Manejo Actual del Sangrado por Varices Gástricas

Transcription

1 Manejo Actual del Sangrado por Varices Gástricas Juan Carlos Garcia-Pagán Barcelona Hepatic Hemodynamic Laboratory. Liver Unit. IMDIM. Hospital Clinic. IDIBAPS. Ciberehd. XXIV Congreso de la Asociación Latinoamericana para el Estudio del Hígado. Santiago de Chile Septiembre 2016

2 Varices Gástricas HDA por varices gástricas (20-30%) Mortalidad elevada (14-45%) Profilaxis Primaria Tratamiento del Episodio Agudo Prevención Recidiva

3 Management of Gastric Varices Very Few RCTs comparing different treatment options in GV. Usually results mixing different types of GV. Different Outcome In most studies more than 50% are GOV1 Cardiofundal Varices Sarin s Classification Optimal Treatment Still Unknown

4 Factores de Riesgo de Primera Hemorragia por Varices Gástricas pts con Varices Cardiofundicas (69% IGV1/ 31% GOV2) - 16 % incidencia anual de Hemorragia por Varices Cardiofund. - Tamaño Varices; Grado de Child; Presencias signos rojos Kim et al. Hepatology % probabilidad de hemorragia pequeño grupo control RCT - Tamaño varices y grado Función hepática. Mayoría GOV2 Mishra et al. J Hepatol 2011

5 Profilaxis Primaria en Varices Gástricas Glue Glue No Rx BB No Rx BB Most Pts GOV2 previously eradicated EV Mishra et al. J Hepatol 2011

6 Baveno VI Recommendation Further studies are needed to evaluate the risk/benefit ratio of using cyanoacrylate in this setting before a recommendation can be made (5;D). French National Survey 98% of 155 (13.3%) Hepatogastroenterologists: 98% used Primary Prophylaxis (96% Beta-Blockers; 16.9% Glue) Weil et al. Eur J Gastroenterol Hepatol 2016 Barcelona Approach: Non-Selective BB if not tolerated, nothing

7 Acute Variceal Bleeding (Esophageal and Gastric) General Management - Antibiotics - Careful replacement of volemia Early Drug Rx Terlipressin Somatostatin and analogues Endoscopy - EBL - Cyanocrilate Glue Scientific Evidence in GOV2 and IGV1? But - Thrombin -

8 Cyanocrylate Injection Intravariceal: Cyanocrylate/lipiodol (1/1); No more than 4 ml Most uncontrolled reports, few RCT (mixed GV types) Initial hemostasis (83-100%); Rebleeding (8-40%)

9 Complications Total rate aprox 4-6% Pulmonary embolism (0.6-3%) Mesenteric /portal vein thrombosis Bacteremia, Infection Stroke Ulcers Splenic infarction Complication Related Mortality 0.5% Cheng et al Clin Gastroenterol Hepatol. 2010

10 Thrombin for Gastric Variceal Bleeding Commercially Available Human Thrombin. Rebleeding 7-50% East JE et al. N Engl J Med 2010;362:2331-4

11 Acute Variceal Bleeding. Gastric Varices Small RCT tissue adhesives vs EBL or vs Sclerotherapy (ethanolamine/ Alcohol) Obliteration more effective than sclerosants but similar to EBL in achieving initial hemostasis but with lower rebleeding rate The endoscopic winner Rx seems to be Glue!

12 In failures of previous treatments or if massive bleeding, Balloon tamponade should be used as a temporary bridge until definitive Rx can be instituted Vs Linton-Nachlas Sengtaken-Blakemore Linton-Nachlas more effective than Sengtaken-Blakemore in a RCT Teres et al. Gastroenterology 1978

13 Early-TIPS in patients with high-risk of Rx Failure In High Risk Patients (Child B + active bleeding or Child C up to 13) with Variceal Bleeding treatment with a pre-emptive TIPS (Early-TIPS) has been shown to improve survival (RCT and Observational Study) Both studies did not include patients with GV, but likely also true

14 Secondary prophylaxis in Cardio Fundal varices Erradication with further endoscopic Rx Cyanoacrylate superior to EIS and EBL Usually achieved with 2-4 injections (2-4 week interval) 1-2 ml per session Cyanoacrylate or BB 2 very small RCT. No differences in one, better Cy in other Cyanoacrylate plus BB vs Cyanoacrylate alone 1 RCT. No significant differences. But

15 Secondary prophylaxis in CardioFundal varices A Role for TIPS as initial Rx after controlling acute bleeding? Current data scarce, low number of patients and a few with cardiofundal varices. But seems effective

16 Baveno VI Recommendation Endoscopic therapy with tissue adhesive (e.g. N- butyl-cyanoacrylate) is recommended for acute bleeding from isolated gastric varices (IGV) and GOV2. To prevent rebleeding, consideration should be given to additional glue injection, beta-blocker treatment or both combined or TIPS (5;D). More data in this area are needed. An early TIPS with PTFE-covered stents must be considered in patients bleeding at high-risk of treatment failure.

17 Balloon-occluded retrograde transvenous Obliteration (BRTO) Occlusion and injection to completely fill the GV (ethanolamine oleate, polidocanol, Sodium tetradecyl sulfate) Technical Succes (GV Obliteration): % (sometimes retx); GV bleeding post-brto (0-15%). Most data from primary prophylaxis, retrospective small cohorts

18 Balloon-occluded retrograde transvenous Obliteration (BRTO) Pros: Reducing Bleeding Risk while Preserving hepatic function and reducing HE risk. Cons: Pain, fever, transient hematuria, portal and renal thrombosis. Increase in Portal Hypertension: Increased Risk of Variceal bleeding; Ascites Further Data, preferentially from RCT are needed

19 Gastric Varices GV without prior history of bleeding Primary Prophylaxis? - Non-selective BBs? - Tissue adhesives? - only in high-risk patients? GOV1 add EBL or Glu (drugs: 2-5 days) Acute GV Bleeding Linton-Nachlas (<24h) Endoscopy NO Antibiotics; careful replacement of volemia; early drug therapy GOV2, IGV Glu + (drugs: 2-5 days) Control of bleeding YES TIPS Consider BRTO if refractory HE Secondary Prophylaxis Further Glue + Non-selective BBs

20 The Barcelona Portal Hypertension Team Vascular liver diseases collaborative group Barcelona Hepatic Hemodynamics Laboratory