References
Calet P, Desmorat H, Vinel JP, Caucanas JP, Ravaud A, Gerin P, Brouet P, et al (1990) Incidence of large esophageal varices in patients with cirrhosis application to prophylaxis of first bleeding. Gut 31:1298–1302
North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices (1988) Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective Multicenter Study. N Engl J Med 319:983–989
Sarin SK, Lahoti D, Saxena SP, Murthi NS, Makwane UK (1992) Prevalence, classification and natural history of gastric varices: a longterm follow-up study in 568 portal hypertension patients. Hepatology 16:1343–1349
Kim T, Shijo H, Kokawa H, et al (1997) Risk factors for haemorrhage from gastric fundal varices. Hepatology 25:307–312
Ben-Ari Z, McCormick AP, Jain P, Burroughs AK (1995) Spontaneous hemoperitoneum caused by ruptured varices in a patient with noncirrhotic portal hypertension. Eur J Gastroenterol Hepatol 7:87–90
Arnold C, Haag K, Blum HE, Rössle M (1997) Acute hemoperitoneum after large-volume paracentesis. Gastroenterology 113:978–982
Hanisch E, Doertenbach J, Usadel KH (1992) Somatostatin in acute bleeding of oesophageal varices. Pharmacology and rationale for use. Drugs 44 [Suppl 2]:24–35
Eriksson LS, Brundin T, Söderlund C, Wahren J (1987) Hemodynamic effects of a long-acting somatostatin analogue in patients with liver cirrhosis. Scand J Gastroenterol 22:919–925
McCormick PA, Dick R, Siringo S, Wagstaff D, Chesta J, McIntyre N, Burroughs AK (1990) Octeotride reduces acygos blood flow in cirrhotic patients with portal hypertension. Eur J Gastroenterol Hepatol 2:489–492
Lin HC, Tsai YT, Lee FT, Lee SD, Hsai LC, Lin WJ, Lo KJ (1992) Hemodynamic evaluation of octreotide in patients with Hepatitis B-related cirrhosis. Gastroenterology 103:229–234
Moller S, Brinch K, Henriksen JH, Becker U (1997) Effect of octreotide on systemic, central, and splanchnic hemodynamics in cirrhosis. J Hepatol 26:1026–1033
Kleber G, Sauerbruch T, Fischer G, Paumgartner G (1988) Somatostatin does not reduce oesophageal variceal pressure in liver cirrhosis. Gut 29:153–156
Nevens F, Van Steenbergen W, Yap SH, Fevery J (1996) Assessment of variceal pressure by continuous non-invasive endoscopic registration: a placebo controlled evaluation of the effect of terlipressin and octreotide. Gut 38:129–134
Avgerinos A, Armoris A, Rekoumis G, Manolakopoulos S, Argirakis G, Raptis S (1995) The effect of somatostatin and octreotide on intravascular esophageal variceal pressure in patients with cirrhosis. J Hepatol 22:379–380
Primignani M, Carpinelli L, Vazzoler MC, Hall de Lima MC, Nolte A, Marcelli R, de Franchis R (1994) Short-term effect of octreotide on intraesophageal variceal pressure: a double-blind placebo controlled study. Eur J Gastroenterol Hepatol 6:1027–1031
Villanueva C, Ortiz J, Minana J, Soriano G, Sabat M, Boadas J, Balanzo J (2000) Somatostatin treatment and risk stratification by continuous portal pressure monitoring during acute variceal bleeding. Gastroenterology 121:110–117
Rössle M, Herz R, Gerok W (1981) Effect of somatostatin on portal pressure in cirrhosis. Hepatology 1:541A
Escorsell A, Bandi JC, Andreu V, Moitinho E, Garcia-Pagan JC, Bosch J, Rhodes J (2001) Desensitazion to the effects of intravenous octreotide in cirrhotic patients with portal hypertension. Gastroenterology 120:161–169
Corley DA, Cello JP, Adkisson W, Ko W-F, Kerlikowske K (2001) Octreotide for acute esophageal variceal bleeding: a meta-analysis. Gastroenterology 120:946–954
Gotzsche PC (2002) Somatostatin or octreotide for acute bleeding oesophageal varices (Cochrain Review). In: The Cochrain Library, issue 1:2002. Oxford
Bosch J, Bordas J, Mastai R, et al (1989) Effect of vasopressin on variceal pressure. Gastroenterology 96:541–542
Iwao T, Toyonaga A, Ikegami M, Oho K, Sumino M, Sakaki M, et al (1993) Effects of vasopressin and nicardipine on hemodynamics and liver function in patients with cirrhosis: comparison with vasopressin alone. J Hepatol 19:345–352
Moreau R, Lebrec D (1990) Nitrovasodilators and portal hypertension. J Hepatol 10:263–267
Lin Hc, Tsai YT, Lee FY, et al (1990) Systemic and portal hemodynamic changes following triglycyl-lysine vasopressin plus nitroglycerin administration in patients with hepatitis B-related cirrhosis. J Hepatol 10:370–374
Moller S, Hansen EF, Becker U, Brinch K, Henriksen JH, Bendtsen F (2000) Central and systemic haemodynamic effects of terlipressin in portal hypertensive patients. Liver 20:51–59
