Refractory acute variceal bleeding: what to do next?
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.
D'Amico
Mario
M
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.
Berzigotti
Annalisa
A
Garcia-Pagan
Juan Carlos
JC
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