Portal hypertension

R. De Franchis, M. Primignani

Research output: Contribution to journalArticle

Abstract

New trends in pathophysiology, methodology and therapy of gastrointestinal bleeding in portal hypertension are presented. As far as pathophysiology is concerned the following issues are discussed: the role of hepatic vascular resistance and its reduction by vasodilators; the role of vasodilatory substances in splanchnic and systemic vasodilation and the future use of specific nitric oxide inhibitors; the future therapeutic strategies to limit the extent of liver fibrosis by the control of lipocyte activation or by cytokines receptors antagonists. From a hemodynamic point of view, the finding of the 12 mm Hg cutoff portal pressure level below which bleeding does not occur can be considered a major clue in pathophysiology, but the impact on clinical management will be more relevant when non invasive, reproducible parameters substitute hemodynamic evaluation. As for methodology, the importance of conventional and cumulative meta-analysis in supplying definitive answers when inconclusive or conflicting results have been provided in individual clinical trials, is stressed. The assessment of the bleeding risk from esophageal varices can be accomplished by means of the NIEC index or a more simplified one, the Simple index, which takes into account the presence of red signs of any kind and intensity on varices, instead of red wale markings. As far as the therapy of esophageal varices is concerned, the role of non selective beta-blockers in the prophylaxis of the first bleeding is well recognized, but the question whether all patients with varices or patients with high risk varices only should be treated is still debated; long-acting nitrates are a reasonable alternative for patients unable to take beta-blockers. The association of beta-blockers with nitrates is under evaluation in clinical trials. In the setting of acute hemorrhage, vasoactive drugs like glypressin, somatostatin and octreotide have been shown to be safe and effective. To prevent rebleeding, endoscopic sclerotherapy is the most effective therapy, but nowadays endoscopic ligation seems to obtain better results and a lower rate of complications. The transjugular intrahepatic portosystemic stent shunt (TIPS) is an effective treatment, but randomized controlled trials are needed to better define its role in the management of portal hypertension.

Original languageEnglish
Pages (from-to)129-136
Number of pages8
JournalOspedale Maggiore
Volume89
Issue number1
Publication statusPublished - 1995

Keywords

  • bleeding
  • endoscopy
  • esophageal varices
  • liver cirrhosis
  • medical treatment
  • meta-analysis

ASJC Scopus subject areas

  • Medicine(all)

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  • Cite this

    De Franchis, R., & Primignani, M. (1995). Portal hypertension. Ospedale Maggiore, 89(1), 129-136.