CIRRHOSIS

Use of nonspecific has been studied extensively in randomized, controlled trials of the primary prophylaxis of variceal bleeding.

β-adrenergic blockade

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

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

Nitrates. (such as isosorbide-5-mononitrate )Nitrates. (such as isosorbide-5-mononitrate )

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 airwayestablishment and maintenance of an airway

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

Vasopressin (antidiuretic hormone)Vasopressin (antidiuretic hormone)

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 octreotideSomatostatin 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.

1. glucagon,2. vasoactive intestinal peptide3. substance P

Endoscopic interventions.

Total injection volume is . 20 to 30 mL

Sclerosing agents include .

sodium morrhuate,ethanolamine, polidocanol, sodium tetradecyl sulfate

sclerotherapyvariceal ligation

Balloon tamponade.

Patients who fail endoscopic or pharmacologic interventions.

The most commonly used tubes are

Sengstaken-Blakemore tube Minnesota tube

Difference?

Significant complication of TIPS is

10% before treatment to 25%

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

hepatic encephalopathy.

Surgical shunts can be divided into three categories:

(a) totally diverting shunts(b) partially diverting shunts(c) selective shunts.

Total shunts Total shunts 1. End-to-side portacaval shunt (Eck fistula)

2. Large-diameter (>10 mm) side-to-side portacaval

3. Mesocaval

4. Central splenorenal shunts.

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.

The distal splenorenal shunt is relatively contraindicated in patients with

significant ascites.significant ascites.

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

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:

(a) liver transplantation(b) shunt procedures (c) devascularization procedures.

Orthotopic liver transplantation,

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