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Review
. 2013 Jul 22:2013:541836.
doi: 10.1155/2013/541836. eCollection 2013.

Gastrointestinal Bleeding in Cirrhotic Patients with Portal Hypertension

Erwin Biecker  1
Affiliations
Review

Gastrointestinal Bleeding in Cirrhotic Patients with Portal Hypertension

Erwin Biecker. ISRN Hepatol. .

Abstract

Gastrointestinal bleeding related to portal hypertension is a serious complication in patients with liver cirrhosis. Most patients bleed from esophageal or gastric varices, but bleeding from ectopic varices or portal hypertensive gastropathy is also possible. The management of acute bleeding has changed over the last years. Patients are managed with a combination of endoscopic and pharmacologic treatment. The endoscopic treatment of choice for esophageal variceal bleeding is variceal band ligation. Bleeding from gastric varices is treated by injection with cyanoacrylate. Treatment with vasoactive drugs as well as antibiotic treatment is started before or at the time point of endoscopy. The first-line treatment for primary prophylaxis of esophageal variceal bleeding is nonselective beta blockers. Pharmacologic therapy is recommended for most patients; band ligation is an alternative in patients with contraindications for or intolerability of beta blockers. Treatment options for secondary prophylaxis include variceal band ligation, beta blockers, a combination of nitrates and beta blockers, and combination of band ligation and pharmacologic treatment. A clear superiority of one treatment over the other has not been shown. Bleeding from portal hypertensive gastropathy or ectopic varices is less common. Treatment options include beta blocker therapy, injection therapy, and interventional radiology.

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Figures

Figure 1
Figure 1
Esophageal varices in a patient with liver cirrhosis, second grade.
Figure 2
Figure 2
Endoscopic view through the transparent cap mounted at the tip of the endoscope at a ligated varix in the lower esophagus.
Figure 3
Figure 3
Flow chart showing the options for primary prevention of esophageal variceal bleeding. Patients at high risk of bleeding are those with medium or large varices, small varices, and red whale signs and patients in a Child class C state.
Figure 4
Figure 4
Flow chart showing the management of acute bleeding from esophageal varices. As an option in high-risk patients, early insertion of a PTFE covered TIPS is an alternative to endoscopic and vasopressor treatment.
Figure 5
Figure 5
Flow chart giving the possible options for patients with rebleeding from esophageal varices (secondary prophylaxis).
Figure 6
Figure 6
Isolated gastric varices type II located in gastric corpus in a patient with splenic vein thrombosis.
Figure 7
Figure 7
Portal hypertensive gastropathy with the typical “snakeskin” pattern in a patient with liver cirrhosis.
Figure 8
Figure 8
Acute bleeding from portal hypertensive gastropathy in a patient with liver cirrhosis.
Figure 9
Figure 9
Duodenal varices in a patient with portal vein and splenic vein thrombosis: (a) endoscopic picture, (b) endosonographic picture.
Figure 10
Figure 10
Acute bleeding from a rectal varix in a patient with liver cirrhosis.
See this image and copyright information in PMC

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