D'Amico G, Pagliaro L, Bosch J (1995) The treatment of portal hypertension: a meta-analytic review. Hepatology 22:332–354
Levacher S, Letoumelin P, Pateron D, Blaise M, Lapandry C, Pourriat J-L (1995) Early administration of terlipressin plus glyceryl trinitrate to control active upper gastrointestinal bleeding in cirrhotic patients. Lancet 346:865–868
Laine LA (2001) Endoscopic treatment of acute or active variceal bleeding. In: De Franchis R (ed) Portal hypertension III. Proceedings of the Third Baveno International Consensus Workshop on Definitions, Methodology, and Therapeutic Strategies. Blackwell, Oxford, pp 156–160
Escorsell A, Ruiz del Arbol L, Planas R, et al (2000) Multicenter randomized controlled trial of terlipressin versus sclerotherapy in the treatment of acute variceal bleeding: the TEST study. Hepatology 32:471–476
Banares R, Albillos A, Rincon D, et al (2002) Endoscopic treatment versus endoscopic plus pharmacologic treatment for acute variceal bleeding: a meta-analysis. Hepatology 35:609–615
Lo GH, Lai KH, Cheng JS, et al (1997) Emergency banding ligation versus sclerotherapy for the control of active bleeding from esophageal varices. Hepatology 25:1101–1104
Laine L, Cook D (1995) Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding: a meta-analysis. Ann Intern Med 123:280–287
Heresbach D, Jacquelinet C, Nouel O, Chaperon J, Bretagne JF, et al (1995) Sclerotherapy versus ligation in hemorrhage caused by rupture of esophageal varices. Direct meta-analysis of randomized trials. Gastroenterol Clin Biol 19:914–920
Soehendra N, Grimm H, Nam V, Berger B (1987) N-Butyl-2-cyanoacrylate: a supplement to endoscopic sclerotherapy. Endoscopy 19:221–224
Lo GH, Lai KH, Cheng JS, Chen MH, Chiang HT (2001) A prospective, randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices. Hepatology 33:1060–1064
Teres J, Cecilia A, Bordas JM, Rimola MB, Bru C, Rodes J (1978) Esophageal tamponade for bleeding varices. Gastroenterology 75:566–569
Norton ID, Andrews JC, Kamath PS (1998) Management of ectopic varices. Hepatology 28:1154–1158
De Franchis R (2001) What have we accomplished? In: De Franchis R (ed) Portal hypertension III. Proceedings of the Third Baveno International Consensus Workshop on Definitions, Methodology, and Therapeutic Strategies. Blackwell, Oxford, pp 1–12
Siringo S, McCormick PA, Mistry P, Kaye G, McIntyre N, et al (1991) Prognostic significance of the white nipple sign in variceal bleeding. Gastrointest Endosc 37:51–55
Rössle M, Siegerstetter V, Huber M, Ochs A (1998) The first decade of the transjugular intrahepatic portosystemic shunt (TIPS): state of the art. Liver 18:73–89
Haskal ZJ (1999) Improved patency of transjugular intrahepatic portosystemic shunts in humans: creation and revision with PTFE stent-grafts. Radiology 213:759–766
Burroughs AK, Patch D (1999) Transjugular intrahepatic portosystemic shunt. Semin Liver Dis 19:457–473
Haag K, Rössle M, Hauenstein KH, et al (1993) Der transjuguläre intrahepatische portosystemische Stent-Shunt (TIPS) in der Notfallbehandlung der portalen Hypertension. Intensivmedizin 30:479–483
Banares R, Casado M, Rodriguez-Laiz JM, et al (1998) Urgent transjugular intrahepatic portosystemic shunt for control of acute variceal bleeding. Am J Gastroenterol 93:75–79
Chau TN, Patch D, Chan YW, Nagral A, Dick R, Burroughs AK (1998) "Salvage" transjugular intrahepatic portosystemic shunts: gastric fundal compared with esophageal variceal bleeding. Gastroenterology 114:981–987
Jalan R, John TG, Redhead DN, et al (1995) A comparative study of emergency transjugular intrahepatic portosystemic stent-shunt and esophageal transection in the management of uncontrolled variceal hemorrhage. Am J Gastroenterol 90:1932–1937
LaBerge JM, Somberg KA, Lake JR, et al (1995) Two-year outcome following transjugular intrahepatic portosystemic shunt for variceal bleeding: results in 90 patients. Gastroenterology 108:1143–1151
Le Moine O, Deviere J, Ghysels M, et al (1994) Transjugular intrahepatic portosystemic stent shunt as a rescue treatment after sclerotherapy failure in variceal bleeding. Scand J Gastroenterol Suppl 207:23–28
McCormick PA, Dick R, Panagou EB, et al (1994) Emergency transjugular intrahepatic portasystemic stent-shunting as salvage treatment for uncontrolled variceal bleeding. Br J Surg 81:1324–1327
