A critical review of the medical treatment of portal hypertension.
There are three distinct phases during which treatment might influence the outcome in patients with portal hypertension and variceal bleeding: treatment of the active bleeding episode, the prevention of recurrent haemorrhage and perhaps most controversially the use of prophylactic therapy to avert the first bleeding episode. For the treatment of active haemorrhage injection sclerotherapy is almost certainly the treatment of choice when the expertise is available. In the absence of such, vasoconstrictor therapy continues to be widely adopted as a temporizing measure. The efficacy of vasopressin as a single agent has been limited by associated cardiovascular complications. The addition of nitroglycerin to a vasopressin regime has recently been shown to reduce such complications and to improve overall efficacy. Somatostatin represents an alternative vasoconstrictor with increasing evidence of efficacy in the absence of serious complications. Long-term injection sclerotherapy is widely accepted as the first line treatment to prevent recurrence of variceal haemorrhage although early rebleeding, prior to the obliteration of varices, represents an important limitation of therapy. Alternative local endoscopic therapy using tissue adhesives or banding of varices are under evaluation. The major claims of benefit initially attributed to oral propranolol for the prevention of rebleeding have now been considerably modified and a specific role remains to be defined. Both injection sclerotherapy and B-adreno-receptor have been proposed as prophylactic therapy to prevent the first variceal haemorrhage. Two extremely positive reports of prophylactic sclerotherapy have received little further support and there are now few protagonists of this approach.(ABSTRACT TRUNCATED AT 250 WORDS)
Westaby
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Liver Unit, King's College Hospital, London.
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D002404:Catheterization; D004932:Esophageal and Gastric Varices / Q000150:complications / Q000628:therapy; D006471:Gastrointestinal Hemorrhage / Q000517:prevention & control; D006801:Humans; D006975:Hypertension, Portal / Q000150:complications / Q000628:therapy*; D015911:Sclerotherapy; D014662:Vasoconstrictor Agents / Q000627:therapeutic use
D000319:Adrenergic beta-Antagonists; D014662:Vasoconstrictor Agents