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home - Liver - Liver Failure - Medical and Endoscopic Treatment of Varices Written by Dr Sebastian Zeki
Knowledge


Assesses the severity of liver dysfunction and its prognostic
significance following haemorrhage

Knows importance of correcting hypovolaemia preventing
complications of GI bleeding and deterioration of liver function and
stopping bleeding

Knows the potential use of blood & clotting factors the role of
antibiotics the use of vasoconstrictors therapeutic endoscopy the
indication for transjugular intra-hepatic portosystemic shunt (TIPS) or
surgical shunt surgery

Aware of the specific complications of bleeding in cirrhotic patients –
including hepatic encephalopathy need for airway protection
nutrition identification of alcohol withdrawal

Skills
Shows proficiency in endoscopy – including emergency endoscopic
techniques of variceal band ligation endoscopic sclerotherapy
injection of cyanoacrylate glues for gastric varices

Can place safely and manage a Sengstaken tube in refractory
variceal bleeding

Can prevent and treat complications including hepatorenal failure
ascites spontaneous bacterial peritonitis and hepatic encephalopathy

Behaviours
Appreciates criteria for referral to specialist centre when appropriate –
such as with bleeding gastric or ectopic varices or consideration of
TIPS

Appreciates need to treat patients using a multi–disciplinary approach
Shows understanding of an empathic approach which may involve


Also....

Knowledge
Knows risks and prognosis of recurrent variceal bleeding in cirrhotic
patients

Aware of role of secondary prophylaxis with either non–selective ?-
blockers endoscopic ligation or both

Skills
Can select suitable endoscopic therapy and perform the appropriate
procedure competently

Behaviours
Appreciates the potential role of other specialists e g interventional
radiologists and nurse specialists

Also...

Knowledge


Understands the mechanisms of biliary metabolism the various
abnormalities that lead to hyperbilirubinaemia and knows and
recognises the causes of the various forms of jaundice

Skills
Selects and interprets appropriate investigations and formulate
management plans

Behaviours
Approaches patients presenting with jaundice in a logical and
methodical manner

Also...
Knowledge


Can define the different types (I and II) of hepatorenal
syndrome(HRS)

Knows the differential diagnosis of different types of renal
failure/impairment in liver disease

Understands the major and minor criteria in diagnosis of HRS and be
able to differentiate between HRS and acute kidney injury

Appreciates the prognostic significance of renal impairment in
patients with chronic liver disease

Knows the options for management and treatment of HRS the role of
colloids and vasoconstrictors as well as renal supportive treatment by
dialysis

Skills
Uses and interprets result of sometimes complex investigations
appropriately

Behaviours
Can judge when to involve other specialists especially nephrologists
radiologists and intensivists

Also...

Knowledge


Understands the pathogenesis of hepatic encephalopathy (HE)
Knows the differential diagnosis of HE including the existence of risk
factors for its causation including metabolic disorders and intracranial
structural disorders (such as subdural haematomas)

Knows factors that may precipitate HE including bleeding electrolyte
disturbance drugs or other organ failure

Knows the various treatment options appropriate for grade of severity

Skills
Can grade the mental state (Glasgow coma score and West Haven
Criteria)

Shows ability to differentiate between acute and acute on chronic liver
injury

Can identify the patient at risk of raised intracranial pressure and
cerebral oedema

Selects and use investigations appropriately and determine timing of
airway protection

Behaviours
Appreciates the role of other specialists and interacts in a
professional manner with intensivists neurologists
neurophysiologists radiologists and other specialists

Makes referral where appropriate to specialist centre for liver
transplantation

Also...

Knowledge


Understands the causes of acute hepatitis including viral druginduced alcohol-induced and auto-immune liver disease

Knows the appropriate plan of investigation and management of
specific diseases including the role of serological investigations and
liver biopsy

Skills
Takes an accurate history from patients with acute liver disease and
performs detailed clinical examination

Utilises investigation in a structured manner
Behaviours
Considers all therapeutic modalities and preparedness to refer to
specialist centre where diagnosis remains in doubt or appropriate
management cannot be performed

Also...

Knowledge
Assessment
Methods GMP
Recognises and knows how to diagnose acute and chronic drug
induced liver injury and dysfunction
SCE 1,2
Aware of methods of diagnosis, role of liver biopsy and therapy
including role of steroids in treatment in selected cases
SCE, CbD 1
Skills
Understands the role of both prescription and recreational drugs and
the aetiology of a wide variety of liver disease and dysfunction often
requiring prompt intervention or involvement of specialist services
SCE, CbD 1,2,3
Has awareness of the range of iatrogenic liver dysfunction SCE, CbD 1,2,3
Behaviours
Able to interact with specialist pharmacy services. Can use yellow
card reporting system of potential adverse effects of drugs.

Also....

