-

Abstract

Esophageal varices are collateral veins at the distal esophagus between gastric and azygos veins arising following increased portal pressure. Vein pressure above 10 mmHg is regarded as portal hypertension, in which portal vein-hepatic vein pressure gradient is increased. This status is seen as "clinically important portal hypertension" and it is most common in liver cirrhosis. Acid and esophageal variceal bleeding is the result of portal hypertension, which are the signs of advanced disease with poorer survival rates. Esophageal varices develop in 30% of the patients with compensated cirrhosis and 60-70% of the patients with decompensated cirrhosis. Varice development incidence is around 4-12% in cirrhotic patients without varices. Esophageal variceal hemorrhage has high recurrence, mortality, and morbidity rates requiring immediate medical treatment and these constitute approximately 10% of upper gastrointestinal bleeding, which is one of the major causes of mortality in patients with cirrhosis. Bleeding develops in 30% of the cirrhotic patients with esophageal varices diagnosed during endoscopy. The mortality of the first bleeding episode ranges from 25 to 70% and after the first bleeding episode rebleeding occurs at a rate of 75-80% in six to twelve months. Variceal diameter, grade, degree of red dots, and cirrhosis are among the factors that increase the risk of variceal bleeding. The risk of bleeding in Grade 1 varices is 8% and a higher grade increases the risk of bleeding four to five folds. Pharmacological endoscopic and antibiotic treatment constitutes the basis for esophageal variceal bleeding treatment. In this study, we aimed to evaluate the current approaches to esophageal variceal bleeding

Keywords

• -

Özofagus Varis Kanamalarına Güncel Yaklaşımlar

Öz

Özofagus varisleri portal kan basıncının artmasına bağlı, özofagusun distalinde gastrik venler ile azigos ven arasında geşilen kolaterallerdir. Portal ven basıncının 10 mm Hg’nin üzerinde olmasına portal hipertansiyon denilir. Portal hipertansiyonda portal ven – hepatik ven basınç gradiyenti artmıştır. Bu durum “klinik olarak önem arz eden portal hipertansiyon” olarak adlandırılmaktadır ve en sık karaciğer sirozunda karşılaşılır. Karaciğer sirozu olan hastalarda asit oluşumu ve özofagus varis kanamalarının olması ilerlemiş hastalık belirtileridir ve bu hastaların beklenen yaşama süresi oldukça kısalmıştır. Kompanze sirozlu hastaların %30’unda dekompanze sirozlu hastaların %60-70’inde özofagus varisi gelişmektedir. Varisi olmayan sirotik hastalarda yıllık varis oluşum hızı %4-12 dolayındadır. Özofagus varis kanaması yüksek rekürrens, mortalite ve morbidite oranına sahip acil medikal tedavi gerektiren hastalıklardan biridir. Özofagus varis kanamaları üst gastrointestinal sistem kanamalarının yaklaşık %10’unu oluştururlar ve sirozlu hastalarda başlıca mortalite nedenlerindendir. Özofagus varis kanaması, endoskopik olarak özofagus varisi saptanan sirotik hastaların %30'unda gelişmektedir. İlk kanama epizodunun mortalitesi % 25-70 arasında değişmektedir ve ilk kanama sonrası varislerin % 75-80’inde altı ay ya da bir yıl içinde yeniden kanama meydana gelir. Varis çapı, grade, kırmızı noktalanmalar ve siroz derecesi varis kanaması riskini arttıran faktörlerdir. Grade 1 varislerde kanama riski %8 iken grade arttıkça kanama riski 4-5 kat artmaktadır. Özofagus varis kanamalarında tedavinin temelini farmakolojik, endoskopik ve antibiyotik tedavisi oluşturur. Bu çalışmada özofagus varis kanamalarına güncel yaklaşımlar ele alınmıştır.

Anahtar Kelimeler

• Özofagus Varis Kanaması, Portal Hipertansiyon, Siroz

Kaynakça

1. Nina D, Frédéric O, Paul C. Current management of the complications of portal hypertension: variceal bleeding and ascites 2006;174:1433-43.
2. Shibayama Y, Nakata K. Localization of increased hepatic vascular resistance in liver cirrhosis. Hepatology 1985;5:643-8.
3. Wiest R, Groszmann RJ. The paradox of nitric oxide in cirrhosis and portal hypertension: too much, not enough. Hepatology 2002;35:478-91.
4. Bosch J, Mastai R, Kravetz D, Navasa M, Rodes J. Hemodynamic evaluation of the patient with portal hypertension. Semin Liver Dis 1986; 6: 309-17.
5. Lee SS, Hadengue A, Moreau R, Sayegh R, Hillon P, Lebrec D. Postprandial hemodynamic responses in patients with cirrhosis. Hepatology 1988;8:647-51.
6. Garcia-Pagan JC, Santos C, Barbera JA, Luca A, Roca J, Rodriguez-Roisin R, et al. Physical exercise increases portalpressure in patients with cirrhosis and portal hypertension. Gastroenterology 1996;111:1300-6.
7. Ioannou GN, Doust J, Rockey DC. Systematic review: terlipressin in acute oesophageal variceal haemorrhage. Aliment Pharmacol Ther 2003;17:53-64.
8. Bosch J, Dell’era A. Vasoactive drugs for the treatment of bleeding esophageal varices. Gastroenterol Clin Biol 2004;28 Spec No 2:B186-9.

