Evaluation and treatment of esophageal varices in the cirrhotic patient.

Portal hypertension is the leading cause of morbidity and mortality in liver cirrhosis. Complications of portal hypertension in cirrhotic patients include esophageal and gastric varices, portal hypertensive gastropathy, ascites, hepatorenal syndrome, hepatopulmonary syndrome and portopulmonary hypertension. The hepatic venous pressure gradient should be at least 10 mmHg for esophageal varices to appear, and more than 12 mmHg for acute esophageal variceal bleeding. This article reviews the pathophysiology responsible for portal hypertension and its complications, and the treatments used for esophageal varices in the setting of primary and secondary prophylaxis and during active bleeding.

Patients whose first episode of bleeding occurs while taking a ß-blocker have high long-term risks of rebleeding and death.

BACKGROUND & AIMS: Patients who have their first episode of variceal bleeding despite primary prophylaxis with a nonselective ß-adrenergic receptor antagonist (also called a nonselective ß-blocker [NSBB]) receive additional treatment by endoscopic band ligation to prevent further bleeding. However, little is known about their long-term outcomes. METHODS: We collected data on 89 consecutive patients with cirrhosis who were admitted to the Liver Unit of Hospital Clínic, Barcelona, with acute esophageal variceal bleeding between June 2007 and February 2011. Thirty-four patients were receiving primary prophylaxis with NSBBs when they had their first episode of variceal bleeding, whereas 55 were not receiving NSBBs (controls). All patients were subsequently treated with a combination of endoscopic band ligation and NSBBs. Patients were examined after 1, 3, and 6 months and every 6 months thereafter until 2 years. RESULTS: After 2 years, a greater proportion of patients who had their first episode of bleeding while on NSBBs had further bleeding, compared with controls (48% vs 24%; P = .01). Primary prophylaxis with NSBBs and serum levels of bilirubin were independent predictors of rebleeding. Overall, 11 patients died, and 5 underwent liver transplantation. Liver transplantation-free survival was lower among patients who had their first episode of bleeding while taking NSBBs (66% vs 88% for controls; P = .02). Primary prophylaxis with NSBBs and Child-Pugh class were independently associated with liver transplantation-free survival. CONCLUSIONS: Patients who have their first episode of variceal bleeding while on primary prophylaxis with a ß-blocking agent have an increased risk of further bleeding and death, despite adding endoscopic band ligation. These patients possibly require alternative treatment approaches.

Non-invasive diagnostic and prognostic evaluation of liver cirrhosis and portal hypertension.

Cirrhosis is the final stage of most of chronic liver diseases, and is almost invariably complicated by portal hypertension, which is the most important cause of morbidity and mortality in these patients. This review will focus on the non-invasive methods currently used in clinical practice for diagnosing liver cirrhosis and portal hypertension. The first-line techniques include physical examination, laboratory parameters, transient elastography and Doppler-US. More sophisticated imaging methods which are less commonly employed are CT scan and MRI, and new technologies which are currently under evaluation are MR elastography and acoustic radiation force imaging (ARFI). Even if none of them can replace the invasive measurement of hepatic venous pressure gradient and the endoscopic screening of gastroesophageal varices, they notably facilitate the clinical management of patients with cirrhosis and portal hypertension, and provide valuable prognostic information.

[Hepatorenal syndrome: pathogenesis and treatment].

Hepatorenal syndrome has been known for many years as one of the main complications of cirrhosis. The etiology was unknown for many years, although it was already accepted in the past as a functional renal failure, without renal pathology. The syndrome mostly develops in advanced cirrhosis patients, and some risk factors hasten its development. In recent years there has been considerable progress in the understanding of this syndrome, and some studies found a connection between renal failure and splanchnic vasodilatation, systemic and renal vasoconstriction, high NO level in the splanchnic system, and high neuroadrenaline and renin levels in the blood. The most accepted theory to explain the etiology of the syndrome in known as the "arterial vasodilatation theory". Lately, cardiac involvement in the syndrome was also found, with low cardiac output. The explanation for this is still unclear. The treatment for the hepatorenal syndrome was recently developed, and is based on pathophysiology. Vasoconstrictors with plasma expanders, mostly albumin, were found effective in improving the renal function in patients with hepatorenal syndrome in some studies, with improved chances to complete liver transplantation successfully. It is now well accepted as the treatment of choice until liver transplantation can be performed.