肝臓学および胃腸疾患ジャーナル
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概要

Pathophysiology and management of

Balwant Singh Gill

EsophagealVarices:Esophagealvarices are dilated submucosal distal esophageal veins connecting the portal and systemic circulations. This happens due to portal hypertension (most commonly a result of cirrhosis), resistance to portal blood flow, and increased portal venous blood inflow. The most common fatal complication of cirrhosis is variceal rupture; the severity of liver disease correlates with the presence of varices and risk of bleeding.

 

 Bleeding esophagealvarices : No single treatment for bleeding esophagealvarices is appropriate for all patients and situations. An algorithm for management of the patient with acute bleeding is presented in this article. The options for long-term, definitive therapy and the criteria for selection of each are discussed.

 

 Pathophysiology and management of esophagealvarices: Esophagealvarices are one of the most common and severe complications of chronic liver diseases. New aspects in epidemiology, pathogenesis, and treatment of varices are reviewed. Sclerotherapy is the first-line treatment for acute hemorrhage. Prevention of first or recurrent bleeding is still unsatisfactory. β-Blockers are slightly superior to sclerotherapy with regard to prophylaxis of first bleeding. β-Blockers or sclerotherapy may be used for prophylaxis of recurrent bleeding. However, prophylactic treatment regimens do not have a major impact on survival. Combination treatment, new drugs, or new devices may help to improve the efficacy of prophylactic measures.

 

Endoscopic Therapy for Esophageal Varices: Among therapeutic endoscopic options for esophagealvarices (EV), endoscopic variceal ligation (EVL) has proven more effectiveness and safety compared with endoscopic sclerotherapy and is currently considered as the first choice.

In acute EV bleeding, vasoactive therapy (either with terlipressin or somatostatin) prior to endoscopy improves outcomes; moreover, antibiotic prophylaxis has to be generally adopted.

Variceal glue injection (cyanoacrylates) seems to be effective in the treatment of esophageal as well as in gastric varices. Prevention of rebleeding can be provided both by EVL alone or

 

 

 

 

combined with non-selective β-blockers. Moreover, EVL can be adopted for primary prophylaxis, with no differences in mortality compared with drugs, in subjects with large varices and unfit for a β-blocker regimen.

 

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