Bosch Jaume, García-Pagán Juan Carlos
Hepatic Haemodynamic Laboratory, Liver Unit, Institut de Malalties Digestives, Hospital Clínic, IDIBAPS, University of Barcelona, 08036, Barcelona, Spain.
Lancet. 2003 Mar 15;361(9361):952-4. doi: 10.1016/S0140-6736(03)12778-X.
Variceal bleeding is the most frequent severe complication of portal hypertension and a leading cause of death and liver transplantation in patients with cirrhosis. Patients surviving a variceal bleed are at high risk of rebleeding (over 60% at 1 year). Portacaval shunts and transjugular intrahepatic portasystemic shunts (TIPS) are effective for prevention of rebleeding but carry a high risk of hepatic encephalopathy. Endoscopic techniques include band ligation (EBL) and injection sclerotherapy (EIS). Drug approaches are based on non-selective beta blocker with or without isosorbide-5-mononitrate (ISMN).
David Patch and colleagues (Gastroenterology 2002; 123: 1013-19) randomised 102 patients surviving a variceal bleeding to EBL or drug therapy with propranolol with the addition of ISMN if target reductions in portal pressure (evaluated by the hepatic venous pressure-gradient [HVPG]) were not achieved at 3 months. Overall, results of drug therapy were similar to those of EBL (44% vs 54% rebleeding at 1 year). There were no differences in survival or non-bleeding complications. Christophe Bureau and colleagues (Hepatology 2002; 36: 1361-66) treated 34 patients with cirrhosis and portal hypertension with propranolol and measured HVPG after a median of 4 days. Target HVPG reductions were achieved in 13 "responders". ISMN was added in the 21 "non-responders" and HVPG measured again: seven more patients achieved target HPVG reduction. Re-bleeding rates were lower in responders than in non-responders (10% vs 64%). Both studies suggest that drug therapy can be improved by adding ISMN to b blockers in those patients with an insufficient decrease in HVPG. WHERE NEXT? Long-term drug therapy is emerging as effective treatment for the prevention of variceal rebleeding. The role of HVPG monitoring as a guide to identifying patients requiring further treatment needs to be further evaluated. Trials to determine the best treatment for patients who do not respond to drug therapies are also required.
静脉曲张破裂出血是门静脉高压最常见的严重并发症，也是肝硬化患者死亡和肝移植的主要原因。静脉曲张出血存活的患者再次出血风险很高（1年内超过60%）。门腔分流术和经颈静脉肝内门体分流术（TIPS）对预防再次出血有效，但有发生肝性脑病的高风险。内镜技术包括套扎术（EBL）和注射硬化疗法（EIS）。药物治疗方法基于使用或不使用5-单硝酸异山梨酯（ISMN）的非选择性β受体阻滞剂。
大卫·帕奇及其同事（《胃肠病学》2002年；123：1013 - 19）将102例静脉曲张出血存活患者随机分为EBL组或普萘洛尔药物治疗组，若3个月时门静脉压力（通过肝静脉压力梯度[HVPG]评估）未达到目标降低值，则加用ISMN。总体而言，药物治疗结果与EBL相似（1年时再次出血率分别为44%和54%）。生存率和无出血并发症方面无差异。克里斯托夫·比罗及其同事（《肝脏病学》2002年；36：1361 - 66）用普萘洛尔治疗34例肝硬化和门静脉高压患者，中位4天后测量HVPG。13例“反应者”实现了目标HVPG降低。21例“无反应者”加用ISMN并再次测量HVPG：又有7例患者实现了目标HPVG降低。反应者的再出血率低于无反应者（分别为10%和64%）。两项研究均表明，对于HVPG降低不足的患者，在β受体阻滞剂中加用ISMN可改善药物治疗效果。
下一步方向？长期药物治疗正成为预防静脉曲张再出血的有效治疗方法。HVPG监测作为识别需要进一步治疗患者的指导作用需要进一步评估。还需要进行试验以确定对药物治疗无反应患者的最佳治疗方法。
