Rapid ReviewPrevention of variceal rebleeding
Section snippets
Treatment of portal hypertension
In cirrhosis, portal hypertension is mainly due to increased resistance to portal blood-flow through the cirrhotic liver, and increased blood-flow in the portal and collateral circulation due to splanchnic vasodilatation and a hyperkinetic circulation. Portal hypertension can therefore be attenuated by decreasing intrahepatic resistance, reducing portal blood-flow, or both.3 Until recently, increased intrahepatic resistance could only be corrected by means of liver transplantation or
Problems with drug therapy
Although it has been customary to adjust the dose of β blockers to achieve a 25% fall in the resting heart-rate, this reduction by no means guarantees an effective fall in HVPG, and there is no correlation between changes in heart rate and changes in HVPG. Our approach is to titrate up to the maximum tolerated dose, with dose escalation every 2 days. Christophe Bureau and colleagues17 used a fixed dose of long-acting propranolol every other day, but this regimen has been criticised.20
HVPG
Conclusions
Drug therapy is a simple and safe way to prevent variceal rebleeding, provided target reductions in HVPG are achieved. Future steps forward include the development of non-invasive ways to assess the haemodynamic response so that therapy can be tailored not only in research studies, but also in clinical practice. However, this tailoring is not likely to be possible in the near future, and unless HVPG measurement is available, physicians will have to make decisions based on published results with
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