Pfisterer Nikolaus, Unger Lukas W, Reiberger Thomas
Medizinische Abteilung für Gastroenterologie und Hepatologie, Klinik Landstraße/Krankenanstalt Rudolfstiftung, Vienna 1030, Austria.
Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna 1090, Austria.
World J Hepatol. 2021 Jul 27;13(7):731-746. doi: 10.4254/wjh.v13.i7.731.
Portal hypertension (PH), a common complication of liver cirrhosis, results in development of esophageal varices. When esophageal varices rupture, they cause significant upper gastrointestinal bleeding with mortality rates up to 20% despite state-of-the-art treatment. Thus, prophylactic measures are of utmost importance to improve outcomes of patients with PH. Several high-quality studies have demonstrated that non-selective beta blockers (NSBBs) or endoscopic band ligation (EBL) are effective for primary prophylaxis of variceal bleeding. In secondary prophylaxis, a combination of NSBB + EBL should be routinely used. Once esophageal varices develop and variceal bleeding occurs, standardized treatment algorithms should be followed to minimize bleeding-associated mortality. Special attention should be paid to avoidance of overtransfusion, early initiation of vasoconstrictive therapy, prophylactic antibiotics and early endoscopic therapy. Pre-emptive transjugular intrahepatic portosystemic shunt should be used in all Child C10-C13 patients experiencing variceal bleeding, and potentially in Child B patients with active bleeding at endoscopy. The use of carvedilol, safety of NSBBs in advanced cirrhosis ( with refractory ascites) and assessment of hepatic venous pressure gradient response to NSBB is discussed. In the present review, we give an overview on the rationale behind the latest guidelines and summarize key papers that have led to significant advances in the field.
门静脉高压（PH）是肝硬化的常见并发症，可导致食管静脉曲张的发生。当食管静脉曲张破裂时，会引起严重的上消化道出血，尽管采用了先进的治疗方法，死亡率仍高达20%。因此，预防措施对于改善PH患者的预后至关重要。多项高质量研究表明，非选择性β受体阻滞剂（NSBBs）或内镜下套扎术（EBL）对静脉曲张出血的一级预防有效。在二级预防中，应常规使用NSBB + EBL联合治疗。一旦食管静脉曲张形成并发生静脉曲张出血，应遵循标准化的治疗方案，以尽量降低与出血相关的死亡率。应特别注意避免过度输血、尽早开始血管收缩治疗、预防性使用抗生素以及早期内镜治疗。对于所有发生静脉曲张出血的Child C10 - C13患者，以及内镜检查时有活动性出血的Child B患者，应考虑预先进行经颈静脉肝内门体分流术（TIPS）。本文还讨论了卡维地洛的使用、NSBBs在晚期肝硬化（伴有难治性腹水）中的安全性以及肝静脉压力梯度对NSBBs反应的评估。在本综述中，我们概述了最新指南背后的基本原理，并总结了该领域取得重大进展的关键文献。
