Zaman Atif
Department of Medicine, Oregon Health & Science University, Mailcode PV310, 3181 SW Sam Jackson Park Road, Portland, OR 97201, USA.
Curr Treat Options Gastroenterol. 2003 Dec;6(6):499-507. doi: 10.1007/s11938-003-0052-3.
Acute variceal hemorrhage is the most lethal complication of cirrhosis. The reported mortality rate from a first episode of variceal hemorrhage is 17% to 57%. Management of varices can be categorized into three phases: 1) prevention of initial bleeding, 2) management of acute bleeding, and 3) prevention of rebleeding. Modalities for treatment include pharmacologic, endoscopic, and shunt therapy. For the prevention of first variceal hemorrhage, cirrhotic patients should undergo endoscopy to identify patients with large varices. Priority for screening for varices should be given to patients with low platelet count, splenomegaly, and advanced cirrhosis. Once large varices are identified, patients should be started on beta-blocker therapy, which reduces the risk of bleeding by 50%. If pharmacologic therapy is not tolerated or contraindicated, endoscopic band ligation should be performed, and surveillance of varices should be performed every 6 months thereafter. Shunt procedures are not indicated due to their higher rates of complications compared with medical therapy. For the management of acute variceal hemorrhage, patients should be started on prophylactic intravenous antibiotics and intravenous octreotide. Endoscopy should be performed to diagnose and treat variceal hemorrhage. Band ligation appears to be as effective as sclerotherapy, but with less complications. If hemostasis is not achieved, balloon tamponade can be used as a bridge to definitive therapy, which in this case would be a transjugular intrahepatic portosystemic shunt (TIPS). If TIPS is unavailable, a surgical shunt is indicated. Once an episode of acute bleeding has been controlled, variceal eradication is best accomplished with repeat band ligation every 10 to 14 days until varices are obliterated. Prevention of recurrent bleeding can be achieved with beta-blocker therapy. The addition of isosorbide mononitrate further reduces recurrent bleeding. This combination pharmacologic therapy has been shown to be superior to sclerotherapy and may be superior to band ligation. However, side effects of combination pharmacologic therapy may limit its effectiveness. Band ligation is preferred to sclerotherapy when considering endoscopic therapy due to less complications and lower cost. Surgical shunts should be used for prevention of rebleeding in patients who do not tolerate or are noncompliant with medical therapy and who have relatively preserved liver function. TIPS should be reserved for patients who have poor liver function and who have failed medical therapy.
急性静脉曲张出血是肝硬化最致命的并发症。据报道，首次静脉曲张出血的死亡率为17%至57%。静脉曲张的管理可分为三个阶段：1）预防初次出血，2）急性出血的管理，3）预防再出血。治疗方式包括药物治疗、内镜治疗和分流治疗。为预防首次静脉曲张出血，肝硬化患者应接受内镜检查以识别大静脉曲张患者。静脉曲张筛查的优先对象应为血小板计数低、脾肿大和晚期肝硬化患者。一旦识别出大静脉曲张，患者应开始使用β受体阻滞剂治疗，这可将出血风险降低50%。如果药物治疗不耐受或禁忌，应进行内镜下套扎术，此后每6个月对静脉曲张进行监测。由于与药物治疗相比，分流手术并发症发生率更高，因此不建议采用。对于急性静脉曲张出血的管理，患者应开始预防性静脉使用抗生素和静脉注射奥曲肽。应进行内镜检查以诊断和治疗静脉曲张出血。套扎术似乎与硬化疗法效果相同，但并发症较少。如果无法实现止血，可使用球囊压迫作为确定性治疗的过渡措施，在这种情况下确定性治疗应为经颈静脉肝内门体分流术（TIPS）。如果无法进行TIPS，则需进行外科分流术。一旦急性出血发作得到控制，最好每10至14天重复进行套扎术直至静脉曲张消失，以实现静脉曲张根除。使用β受体阻滞剂治疗可预防再出血。加用单硝酸异山梨酯可进一步降低再出血率。这种联合药物治疗已被证明优于硬化疗法，可能也优于套扎术。然而，联合药物治疗的副作用可能会限制其有效性。考虑内镜治疗时，由于并发症较少且成本较低，套扎术优于硬化疗法。对于不耐受或不依从药物治疗且肝功能相对保留的患者，应使用外科分流术预防再出血。TIPS应保留给肝功能差且药物治疗失败的患者。
