Diagnosis and treatment of gastrointestinal bleeding secondary to portal hypertension. American College of Gastroenterology Practice Parameters Committee.

UNLABELLED

Guidelines for clinical practice are intended to suggest preferable approaches to particular medical problems as established by interpretation and collation of scientifically valid research, derived from extensive review of published literature. When data are not available that will withstand objective scrutiny, a recommendation may be made based on a consensus of experts. Guidelines are intended to apply to the clinical situation for all physicians without regard to specialty. Guidelines are intended to be flexible, not necessarily indicating the only acceptable approach, and should be distinguished from standards of care, which are inflexible and rarely violated. Given the wide range of choices in any health care problem, the physician should select the course best suited to the individual patient and the clinical situation presented. These guidelines are developed under the auspices of the American College of Gastroenterology and its practice parameters committee. These guidelines are also approved by the governing boards of American College of Gastroenterology and Practice Parameters Committee. Expert opinion is solicited from the outset for the document. Guidelines are reviewed in depth by the committee, with participation from experienced clinicians and others in related fields. The final recommendations are based on the data available at the time of the production of the document and may be updated with pertinent scientific developments at a later time. The following guidelines are intended for adults and not for pediatric patients.

OBJECTIVE

To develop practice guidelines for the management of gastrointestinal bleeding in adult patients with cirrhosis and portal hypertension.

METHOD

Randomized controlled trials published through October of 1993 were evaluated by members of the American College of Gastroenterology Practice Parameters Committee. Each paper was reviewed by three members of the committee and rated for quality of design by predetermined criteria. Meta-analysis of the studies for each treatment were evaluated for both outcome and quality of design and formed the basis for recommendations for treatment. Randomized controlled trials published between October of 1993 and August of 1995 have been added to update and modify the recommendations. The reader is referred to an excellent article by D'Amico et al. (The treatment of portal hypertension: A meta-analytic review. Hepatology 1995;22:332-354), which presents most of the meta-analyses reviewed by this committee.

CONCLUSIONS

Once esophageal varices have been established by endoscopy as the site of bleeding, either sclerotherapy or endoscopic variceal ligation should be performed to control the bleeding episodes. Concomitant use of vasoactive drugs lowers portal pressure, potentially offers the endoscopist a clearer field in which to work, and is the only noninvasive treatment for nonesophagogastric variceal sites of bleeding related to portal hypertension. For patients failing medical therapy, the transjugular intrahepatic portasystemic shunt procedure is a reasonable alternative to an emergency surgically created shunt. Nonselective beta-adrenergic blockers are the only proven therapy for prevention of first variceal hemorrhage. Both nonselective beta-adrenergic blockers and endoscopic variceal ligation (which has replaced sclerotherapy for this indication) are effective in reducing the risk of recurrent variceal bleeding. For patients failing these approaches, selective or total shunts or, in selected patients, liver transplantation are appropriate rescue procedures.