Portal hypertension revisited

摘要

The modern management of portal hypertension, and gastro-oesophageal varices in particular, has recently changed after an uneventful period. Ten years ago, propranolol to prevent variceal bleeding and rebleed-ing, was becoming established, and endoscopic injection sclerotherapy was accepted as the treatment of choice to arrest active variceal bleeding and reduce its chances of recurrence. The recent introduction of endoscopic band ligation of varices and transjugular intrahepatic portasystemic stent-shunts (TIPSS) has required a reassessment of the most effective treatments available. Treatment options can be considered under three groupings: management of active variceal bleeding; prevention of rebleeding; and primary prophylaxis of variceal haemorrhage. As regards the first of these, a diagnosis of variceal haemorrhage requires upper gastrointestinal endo-scopy, and there are therefore intrinsic advantages in treatments that can be applied during this diagnostic process. Injection sclerotherapy is effective in controlling haemorrhage in approximately 90% of cases, but has the disadvantage that it commonly causes ulceration which in turn may result in life-threatening haemorrhage. Three recent studies comparing injection sclerotherapy with endoscopic band ligation have demonstrated the superiority of the latter, particularly in respect of a reduction in side-effects and quicker eradication of varices. In many liver units, band ligation has all but replaced injection sclerotherapy, though band ligation is not without its own problems. For example, in the presence of heavy active bleeding, the suction required to prolapse the varix into the banding device draws blood into the field of view, significantly reducing visibility.