Sanyal AJ, Freedman AM, Luketic VA, et al (1996) Transjugular intrahepatic portosystemic shunts for patients with active variceal hemorrhage unresponsive to sclerotherapy. Gastroenterology 111:138–146
Gerbes AL, Gülberg V, Waggershauser T, Holl J, Reiser M (1998) Transjugular intrahepatic portosystemic shunt (TIPS) for variceal bleeding in portal hypertension. Comparison of emergency and elective interventions. Dig Dis Sci 43:2463–2469
Sarfeh IJ, Rypins EB, Conroy RM, Mason JR (1983) Portacaval H-graft: relationship of shunt diameter, portal flow patterns and hepatic encephalopathy. Ann Surg 197:422–426
Feu F, Garcia-Pagan JC, Bosch J, Luca A, Teres J, Escorsell A, Rodes J (1995) Relation between portal pressure response to pharmacotherapy and risk of recurrent variceal haemorrhage in patients with cirrhosis. Lancet 346:1056–1059
Villanueva C, Balanzo J, Novella MT, Soriano G, Sainz S, Torras X, Cusso X, Guarner C, Vilardell F (1996) Nadolol plus isosorbide mononitrate compared with sclerotherapy for the prevention of variceal rebleeding. N Engl J Med 334:1624–1629
Rössle M, Siegerstetter V, Olschewski M, Ochs A, Berger E, Haag K (2001) How much reduction in portal pressure is necessary to prevent variceal rebleeding? A longitudinal study in 225 patients with a transjugular intrahepatic portosystemic shunt. Am J Gastroenterol 96:3379–3383
Huonker M, Schumacher YO, Ochs A, Sorichter S, Keul J, Rossle M (1999) Cardiac function and haemodynamics in alcoholic cirrhosis and effects of the transjugular intrahepatic portosystemic stent shunt. Gut 44:743–748
Jalan R, Elton RA, Redhead DN, Finlayson NDC, Hayes PC (1995) Analysis of prognostic variables in the prediction of mortality, shunt failure, variceal rebleeding and encephalopathy following the transjugular intrahepatic portosystemic stent-shunt for variceal haemorrhage. J Hepatol 23:123–128
Chalasani N, Clark WS, Martin LG, Kamean J, Khan MA, Patel NH, Boyer TD (2000) Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic shunting. Gastroenterology 118:138–144
Brensing KA, Raab P, Textor J, Görich J, Schiedermaier P, Strunk H, et al (2002) Prospective evaluation of a clinical score for 60-day mortality after transjugular intrahepatic portosystemic stent-shunt: Bonn TIPSS early mortality analysis. Eur J Gastroenterol Hepatol 14:723–731
Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, Ter Borg PCJ (2000) A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 31:865–871
Rubin RA, Haskal ZJ, O'Brian CB, Cope C, Brass CA (1995) Transjugular intrahepatic portosystemic shunting: decreased survival for patients with high APACHE II scores. Am J Gastroenterol 90:556–563
Patch D, Nikolopoulo V, McCormick A, Dick R, Armonis A, Wannamethee G, Burroughs AK (1998) Factors related to early mortality after transjugular intrahepatic portosystemic shunt for failed endoscopic therapy in acute variceal bleeding. J Hepatology 28:454–460
Shellman R, Fulkerson W, De Long F, Piantadosi C (1988) Prognosis of patients with cirrhosis and chronic liver disease admitted to the medical intensive care unit. Crit Care Med 16:671–678
Hendersen JM, Nagle A, Curtas S, Geisinger M, Barnes D (2000) Surgical shunts and TIPS for variceal decompression in the 1990s. Surgery 128:540–547
Helton WS, Maves R, Wicks K, Johansen K (2001) Transjugular intrahepatic portosystemic shunt vs surgical shunt in good-risk cirrhotic patients. Arch Surg 136:17–20
Rosemurgy AS, Goode SE, Zwiebel BR, Black TJ, Brady PG (1996) A prospective trial of transjugular intrahepatic portosystemic stent shunts versus small-diameter prosthetic H-graft portacaval shunts in the treatment of bleeding varices. Ann Surg 224:378–386
Wolff M, Kalff JC, Hirner A (1999) Portosystemische Shuntchirurgie und transjugulärer intrahepatischer Stent (TIPS) in Deutschland. Chirurg 70:447–452
Barange K, Peron J-M, Imani K, et al (1999) Transjugular intrahepatic portosystemic shunt in the treatment of refractory bleeding from ruptured gastric varices. Hepatology 30:1139–1143
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Rössle, M. When endoscopic therapy or pharmacotherapy fails to control variceal bleeding: what should be done? . Langenbecks Arch Surg 388, 155–162 (2003). https://doi.org/10.1007/s00423-003-0372-8
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DOI: https://doi.org/10.1007/s00423-003-0372-8