肝硬化 食道靜脈曲張出血的處置

Management of Varices and Variceal Hemorrhage in Cirrhosis

Management of Varices and Variceal Hemorrhage in Cirrhosis N Engl J Med March 4, 2010;362:823-32 Purpose of Therapy

1. Primary prophylaxis: prevent a first episode of variceal hemorrhage
2. Treatment of the acute bleeding episode
3. Secondary prophylaxis: prevention of recurrent variceal hemorrhage

Risk Stratification for Patients with Portal Hypertension 1. Esophagogastroduodenoscopy

• to evaluate the presence of varices, red wale marks, and variceal size

2. HVPG (hepatic venous pressure gradient)

• Portal hypertension is clinically significant when HVPG >10 mmHg, this pressure is the strongest predictor of the development of varices, clinical decompensation, and HCC.
• In patients with variceal hemorrhage, HVPG >20 mmHg (measured within 24 hours after admission) is the best predictor of a poor outcome.

3. Child-Turcotte-Pugh classification system

Treatment of Acute Variceal Hemorrhage Standard Therapy

1. Combination of vasoconstrictor (terlipressin, somatostatin, or octreotide, administered from the time of admission and maintained for 2 to 5 days) and endoscopic therapy (preferably endoscopic variceal ligation, performed at diagnostic endoscopy <12 hours after admission), together with short-term prophylactic antibiotics (either norfloxacin or ceftriaxone).
2. Placement of a TIPS is currently considered a salvage therapy for the 10 to 20% of patients in whom standard medical therapy fails.
3. Endoscopic variceal obturation is the best endoscopic technique to control acute hemorrhage and the TIPS is more effective than variceal obturation in preventing recurrent hemorrhage.