Knowledge


Understands the causes and pathophysiology of acute liver failure
Can plan appropriate investigation evaluate prognosis and construct
a detailed management plan

Identifies those potentially suitable for emergency liver transplantation
Skills
Develops ability to make accurate evaluation of patients with liver
failure at the stage of initial presentation

Can deliver management plan appropriately evaluate changes in
patient’s condition and react accordingly

Utilises the range of medical interventions necessary to support
critically ill patients

Behaviours
Demonstrates ability to identify patients at risk of developing acute
liver failure and understand the criteria for referral to specialist centres

Works collaboratively with nurses and all ITU staff as well as
colleagues in other clinical disciplines to deliver the highest standard
of clinical care

Communicates effectively and relates with empathy to family and
close friends of patients

Medical and Endoscopic Treatment of Varices

Variceal bleeds SclerotherapyRebleeding is reduced by 20 % and death by 15 %.Only oesophageal varices and gastric varices in direct continuity with oesophageal varices are treatable by endoscopic sclerotherapy. Balloon Tamponade Gives control of bleeding rates in 30-90%.It is less successful if failed pharmacological tx or early rebleeding.Major complications in 14 % including oesophageal rupture.Always have an intubated patient.It is usually a temporizing measure only. Gastric Varices:Current treatment:Octreotide (or somatostatin or terlipressin) and balloon tamponade followed by either TIPS or surgery.Successful hemostasis and obliteration of gastric varices has been reported with intravariceal injections of sclerosant, absolute alcohol, fibrin glue, and cyanoacrylatethrombin (bovine) haemostasis in 94% in trials, 18% rebleedVariceal band ligation was successfulin 88% in one report. Bleeding recurred in 19%( all schistosomiasis patients) Shunt operations can be categorized as follows: Nonselective — Decompress entire portal tree and divert all flow away from the portal system, eg. portacaval shunts. Preferable in patients with marked ascites. Selective — Compartmentalize portal tree into decompressed variceal system while maintaining sinusoidal perfusion via a hypertensive superior mesenteric-portal compartment eg. distal splenorenal shuntMay significantly exacerbate marked ascites. Partial — Incom-pletely decompress entire portal tree and thereby also maintain some hepatic perfusion Include either esophageal transection (distal esophagus is transected and then stapled back together after varices have been ligated) or GOJ devascularization (Sugiura procedure)- for thoseunable to have shunts.Esophageal transection appears to be as effective as sclerotherapy.However, troublesome bleeding can occur from the suture line and, since transection does not treat the portal hypertension, varices recur after a variable period of time Nonshunt operations Surgery for Varices The ideal patient for surgical therapy is one with well preserved liver function who fails emergent endoscopic treatment and has no complications from the bleeding or -Both portal decompressive surgery and esophageal transection are highly effective in achieving hemostasis. -Emergency portacaval shunts are more likely to thrombose than elective shunts.-In addition, portacaval shunts alter vascular anatomy, complicate future liver transplant surgery, and assoc. with 50% encephalopathy incidence. Shunts diverting portal venous blood flow from the liver. (A), Portacaval shunt; (B), splenorenal shunt. Complication rate of 11%-Uncommonly get spasm pain immediately after the bands are applied. Responds to an oral 50:50 mixture of lidocaine-antacid mixture (Mylanta or Maalox)-Transient bacteremia.-Pulmonary infections rare; frequency withvEVL=ES -Superficial oesophageal ulcers develop at all successful ligation sites after 3-10 days. Sucralfate and PPIs dont work for these Salvage therapy for patients who are good surgical candidates TIPS is preferred to surgery in refractory oesophageal variceal bleeding Bleeding gastric varicesTIPS can be effective but less so than surgery if have spontaneous splenorenal collaterals (feed gastrc varices)- persists after TIPS.Where surgical expertise is available, ligation of the splenorenal collateral and portal decompression is the treatment of choice..TIPs usueful in absence of surgery or poor surgical candidate.Bleeding ectopic varicesCan get duodenal, rectal, and peristomal varices (around colostomy)Treatment usually surgical as endoscopic doesnt work.Anecdotal reports have noted that the bleeding can also be controlled by TIPS Resuscitate CVP 4-8 Hb 9-10 4FFP/4 units blood Cryo if fibrinogen < 0.2 PLT >50 Vit K (no more than 3 x 10 mg) Watch hypocalcaemia Desmopressin if all else fails Sengstaken Sclerotherapy =Banding Vasopressors = Sclero-therapy + Vasopres-sin Banding+ Terlipressin (66% control of bleeding) Sengstaken+ vasopressors < < Local complications — UlcerationBleedingDysmotilityStricture formationPortal hypertensive gastropathy Regional complications — Oesophageal perforationMediastinitis Systemic complications — sepsis, and aspiration with ventilation perfusion mismatch and hypoxemia Portal hypertensive gastropathy and gastric varices —A concern with both EVL and ES has been the potential to worsen portal hypertensive gastropathy (PHG), which could result in bleeding The development of PHG may be more common with EVL than EVL Efficacy for Rebleeding Reduction < Alone Alone Alone Bleed Management Types include:Sengstaken-Blakemore tubeMinnesota tube Linton-Nachlas tube Technique and complications —Injection of the sclerosing agent causes necrosis of esophageal tissues and mucosal ulcers (intravariceal injections or paravariceal injections)Small ulcers appear within the first few days in most patients and larger ulcers develop in approximately 50 %Many patients have transient retrosternal discomfort UGI bleed/varices Oesophageal variceal bleed Variceal band ligation/ sclerotherapy Balloon tamponade Banding eradication programme TIPSS/ Surgery Eradicated FU at 3 and 6m and then yearly Reurrent variceal bleeding Consider referral for TIPSS surgery Gastric variceal bleed Gastro-oesophageal varices Isolated gastric varices TIPSS Treat as oesophageal varices Uncontrolled Controlled Written by Dr Sebastian Zeki Inferior vena cava Renal vein Splenic vein Portal vein Inferior vena cava Renal vein Splenic vein Portal vein A) B)

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