Swiss Liver Center, Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
Hepatic Hemodynamic Laboratory, Hospital Clinic-IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain.
Liver Int. 2017 Jan;37 Suppl 1:104-115. doi: 10.1111/liv.13277.
Variceal haemorrhage is a major complication of portal hypertension that still causes high mortality in patients with cirrhosis. Improved knowledge of the pathophysiology of portal hypertension has recently led to a more comprehensive approach to prevent all the complications of this condition. Thus, optimal treatment of portal hypertension requires a strategy that takes into account the clinical stage of the disease and all the major variables that affect the risk of progression to the next stage and death. In patients with compensated liver disease, the correction of factors influencing the progression of fibrosis, in particular aetiologic factors, is now feasible in many cases and should be achieved to prevent the development or progression of gastroesophageal varices and hepatic decompensation. Once gastroesophageal varices have developed, non-selective beta-blockers remain the cornerstone of therapy. Carvedilol provides a greater decrease in portal pressure and is currently indicated as a first-choice therapy for primary prophylaxis. The treatment of acute variceal haemorrhage includes a combination of vasoactive drugs, antibiotics and endoscopic variceal band ligation. In high-risk patients, the early use of transjugular intrahepatic portosystemic shunt (TIPS) lowers the risk of re-bleeding and improves survival. Transjugular intrahepatic portosystemic shunt is the choice for uncontrolled variceal bleeding; a self-expandable metal stent or balloon tamponade can be used as a bridging measure. The combination of non-selective beta-blockers and endoscopic variceal band ligation reduces the risk of recurrent variceal bleeding and improves survival. In these cases, statins seem to further improve survival. Transjugular intrahepatic portosystemic shunt is indicated in patients who rebleed during secondary prophylaxis.
静脉曲张出血是门静脉高压症的主要并发症，仍导致肝硬化患者死亡率高。对门静脉高压症病理生理学的认识的提高，最近导致了更全面的方法来预防这种情况的所有并发症。因此，门静脉高压症的最佳治疗需要一种策略，该策略考虑到疾病的临床阶段以及影响进展到下一个阶段和死亡风险的所有主要变量。在代偿性肝病患者中，纠正影响纤维化进展的因素，特别是病因因素，在许多情况下现在是可行的，应该实现以预防胃食管静脉曲张和肝功能失代偿的发展或进展。一旦胃食管静脉曲张发展，非选择性β受体阻滞剂仍然是治疗的基石。卡维地洛可更大程度地降低门静脉压力，目前被指定为原发性预防的首选治疗药物。急性静脉曲张出血的治疗包括血管活性药物、抗生素和内镜下食管静脉曲张结扎术的联合应用。在高危患者中，早期使用经颈静脉肝内门体分流术（TIPS）可降低再出血的风险并提高生存率。TIPS 是用于治疗无法控制的静脉曲张出血的选择；自扩张金属支架或气囊填塞可作为桥接措施。非选择性β受体阻滞剂和内镜下食管静脉曲张结扎术的联合应用可降低复发性静脉曲张出血的风险并提高生存率。在这些情况下，他汀类药物似乎进一步提高了生存率。TIPS 适用于二级预防中再出血的患者。