9. Bosch J, Kravetz D, Rodes J. Effects of somatostatin on hepatic and systemic hemodynamics in patients with cirrhosis of the liver: comparison with vasopressin.Gastroenterology 1981;80:518-25.
10. Moller S, Brinch K, Henriksen JH, Becker U. Effect of octreotide on systemic, central,and splanchnic haemodynamics in cirrhosis. J Hepatol 1997;26:1026-33.
11. Group IOVS, Burroughs AK. Double blind RCT of 5-day octreotide versus placebo, associated with sclerotherapy for trial/failures [abstract]. Hepatology 1996;24:352A.
12. Calès P, Masliah C, Bernard B, Garnier PP, Silvain C, Szostak-Talbodec N, et al. Early administration of vapreotide for variceal bleeding in patients with cirrhosis. French Club for the Study of Portal Hypertension. N Engl J Med 2001;344:23-8.
13. Bureau C, Otal P, Pomier-Layrargues G, Chabbert V, Cortez C, Perreault P, et al. Improved clinical outcome using polytetrafluoroethylene-coated stents for TIPS: results of a randomized study. Gastroenterology 2004;126:469-75.
14. Duggan JM. Review article: transfusion in gastrointestinal haemorrhage — If, when and how much? Aliment Pharmacol Ther 2001;15:1109-13.
15. Goulis J, Armonis A, Patch D, Sabin C, Greenslade L, Burroughs AK. Bacterial infection is independently associated with failure to control bleeding in cirrhotic patients with gastrointestinal hemorrhage. Hepatology 1998;27:1207-12.
16. Lebrec D, Vinel JP, Dupas JL. Complications of portal hypertension in adults: a French consensus. Eur J Gastroenterol Hepatol 2005;17:403-10.
17. Groszmann RJ, Bosch J, Grace ND, Conn HO, Garcia-Tsao G, Navasa M, et al. Hemodynamic events in a prospective randomized trial of propranolol versus placebo in the prevention of a first variceal hemorrhage. Gastroenterology 1990;99:1401-7.
18. Vinel JP, Cassigneul J, Levade M, Voigt JJ, Pascal JP. Assessment of short-term prognosis after variceal bleeding in patients with alcoholic cirrhosis by early measurement of portohepatic gradient. Hepatology 1986;6:116-7.
19. Dib N, Konate A, Oberti F, Cales P. Non-invasive diagnosis of portal hypertension in cirrhosis. Application to the primary prevention of varices. Gastroenterol Clin Biol 2005;29:957-87.
20. Huet PM, Pomier-Layrargues G. The hepatic venous pressure gradient: “remixed and revisited” [review]. Hepatology 2004;39:295-8.
21. Garcia-Pagan JC, Navasa M, Bosch J, Bru C, Pizcueta P, Rodes J. Enhancement of portal pressure reduction by the association of isosorbide-5-mononitrate to propranolol administration in patients with cirrhosis. Hepatology 1990;11:230-8.
22. De Franchis R. Evolving consensus in portal hypertension. Report of the Baveno IVconsensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2005;43:167-76.
23. Garcia-Pagan JC, Villanueva C, Vila MC, Albillos A, Genescà J, Ruiz-del-Arbol L, et al. Isosorbide mononitrate in the prevention of first variceal bleed in patients who cannot receive beta-blockers. Gastroenterology 2001;121:908-14.
24. Karsan HA, Morton SC, Shekelle PG, Spiegel BM, Suttorp MJ, Edelstein M, et al. Combination endoscopic band ligation and sclerotherapy compared with endoscopic band ligation alone for the secondary prophylaxis of esophageal variceal hemorrhage: a meta-analysis. Dig Dis Sci 2005;50:399-406.
25. Lo GH, Lai KH, Cheng JS, Chen MH, Huang HC, Hsu PI, et al. Endoscopic variceal ligation plus nadolol and sucralfate compared with ligation alone for the prevention of variceal rebleeding: a prospective, randomized trial. Hepatology 2000;32:461-5.
26. Luca A, D’Amico G, La Galla R, Midiri M, Morabito A, Pagliaro L. TIPS for prevention of recurrent bleeding in patients with cirrhosis: meta-analysis of randomized clinical trials. Radiology 1999;212:411-21.
27. Spina GP, Henderson JM, Rikkers LF, Teres J, Burroughs AK, Conn H, et al. Distal spleno-renal shunt versus endoscopic sclerotherapy in the prevention of variceal rebleeding. A meta-analysis of 4 randomized clinical trials. J Hepatol 1992;16:338-45.