Evaluation and treatment of portal hypertension
Authors:
doc. CSc. Mudr Radan Brůha; MUDr. CSc. Jaromír Petrtýl
Authors‘ workplace:
IV. interní klinika 1. LF UK a VFN: U Nemocnice, 128 08 Praha
2
Published in:
Čas. Lék. čes. 2016; 155: 76-80
Category:
Review Articles
Overview
Liver cirrhosis is a serious disease shortening the life expectancy. Unavoidable consequence of cirrhosis is portal hypertension, which usually limits the prognosis by its complications. Portal hypertension is a prognostic factor for cirrhosis decompensation, variceal bleeding and even the mortality in cirrhotic patients. In the evaluation of portal hypertension hepatic venous pressure gradient (HVPG) measurement is used.
Measurement of HVPG is used in clinical praxis in these situations:
- diagnosis of portal hypertension,
- evaluation of prognosis of patients with cirrhosis,
- monitoring the treatment efficacy in the prevention of variceal bleeding,
- management of acute variceal bleeding.
Decrease of HVPG below 12 mmHg or at least for more than 20% of initial value in the treatment by beta-blockers is associated with the lower risk of bleeding from varices or other complications. HVPG above 20 mm Hg is associated with the high risk of early rebleeding from varices and can discriminate those patients profiting from early TIPS.
HVPG measurement is an invasive, but simple, reproducible and safe catheterization technique with minimal complication rate. The most frequent complication could be incorrect assessment of obtained values. HVPG measurement should be a routine technique in centers specialized to liver diseases.
Keywords:
cirrhosis; HVPG (hepatic venous pressure gradient); portal hypertension; variceal bleeding
Sources
1. Ehrmann J, Hůlek P. Hepatologie. Praha: Grada Publishing 2010, 616 stran.
2. Garcia-Tsao G, Friedman S, Iredale J, Pinzani M. Now there are many (stages) where before there was one: In search of a pathophysiological classification of cirrhosis. Hepatology 2010; 51: 1445−1449.
3. Myers JD, Taylor WJ. Occlusive hepatic venous catheterization in the study of the normal liver, cirrhosis of the liver and noncirrhotic portal hypertension. Circulation 1956; 13: 368−380.
4. Thalheimer U, Leandro G, Samonakis DN et al. Assessment of the agreement between wedge hepatic vein pressure and portal vein pressure in cirrhotic patients. Dig Liver Dis 2005; 37: 601−608.
5. de Franchis R. Evolving consensus in portal hypertension. Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2005; 43: 167−176.
6. Garcia-Tsao G, Groszmann RJ, Fisher RL et al. Portal pressure, presence of gastroesophageal varices and variceal bleeding. Hepatology 1985; 5: 419-424.
7. Groszmann RJ, Wongcharatrawee S. The hepatic venous pressure gradient: anything worth doing should be done right. Hepatology 2004; 39: 280−282.
8. Zipprich A, Winkler M, Seufferlein T, Dollinger MM. Comparison of balloon vs. straight catheter for the measurement of portal hypertension. Aliment Pharmacol Ther 2010; 32: 1351−1356.
9. Ready JB, Robertson AD, Goff JS, Rector WG jr. Assessment of the risk of bleeding from esophageal varices by continuous monitoring of portal pressure. Gastroenterology 1991; 100: 1403−1410.
10. Villanueva C, Ortiz J, Minana J et al. Somatostatin treatment and risk stratification by continuous portal pressure monitoring during acute variceal bleeding. Gastroenterology 2001; 121: 110−117.
11. Avgerinos A, Armonis A, Stefanidis G et al. Sustained rise of portal pressure after sclerotherapy, but not band ligation, in acute variceal bleeding in cirrhosis. Hepatology 2004; 39: 1623−1630.
12. Abraldes JG, Villanueva C, Banares R et al. Hepatic venous pressure gradient and prognosis in patients with acute variceal bleeding treated with pharmacologic and endoscopic therapy. J Hepatol 2008; 48: 229−236.
13. Garcia-Pagan JC, Caca K, Bureau C et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 2010; 362: 2370−2379.
14. Monescillo A, Martinez-Lagares F, Ruiz-del-Arbol L et al. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology 2004; 40: 793−801.
15. Bernard B, Lebrec D, Mathurin P et al. Beta-adrenergic antagonists in the prevention of gastrointestinal rebleeding in patients with cirrhosis: a meta-analysis. Hepatology 1997; 25: 63−70.
16. Thiele M, Krag A, Rohde U, Gluud LL. Meta-analysis: banding ligation and medical interventions for the prevention of rebleeding from oesophageal varices. Aliment Pharmacol Ther 2012; 35: 1155−1165.
17. Reiberger T, Ferlitsch A, Payer BA et al. Non-selective betablocker therapy decreases intestinal permeability and serum levels of LBP and IL-6 in patients with cirrhosis. J Hepatol 2013; 58: 911−921.
18. Feu F, Garcia-Pagan JC, Bosch J et al. Relation between portal pressure response to pharmacotherapy and risk of recurrent variceal haemorrhage in patients with cirrhosis. Lancet 1995; 346: 1056−1059.
19. McCormick PA, Patch D, Greenslade L et al. Clinical vs haemodynamic response to drugs in portal hypertension. J Hepatol 1998; 28: 1015−1019.
20. Villanueva C, Lopez-Balaguer JM, Aracil C et al. Maintenance of hemodynamic response to treatment for portal hypertension and influence on complications of cirrhosis. J Hepatol 2004; 40: 757−765.
21. Albillos A, Banares R, Gonzalez M et al. Value of the hepatic venous pressure gradient to monitor drug therapy for portal hypertension: a meta-analysis. Am J Gastroenterol 2007; 102: 1116−1126.
