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Tuesday, 3 December 2013

Cirrhosis - Treatment of the complications of cirrhosis -Variceal bleeding

Cirrhosis is defined as a condition of irreversible scarring liver as a result of liver tissue by fibrosis due to final phase of chronic liver diseases of that can lead to poor function of the liver and liver failure. According to the statistics, Number of discharges with chronic liver disease or cirrhosis as the first-listed diagnosis: 101,000 in 2009 and Deaths per 100,000 population: 10.3 in 2010(a). Hepatitis B infection cause of the disease is very prevalent in South-East Asia.
Treatment of the complications of cirrhosis
Variceal bleeding as a complication of liver cirrhosis is a result of veins in the esophagus, stomach, and rectum enlarge due to blood flow through the liver was blocked. Patients with variceal bleeding, are at 70% greater risk  to have a further bleed within 2 yr after, and patients with acute variceal bleeding has a significant mortality of 5% to 50%.
The amin purpose of the treatment to reduce and stop blood loss
A.2.3.1. In conventional medicine
Portal hypertension can lead to life-threatening hemorrhage, ascites, and encephalopathy. In the study to review the pathophysiology and multidisciplinary management of portal hypertension and its complications, including the indications for and techniques of the various surgical shunts. Variceal bleeding is the most dreaded complication of portal hypertension, showed that treatment of acute variceal bleeding includes resuscitation followed by upper endoscopy for sclerosis or band ligation of varices, which can control bleeding in up to 85% of patients. Medical therapies such as vasopressin and somatostatin can also be useful adjuncts. Shunt therapy, preferably the placement of a TIPS, is indicated for refractory acute variceal bleeding. Recurrent variceal bleeding is common and is associated with a high mortality. Therapies to prevent recurrent variceal bleeding include chronic endoscopic therapy, nonselective beta-blockade, operative or nonoperative (TIPS) shunts, devascularization operations, and liver transplantation. Recommendations and a treatment algorithm are provided, taking into account both the etiology and the manifestations of portal hypertension(90).

1. Anticoagulation
In the study to determine the safety and efficacy of anticoagulation treatment for portal vein thrombosis in cirrhosis patients with acute variceal bleeding, with patient eligibility determined by contrast ultrasonography findings, indicated that early anticoagulation treatment in cirrhosis patients with portal vein thrombosis and acute variceal bleeding may be safe, tolerated, and effective in cases with positive intra-thrombus enhancement on contrast ultrasonography(91).

2. Prophylactic antibiotics
According to the study by Jasmohan S Bajaj, MD, Arun J Sanyal, MD, in the article of Treatment of active variceal hemorrhag, Multiple trials evaluating the effectiveness of prophylactic antibiotics in cirrhotic patients hospitalized for bleeding suggest an overall reduction in infectious complications and possibly decreased mortality. Antibiotics may also reduce the risk of recurrent bleeding in hospitalized patients who bled from esophageal varices. Thus, patients with cirrhosis who present with upper GI bleeding(92).

3. Variceal banding ligation and Injection sclerotherapy
Injection sclerotherapy of bleeding oesophageal varices is undoubtedly beneficial but it is associated with a substantial complication rate, and variceal rebleeding is common during the treatment period before variceal obliteration is achieved. According to the study to compare whether endoscopic variceal banding ligation is safer and more effective by King's College Hospital, showed that there was no difference in outcome between the groups, but 14 sclerotherapy patients were withdrawn from the trial (7 for orthotopic liver transplantation) compared with only 5 (1 for liver transplantation) in the banding ligation group (p < 0.05). Complication rates were similar in the two groups. Variceal banding ligation is a safe and effective technique, which obliterates varices more quickly and with a lower rebleeding rate than injection sclerotherapy(93).

4. Transjugular Intrahepatic Portosystemic Shunt (TIPS) and endoscopy
According to the study to compare early use of transjugular intrahepatic portosystemic shunt (TIPS) with endoscopic treatment (ET) for the prophylaxis of recurrent variceal bleedingby the First Affiliated Hospital of Xi'an Jiaotong University, early use of TIPS is more effective than endoscopic treatment in preventing variceal rebleeding and improving survival rate, and does not increase occurrence of hepatic encephalopathy(94).

5. Distal splenorenal shunt (DSRS
In the study to examine the cost and cost effectiveness of distal splenorenal shunt (DSRS) and transjugular intrahepatic portosystemic shunt (TIPS) in the prevention of variceal rebleeding, showed that
TIPS is as effective as DSRS in preventing variceal rebleeding and may be more cost effective. TIPS, in all aspects, is equal to DSRS in the prevention of variceal rebleeding in patients who are medical failures(95).

6. Periesophagogastric devascularization and fundectomy
Cirrhotic patients with gastric fundal bleeding occasionally require operative intervention. According to the study by the Seoul National University, indicated that patients who were successfully stabilized by preoperative endoscopic intervention had significantly lower mortality ( p < 0.001). During follow-up there was no recurrent bleeding from gastric varices, and there was only one case (4.35%) of hemorrhage from esophageal varices. Hence, periesophagogastric devascularization and fundectomy offers an alternative operative method for cirrhotic patients with variceal hemorrhaging from the gastric fundus(96).

7. Etc.

A.2.3.2. In traditional Chinese medicine
In the study to find a method for inducing Chinese drugs to adhere to the esophageal mucosa to control bleeding from ruptured esophageal varices, showed that The adhesion of Chinese hemostatie drugs remained in the lower segment of esophagus for more than 15 minutes in lying posture, longer than that in standing posture (P < 0.01). (2) The effectiveness of controlling bleeding esophageal varices had no significant difference between the balloon tamponade and adhesion of Chinese hemostatie drugs (P >0. 05)(96a).
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Sources
(a) http://www.cdc.gov/nchs/fastats/liverdis.htm

(90) http://www.ncbi.nlm.nih.gov/pubmed/16137597
(91) http://www.ncbi.nlm.nih.gov/pubmed/22472055
(92) http://www.uptodate.com/contents/treatment-of-active-variceal-hemorrhage
(93) http://www.ncbi.nlm.nih.gov/pubmed/8101900
(94) http://www.ncbi.nlm.nih.gov/pubmed/23326143
(95) http://www.ncbi.nlm.nih.gov/pubmed/18045724
(96) http://www.ncbi.nlm.nih.gov/pubmed/14994139 
(96a) http://link.springer.com/article/10.1007%2FBF02935102