Internal Medicine

0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:57

Portal Hypertensive Bleeding 1197

■endotracheal intubation performed in patients with a major bleed

or significant hepatic encephalopathy to protect the airway

■antibiotics such as norfloxacin administered to prevent spontaneous

bacterial peritonitis

specific therapy

Treatment Options: Routine

■vasoactive drugs: octreotide, or vasopressin and nitroglycerin, initi-

ated to decrease portal flow

■endoscopic therapy: either variceal band ligation or sclerotherapy

effective in control of acute hemorrhage

■band ligation is preferable to sclerotherapy because of less com-

plications, lower rate of rebleeding, and decrease in the number of

sessions required to obliterate varices

■gastric varices are more difficult to control, and typically require TIPS

■in rare circumstances, balloon tamponade, emergency portosys-

temic shunt or transection of the esophagus required for exsan-

guinating hemorrhage

Side Effects and Contraindications

■Vasopressin

➣side effects: bradycardia, angina, myocardial infarction, hyper-

tension, abdominal pain

➣contraindications: caution in patients with coronary artery dis-

ease, congestive heart failure or elderly patients

■Octreotide (or somatostatin)

➣side effects: nausea, abdominal pain, flushing

➣contraindications: use with caution in diabetics or patients with

renal dysfunction

Treatment Options: Alternative

■TIPS for patients with continued bleeding in spite of endoscopic

variceal banding or sclerotherapy, or recurrent bleeding in spite of

banding therapy

■technical success of TIPS in control of bleeding: 90–95% of cases

■side effects: early morbidity occurs in 20% of patients, includ-

ing arrhythmias or intraperitoneal bleeding, early precipitation

of liver failure, and exacerbation or precipitation of hepatic

encephalopathy; early mortality is 5%; other problems include TIPS

stenosis or occlusion that may require TIPS revision; late chronic

encephalopathy uncommon, but may be severe in 5% of patients.