Coelho Fabricio Ferreira, Perini Marcos Vinícius, Kruger Jaime Arthur Pirola, Fonseca Gilton Marques, Araújo Raphael Leonardo Cunha de, Makdissi Fábio Ferrari, Lupinacci Renato Micelli, Herman Paulo
Department of Gastroenterology, University of São Paulo Medical School.
Instituto do Câncer do Estado de São Paulo in São Paulo, Brazil.
Arq Bras Cir Dig. 2014 Apr-Jun;27(2):138-44. doi: 10.1590/s0102-67202014000200011.
The treatment of portal hypertension is complex and the the best strategy depends on the underlying disease (cirrhosis vs. schistosomiasis), patient's clinical condition and time on it is performed (during an acute episode of variceal bleeding or electively, as pre-primary, primary or secondary prophylaxis). With the advent of new pharmacological options and technical development of endoscopy and interventional radiology treatment of portal hypertension has changed in recent decades.
To review the strategies employed in elective and emergency treatment of variceal bleeding in cirrhotic and schistosomotic patients.
Survey of publications in PubMed, Embase, Lilacs, SciELO and Cochrane databases through June 2013, using the headings: portal hypertension, esophageal and gastric varices, variceal bleeding, liver cirrhosis, schistosomiasis mansoni, surgical treatment, pharmacological treatment, secondary prophylaxis, primary prophylaxis, pre-primary prophylaxis.
Pre-primary prophylaxis doesn't have specific treatment strategies; the best recommendation is treatment of the underlying disease. Primary prophylaxis should be performed in cirrhotic patients with beta-blockers or endoscopic variceal ligation. There is controversy regarding the effectiveness of primary prophylaxis in patients with schistosomiasis; when indicated, it is done with beta-blockers or endoscopic therapy in high-risk varices. Treatment of acute variceal bleeding is systematized in the literature, combination of vasoconstrictor drugs and endoscopic therapy, provided significant decline in mortality over the last decades. TIPS and surgical treatment are options as rescue therapy. Secondary prophylaxis plays a fundamental role in the reduction of recurrent bleeding, the best option in cirrhotic patients is the combination of pharmacological therapy with beta-blockers and endoscopic band ligation. TIPS or surgical treatment, are options for controlling rebleeding on failure of secondary prophylaxis. Despite the increasing evidence of the effectiveness of pharmacological and endoscopic treatment in schistosomotic patients, surgical therapy still plays an important role in secondary prophylaxis.
门静脉高压的治疗较为复杂，最佳治疗策略取决于潜在疾病（肝硬化与血吸虫病）、患者的临床状况以及进行治疗的时机（在静脉曲张破裂出血的急性发作期，还是择期进行，如作为初级预防、一级预防或二级预防）。随着新的药物治疗选择的出现以及内镜检查和介入放射学技术的发展，门静脉高压的治疗在近几十年发生了变化。
回顾肝硬化和血吸虫病患者静脉曲张破裂出血的择期和急诊治疗策略。
通过检索截至2013年6月的PubMed、Embase、Lilacs、SciELO和Cochrane数据库中的出版物，使用以下主题词：门静脉高压、食管和胃静脉曲张、静脉曲张破裂出血、肝硬化、曼氏血吸虫病、手术治疗、药物治疗、二级预防、一级预防、初级预防。
初级预防没有特定的治疗策略；最佳建议是治疗潜在疾病。肝硬化患者应使用β受体阻滞剂或内镜下静脉曲张套扎术进行一级预防。血吸虫病患者一级预防的有效性存在争议；如有指征，高危静脉曲张患者可使用β受体阻滞剂或内镜治疗。急性静脉曲张破裂出血的治疗在文献中有系统阐述，血管收缩药物与内镜治疗相结合，在过去几十年中死亡率显著下降。经颈静脉肝内门体分流术（TIPS）和手术治疗是挽救治疗的选择。二级预防在减少再出血方面起着重要作用，肝硬化患者的最佳选择是β受体阻滞剂药物治疗与内镜下套扎术相结合。TIPS或手术治疗是二级预防失败时控制再出血的选择。尽管越来越多的证据表明药物和内镜治疗对血吸虫病患者有效，但手术治疗在二级预防中仍起着重要作用。
