Esophageal Varices: Primary Prophylaxis and Prevention and Management of Rebleeding
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PORTAL HYPERTENSION (J GONZALEZ-ABRALDES AND E TSOCHATZIS, SECTION EDITORS)
Esophageal Varices: Primary Prophylaxis and Prevention and Management of Rebleeding Mengfei Liu 1 & Moira Hilscher 1 & Patrick S. Kamath 1
# Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Purpose of Review Portal hypertension is an important manifestation of chronic liver diseases, and the complications of portal hypertension, especially gastroesophageal variceal hemorrhage, are associated with high morbidity and mortality. Recent Findings Important advances made in the past several decades in risk stratification and management of patients with portal hypertension and varices have significantly improved patient outcomes. Summary This review addresses the pathophysiology, natural history, differential diagnoses, and diagnostic criteria of portal hypertension. We will also discuss the primary prevention, acute management, and secondary prevention of esophageal and gastric varices. Despite many improvements, there remain significant challenges in the prevention and treatment of portal hypertension, and further research, both in basic and clinical studies are needed to fill current gaps in knowledge. Keywords Portal hypertension . Esophageal varices . Gastric varices . Cirrhosis . Nonselective beta blockers . TIPS
Introduction Variceal hemorrhage is a dreaded complication of portal hypertension and a major cause of mortality in patients with cirrhosis. In recent years, practice guidelines on management of varices have continued to evolve based on data from clinical trials, metaanalyses, and consensus recommendations [1, 2]. These practice guidelines offer a platform for evidencebased clinical decision-making but cannot substitute for a comprehensive understanding of pathophysiological bases of varices and available therapies. This review highlights the natural history and pathophysiology of varices; discusses diagnostic approaches of portal hypertension; and focuses on primary prophylaxis of gastroesophageal varices (prevention of first bleeding episode), management strategies of acute This article is part of the Topical Collection on Portal Hypertension * Patrick S. Kamath [email protected] Mengfei Liu [email protected] Moira Hilscher [email protected] 1
Mayo Clinic Division of Gastroenterology and Hepatology, 200 First St. S.W., Rochester, MN 55905, USA
variceal hemorrhage, and secondary prophylaxis of gastroesophageal varices (prevention of recurrent variceal bleeding).
Natural History and Epidemiology At least two-thirds of patients with cirrhosis will develop varices in the course of their illness, and about one-third of these patients will experience variceal bleeding [3, 4]. In cirrhotic patients whose index examination was negative for varices, the incident rate of esophageal varices is around 7% per year, and progression rate from small to large esophageal varices depending on severity of liver disease is around 10–15% per year [5]. In noncirrhotic portal hypertension (NCPH), variceal
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