Augustin Salvador, González Antonio, Genescà Joan
Salvador Augustin, Antonio González, Joan Genescà, Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona 08035, Spain.
World J Hepatol. 2010 Jul 27;2(7):261-74. doi: 10.4254/wjh.v2.i7.261.
Management of acute variceal bleeding has greatly improved over recent years. Available data indicates that general management of the bleeding cirrhotic patient by an experienced multidisciplinary team plays a major role in the final outcome of this complication. It is currently recommended to combine pharmacological and endoscopic therapies for the initial treatment of the acute bleeding. Vasoactive drugs (preferable somatostatin or terlipressin) should be started as soon as a variceal bleeding is suspected (ideally during transfer to hospital) and maintained afterwards for 2-5 d. After stabilizing the patient with cautious fluid and blood support, an emergency diagnostic endoscopy should be done and, as soon as a skilled endoscopist is available, an endoscopic variceal treatment (ligation as first choice, sclerotherapy if endoscopic variceal ligation not feasible) should be performed. Antibiotic prophylaxis must be regarded as an integral part of the treatment of acute variceal bleeding and should be started at admission and maintained for at least 7 d. In case of failure to control the acute bleeding, rescue therapies should be immediately started. Shunt therapies (especially transjugular intrahepatic portosystemic shunt) are very effective at controlling treatment failures after an acute variceal bleeding. Therapeutic developments and increasing knowledge in the prognosis of this complication may allow optimization of the management strategy by adapting the different treatments to the expected risk of complications for each patient in the near future. Theoretically, this approach would allow the initiation of early aggressive treatments in high-risk patients and spare low-risk individuals unnecessary procedures. Current research efforts will hopefully clarify this hypothesis and help to further improve the outcomes of the severe complication of cirrhosis.
近年来，急性静脉曲张出血的管理有了很大改善。现有数据表明，由经验丰富的多学科团队对出血性肝硬化患者进行综合管理，对该并发症的最终结局起着主要作用。目前建议将药物治疗和内镜治疗联合用于急性出血的初始治疗。一旦怀疑有静脉曲张出血（理想情况是在转院期间），应立即开始使用血管活性药物（首选生长抑素或特利加压素），并持续使用2 - 5天。在通过谨慎的液体和血液支持使患者病情稳定后，应进行急诊诊断性内镜检查，并且一旦有技术熟练的内镜医师，应进行内镜下静脉曲张治疗（首选套扎术，若内镜下静脉曲张套扎术不可行则采用硬化疗法）。抗生素预防必须被视为急性静脉曲张出血治疗的一个组成部分，应在入院时开始并持续至少7天。如果未能控制急性出血，应立即开始抢救治疗。分流疗法（尤其是经颈静脉肝内门体分流术）在控制急性静脉曲张出血后的治疗失败方面非常有效。随着该并发症治疗方法的发展以及对其预后认识的增加，在不久的将来，可能通过根据每个患者预期的并发症风险调整不同治疗方法来优化管理策略。从理论上讲，这种方法将允许对高危患者尽早开始积极治疗，并使低风险个体避免不必要的手术。目前的研究工作有望阐明这一假设，并有助于进一步改善肝硬化严重并发症的治疗结果。
