title: Refractory acute variceal bleeding: what to do next?
abstract: Current recommendations for the treatment of acute variceal bleeding (AVB) are to combine hemodynamic stabilization, antibiotic prophylaxis, pharmacologic agents, and endoscopic treatment. However, despite the application of the current gold-standard pharmacologic and endoscopic treatment, failure to control bleeding or early rebleed within 5 days still occurs in 15% to 20% of patients with AVB. In case of treatment failure of the acute bleeding episode, if bleeding is mild and the patient is hemodynamically stable, a second endoscopic therapy may be attempted. If this fails, or if bleeding is severe, it is usually controlled temporarily with balloon tamponade until a definitive derivative treatment is applied. Transjugular intrahepatic portosystemic shunt is highly effective in this situation; however, despite the control of bleeding, a high proportion of these patients die of liver and multiorgan failure. Strategies intended to improve the prognosis of these patients should focus on identifying those high-risk patients in whom standard therapy is likely to fail, and who are therefore candidates for more aggressive therapies early after the development of AVB.
authors.affiliation: Hospital Clinic, Institut d'Investigacions Biomediques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Spain.
authors.forename: Mario
authors.initials: M
authors.lastname: D'Amico
authors.forename: Annalisa
authors.initials: A
authors.lastname: Berzigotti
authors.forename: Juan Carlos
authors.initials: JC
authors.lastname: Garcia-Pagan
mesh_terms: D021721:Balloon Occlusion / Q000009:adverse effects; D000075202:Contraindications; D020776:Endoscopes, Gastrointestinal / Q000009:adverse effects; D004932:Esophageal and Gastric Varices / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D006471:Gastrointestinal Hemorrhage / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000628:therapy; D006801:Humans; D006975:Hypertension, Portal / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D008103:Liver Cirrhosis / Q000150:complications / Q000503:physiopathology; D019168:Portasystemic Shunt, Transjugular Intrahepatic / Q000009:adverse effects / Q000379:methods; D016879:Salvage Therapy / Q000009:adverse effects / Q000379:methods; D015607:Stents; D017211:Treatment Failure; D016896:Treatment Outcome