Working Group For Portal Hypertension At The Czech Society Of Hepatology; Czech Medical Association Of J. E. Purkyně: Coordinator: R. Brůha 1; Group Members (in Alphabetical Order): P. Drastich 2; T. Fejfar 3; P. Hůlek 3; J. Lata 4; Z. Mareček 5; J. Petrtýl 1; V. Procházka 6; J. Špičák 2; I. Tozzi 6; T. Vaňásek 3; P. Zdeněk 7
Charles University in Prague, 1st Faculty of Medicine and General Faculty Hospital, th Department of Internal Medicine, Department of Hepatogastroenterology
1; IKEM in Prague, Hepatogastroenterology Department
2; Charles University in Prague, Hradec Králové Faculty of Medicine and Faculty Hospital, 2nd Department of Internal Medicine
3; Ostrava University in Ostrava, Faculty of Medicine and Faculty Hospital Ostrava, Department of Internal Medicine
4; Central Military Hospital Prague, Department of Internal Medicine
5; Palacký University Olomouc, Faculty of Medicine and Faculty Hospital, 2nd Department of Internal Medicine
6; Charles University in Prague, Faculty of Medicine and Faculty Hospital Plzeň, 1st Department of Internal Medicine
Gastroent Hepatol 2011; 65(3): 141-142
Hepatology: Best Practises
cirrhosis – bleeding from oesophageal varices – portal hypertension – TIPS
the event of suspected bleeding into the digestive tract caused by
portal hypertension, the Czech Society of
Hepatology’s working group for portal
hypertension recommends the following set of diagnostic measures
first contact with the patient:
the essential anamnestic data:
- Determine when bleeding
- Estimate the extent of
- Find out whether this
is the first instance of bleeding, or a repeat occurrence
- Has there been any
known occurrence of liver disease, alcohol abuse or use of
out a physical examination with emphasis on
- State of consciousness
- Blood pressure, pulse
frequency, breathing frequency
- Symptoms of anaemia
- Physical examination of
- Intravenous link
- Infusion of
crystalloids or plasma expanders
administration of 1 mg terlipressin (Remestyp) while respecting
- Monitor basic vital
functions during transport
admission of patient to healthcare facility
further treatment at an intensive care unit (ICU), preferably an
internal one, with the option of urgent therapeutic endoscopy
- Apart from standard ICU
examinations, assess rating according to Child-Pugh
- Continue replacing
intravasal volume/hemosubstitution with the aim of stabilising the
patient’s circulation. Haemoglobin levels should be maintained
at 70–80 g/l with regard to ancillary illnesses and the
patient’s condition. There is insufficient data to make any
unequivocal recommendations as regards treatment of coagulopathy.
- Standard administration
of broad-spectrum antibiotics / chemotherapy according to the
principles of antimicrobial prophylaxis. While most have experience
with quinolones or cephalosporins (Ceftriaxone), a specific ATB
should be selected based on the epidemiological situation in the
given region and healthcare facility and following consultation with
the relevant ATB centre.
pharmacological treatment intravenously with 1–2 mg terlipressin
every four hours; in the event of contraindications or adverse
effects, administer 250 μg i.v. of somatostatin bolus and further
250 μg/hour on a continual basis or 25 μg/hour of octreotide
(while respecting contraindications).
- Carry out endoscopic
examination as early as possible, ideally immediately after the
stabilisation of circulation.
- The aim of endoscopic
examination is to: determine the source and level of bleeding and to
carry out an endoscopic examination. Endoscopic band
ligation of the varices is preferred for this treatment or,
alternatively, endoscopic sclerotisation in situations
where ligature is not technically possible or unavailable.
- Continue the
administration of equal doses of vasoactive substances
(terlipressin, somatostatin, analogue of somatostatin) for
a period of 5 days.
In the event that bleeding from the oesophageal varices
cannot be stopped during the initial endoscopy, then the temporary
blockage of the varices using an inflated tamponade should be
considered; the maximum blockage period is 24 hours. A possible
alternative in this situation is the use of a self-expanding,
coated oesophageal stent.
The failure of treatment (continued bleeding,
haemodynamic instability, and recurrence of bleeding) is an
indication for control endoscopy.
In the event of failure of the second therapeutic
endoscopy and concurrent pharmacotherapy, carry out a portosystemic
shunt, preferably a transjugular intraheptal portosystemic
shunt (TIPS). In the event that TIPS is not feasible, then
a surgical solution, preferably devascularisation, can be
Continue to administer antimicrobial prophylactics and
haemosubstitutes if necessary. An adequate energy supply must be
provided. Treatment with diuretics is suitable for patients with
tension ascites. Encephalopathy may be prevented through the use
Once acute bleeding has been stemmed
bleeding caused by
patient must be treated with the aim of preventing the recurrence
of bleeding (secondary prevention). The cause of portal
hypertension and hepatopathy must be subjected to close examination
and the basic disease treated, including consideration of a liver
- Endoscopic treatment of
the varices until varices have been eliminated (preferably using
- Constant administration
of adequate doses of non-selective* beta blockers to achieve a heart
rate reduction by 20% or to 55 beats/minute, while respecting
contraindications. In the event that the hepatic venous pressure
gradient (HVPG) can be measured, it is appropriate to verify the
effects of the beta blockers with this examination.
- The combination of the
endoscopic approach and the concurrent administration of beta
blockers is likely the most suitable method of preventing repeat
- Once eradication has
been achieved, carry out endoscopic checks once every 6 months.
- In the event of
a recurrence of bleeding during full secondary prevention, it is
necessary to consider TIPS. In the event that TIPS is not feasible,
an alternative for patients with Child-Pugh scores A and
B is a surgical shunt; the type of procedure should be
selected with regard to the possibility of a liver transplant.
prevention (for patients who do not yet show bleeding from
- Patients with medium to
large varices, patients with small varices with ‘red marks’ and
patients with small, Child-Pugh C varices should be given
preventative treatment with the aim of preventing initial bleeding.
- The sustained
administration of non-selective* beta blockers under the same
conditions as for secondary prevention is standard procedure.
- A suitable primary
preventative procedure to use in the event of
contraindications or intolerance towards beta
blockers is endoscopic ligation of varices.
view of the fact that no beta blockers proved by long-term studies
(i.e. propranolol and nadolol) are currently available in
the Czech Republic, the use can be permitted, with certain
reservations, of metipralol (Trimepranol; the disadvantage
of this is its short half-life), atenolol (whose disadvantage is its
selectivity) or carvedilol (of the available substances, this one
seems the most suitable, even there is insufficient data
available from long-term treatment).
version of ‘Recommended Procedure’ approved by the board
of the Czech Society of Hepatology in February 2011.
MUDr. Radan Brůha, CScIV.
interní klinika VFN a 1. LF UK v Praze
2, 128 08 Praha 2
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