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CIRRHOSIS. β-adrenergic blockade. Use of nonspecific has been studied extensively in randomized, controlled trials of the primary prophylaxis of variceal bleeding.

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slide2

β-adrenergic blockade

  • Use of nonspecific has been studied extensively in randomized, controlled trials of the primary prophylaxis of variceal bleeding.
slide3
The mechanism of action of these drugs (propranolol, nadolol) involves effects of both β1-adrenergic and β2-adrenergic blockade, including cardiac output and splanchnic arteriolar vasoconstriction as a result of the loss of opposing β2-adrenergic dilation.

decreased

increased

slide4
These agents may be used alone in patients with contraindications to beta-blocker therapy?

Nitrates. (such as isosorbide-5-mononitrate )

slide5
Initial management. Initial management of the patient with acute variceal includes the following:
  • (a)
  • (b) hemodynamic monitoring;
  • (c) placement of large-bore intravenous lines;
  • (d) full laboratory investigation, including measurement of hemoglobin and hematocrit, coagulation profile, liver function tests, measurement of electrolytes, and assessment of renal function;
  • (e) administration of blood products as needed, including packed red cells, platelets, and fresh frozen plasma; and (f) intensive care unit monitoring.

establishment and maintenance of an airway

slide6
Has potent splanchnic vasoconstrictive properties that decrease portal venous and collateral flow and reduce portal pressure.

Vasopressin (antidiuretic hormone)

slide7
Because of coronary vasoconstrictive effects, vasopressin is often used in combination with a such as
  • The combination provides protection from adverse cardiac events and increases the effectiveness of vasopressin by decreasing intrahepatic and collateral resistance.

vasodilator

nitroglycerin

somatostatin and octreotide
Somatostatin and octreotide
  • It is the initial drug of choice for the treatment of acute variceal hemorrhage
  • These agents decrease splanchnic blood flow indirectly by reducing the levels of other factors, such as
  • rather than by direct vasoconstriction. The effects of somatostatin are limited to the splanchnic circulation, so that side effects are minimized. A somatostatin/octreotide has proved to be as effective as vasopressin, sclerotherapy, and balloon tamponade in multiple studies.
  • glucagon,
  • vasoactive intestinal peptide
  • substance P
slide9
Endoscopic interventions.
  • sclerotherapy
  • variceal ligation

Sclerosing agents include

.

sodium morrhuate,

ethanolamine,

polidocanol,

sodium tetradecyl sulfate

Total injection volume is

.

20 to 30 mL

balloon tamponade
Balloon tamponade.
  • Patients who fail endoscopic or pharmacologic interventions.

The most commonly used tubes are

  • Sengstaken-Blakemore tube
  • Minnesota tube

Difference?

slide11

Significant complication of TIPS is

hepatic encephalopathy.

After placement of a TIPS, the incidence of hepatic encephalopathy rises from

10% before treatment to 25%

slide12
Surgical shunts can be divided into three categories:

(a) totally diverting shunts

(b) partially diverting shunts

(c) selective shunts.

slide13
Total shunts
  • End-to-side portacaval shunt (Eck fistula)
  • Large-diameter (>10 mm) side-to-side portacaval
  • Mesocaval
  • Central splenorenal shunts.
slide14
What is the main difference between end-to-side and side-to-side shunts?

Maintenance of high pressure with end-to-side shunts may worsen ascites, whereas side-to-side procedures effectively relieve this problem by reducing sinusoidal pressure.

slide15
The distal splenorenal shunt is relatively contraindicated in patients with

significant ascites.

  • Because no portal venous decompression occurs, ascites may increase after a distal splenorenal shunt.
slide16

(a) liver transplantation

(b) shunt procedures

(c) devascularization procedures.

  • Surgical interventions for the treatment of bleeding varices are divided into three main types:

The only definitive procedure for the treatment of portal hypertension caused by cirrhosis is:

Orthotopic liver transplantation,

slide17
TREATMENT OF ASCITES
  • Sodium restriction  
  •  1–2 g/d (45–90 mEq/d)
  • Fluid restriction   
  • 1–1.5 L/d
  • Diuretics   
  • Spironolactone 50 mg po q8h maximum of 100 mg q6h  
  • Furosemide 40–370 mg/d