22. Villanueva C, Aracil C, Colomo A et al. Acute hemodynamic response to beta-blockers and prediction of long-term outcome in primary prophylaxis of variceal bleeding. Gastroenterology 2009; 137: 119−128.
23. Bureau C, Peron JM, Alric L et al. "A la carte" treatment of portal hypertension: adapting medical therapy to hemodynamic response for the prevention of bleeding. Hepatology 2002; 36: 1361−1366.
24. de Franchis R. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2010; 53: 762−768.
25. Thalheimer U, Bellis L, Puoti C, Burroughs AK. Should we routinely measure portal pressure in patients with cirrhosis, using hepatic venous pressure gradient (HVPG) as a guide for prophylaxis and therapy of bleeding and rebleeding? No. Eur J Intern Med 2011; 22: 5−7.
26. Cheng JW, Zhu L, Gu MJ, Song ZM. Meta analysis of propranolol effects on gastrointestinal hemorrhage in cirrhotic patients. World J Gastroenterol 2003; 9: 1836−1839.
27. Gluud LL, Krag A. Banding ligation versus beta-blockers for primary prevention in oesophageal varices in adults. Cochrane Database Syst Rev 2012; 8: CD004544.
28. Funakoshi N, Duny Y, Valats JC et al. Meta-analysis: beta-blockers versus banding ligation for primary prophylaxis of esophageal variceal bleeding. Ann Hepatol 2012; 11: 369−383.
29. Dell'Era A, Sotela JC, Fabris FM et al. Primary prophylaxis of variceal bleeding in cirrhotic patients: a cohort study. Dig Liver Dis 2008; 40: 936−943.
30. Merkel C, Bolognesi M, Sacerdoti D et al. The hemodynamic response to medical treatment of portal hypertension as a predictor of clinical effectiveness in the primary prophylaxis of variceal bleeding in cirrhosis. Hepatology 2000; 32: 930−934.
31. Groszmann RJ, Bosch J, Grace ND et al. Hemodynamic events in a prospective randomized trial of propranolol versus placebo in the prevention of a first variceal hemorrhage. Gastroenterology 1990; 99: 1401−1407.
32. Hicken BL, Sharara AI, Abrams GA et al. Hepatic venous pressure gradient measurements to assess response to primary prophylaxis in patients with cirrhosis: a decision analytical study. Aliment Pharmacol The r2003; 17: 145−153.
33. Kalambokis G, Manousou P, Vibhakorn S et al. Transjugular liver biopsy − indications, adequacy, quality of specimens, and complications − a systematic review. J Hepatol 2007; 47: 284−294.
34. Armonis A, Patch D, Burroughs A. Hepatic venous pressure measurement: an old test as a new prognostic marker in cirrhosis? Hepatology 1997; 25: 245−248.
35. Vorobioff J, Groszmann RJ, Picabea E et al. Prognostic value of hepatic venous pressure gradient measurements in alcoholic cirrhosis: a 10-year prospective study. Gastroenterology 1996; 111: 701−709.
36. Triantos CK, Nikolopoulou V, Burroughs AK. Review article: the therapeutic and prognostic benefit of portal pressure reduction in cirrhosis. Aliment Pharmacol Ther 2008; 28: 943−952.
37. Ripoll C, Groszmann R, Garcia-Tsao G et al. Hepatic venous pressure gradient predicts clinical decompensation in patients with compensated cirrhosis. Gastroenterology 2007; 133: 481−488.
38. Bosch J, Mastai R, Kravetz D et al. Hemodynamic evaluation of the patient with portal hypertension. Semin Liver Dis 1986; 6: 309−317.
39. Morali GA, Sniderman KW, Deitel KM et al. Is sinusoidal portal hypertension a necessary factor for the development of hepatic ascites? J Hepatol 1992; 16: 249−250.
40. Conn HO, Grace ND, Bosch J et al. Propranolol in the prevention of the first hemorrhage from esophagogastric varices: A multicenter, randomized clinical trial. The Boston-New Haven-Barcelona Portal Hypertension Study Group. Hepatology 1991; 13: 902−912.
41. Ripoll C, Groszmann RJ, Garcia-Tsao G et al. Hepatic venous pressure gradient predicts development of hepatocellular carcinoma independently of severity of cirrhosis. J Hepatol 2009; 50: 923−928.
42. Burroughs AK, Groszmann R, Bosch J et al. Assessment of therapeutic benefit of antiviral therapy in chronic hepatitis C: is hepatic venous pressure gradient a better end point? Gut 2002; 50: 425−427.
43. Rincon D, Lo Iacono O, Ripoll C et al. Prognostic value of hepatic venous pressure gradient for in-hospital mortality of patients with severe acute alcoholic hepatitis. Aliment Pharmacol Ther 2007; 25: 841−848.
44. Abraldes JG, Tarantino I, Turnes J et al. Hemodynamic response to pharmacological treatment of portal hypertension and long-term prognosis of cirrhosis. Hepatology 2003; 37: 902−908.
Labels
Addictology Allergology and clinical immunology Angiology Audiology Clinical biochemistry Dermatology & STDs Paediatric gastroenterology Paediatric surgery Paediatric cardiology Paediatric neurology Paediatric ENT Paediatric psychiatry Paediatric rheumatology Diabetology Pharmacy Vascular surgery Pain managementArticle was published in
Journal of Czech Physicians
Most read in this issue
- Evaluation and treatment of portal hypertension
- Refeeding syndrome
- Desaturases of fatty acids (FADS) and their physiological and clinical implication
- Czech section of International College of Surgeons and Jubilee surgical world congress