Page 24 - Gastrointestinal Bleeding (Xuất huyết tiêu hóa)

298 PART III Symptoms, Signs, and Biopsychosocial Issues

normalized the PT in all 10 patients within 30 minutes, with Endoscopic Band Ligation
immediate control of bleeding in all patients. 212 In a large ran- The technique of endoscopic band ligation is similar to that used
domized, placebo-controlled study, administration of recombi- for band ligation of internal hemorrhoids (see Chapter 129). A
nant factor VIIa in addition to endoscopic hemostasis decreased rubber band is placed over a varix, which subsequently under-
rebleeding rates in patients with Child-Pugh class B and C cir- goes thrombosis, sloughing, and fibrosis. Prospective random-
rhosis who had bled from varices. 213 Because recombinant factor ized controlled trials have shown that endoscopic band ligation
VIIa is expensive and associated with a risk of thrombosis, its use is as effective as sclerotherapy in achieving initial hemostasis and
should be reserved for patients with severe ongoing bleeding and reducing the rate of rebleeding from esophageal varices. Acute
irreversible coagulopathy, pending the results of additional clini- hemostasis can generally be achieved in 80% to 85% of cases,
cal and cost-effectiveness studies. with a rebleeding rate of 25% to 30%. Band ligation is associated
Up to 20% of cirrhotic patients who are hospitalized with GI with fewer local complications, especially esophageal strictures,
bleeding have a bacterial infection at the time of admission to the and in one study required fewer endoscopic treatment sessions
hospital, and infection develops during the hospitalization in up than sclerotherapy. 222 A meta-analysis has reported that variceal
to 50% (see Chapter 93). Meta-analyses suggest that administra- band ligation reduces the rates of rebleeding, overall mortality,
tion of an antibiotic to cirrhotic patients with variceal bleeding is and death from bleeding compared with sclerotherapy. 223 Band
associated with a decrease in the rates of mortality and bacterial ligation, however, may be more technically difficult to perform
infections. 214,215 Commonly prescribed antibiotics are fluoroqui- than sclerotherapy during active variceal bleeding. Devices used
nolones, such as oral norfloxacin (400 mg twice daily) (not avail- for band ligation allow up to 10 bands to be placed, without the
able in the USA), IV ciprofloxacin (400 mg every 12 hours), IV need to remove the endoscope to reload the banding device. The
levofloxacin (500 mg every 24 hours), and, most commonly, IV recommended strategy is to control active bleeding first and then
ceftriaxone, 1 g every 24 hours, administered for 7 days. place 2 bands on each esophageal variceal column, one distally
near the gastroesophageal junction and another 4 to 6 cm proxi-
Balloon Tamponade mally. 224,226
Although balloon tamponade of varices is seldom used now to
control gastroesophageal variceal bleeding, it may be used to sta- TIPS
bilize a patient with massive bleeding prior to definitive therapy Placement of a TIPS is an interventional radiologic procedure
(see Chapter 92). Three types of tamponade balloons are avail- in which an expandable metal stent is placed via percutaneous
able. The Sengstaken-Blakemore tube has gastric and esopha- insertion between the hepatic and portal veins, thereby creating
geal balloons, with a single aspirating port in the stomach. The an intrahepatic portosystemic shunt. TIPS is effective for short-
Minnesota tube also has gastric and esophageal balloons and term control of bleeding gastroesophageal varices, especially
has aspiration ports in the esophagus and stomach. The Linton- those that fail endoscopic therapy. 226,227 Initially envisioned as
Nachlas tube has a single large gastric balloon and aspiration a bridge to LT, it has been used with increased frequency in
ports in the stomach and esophagus. Most reports suggest that nontransplantation situations. Randomized trials that have com-
balloon tamponade provides initial control of bleeding in 85% to pared TIPS with endoscopic sclerotherapy suggest that TIPS
98% of cases, but variceal rebleeding recurs soon after the balloon is more effective for the long-term prevention of rebleeding. 228
is deflated in 21% to 60% of patients. 216 The major problem with The main problems with TIPS are a rate of shunt occlusion
tamponade balloons is a 30% rate of serious complications such of up to 80% (less with use of polytetrafluoroethylene-coated
as aspiration pneumonia, esophageal rupture, and airway obstruc- stents) within 1 year and development of new or worsening
tion. Patients should be intubated before placement of a tampon- hepatic encephalopathy in approximately 20% of patients. 229
ade balloon to minimize the risk of pulmonary complications. Most relevant studies have shown that TIPS does not prolong
Clinical studies have not shown a significant difference in efficacy survival of patients with variceal bleeding compared with endo-
between vasopressin administration and balloon tamponade. scopic treatment. In the management of acute variceal bleed-
ing, TIPS is generally reserved for patients who fail endoscopic
Endoscopic Sclerotherapy treatment. In one study of patients with predominantly alco-
Endoscopic variceal sclerotherapy involves injecting a sclerosant holic cirrhosis and active drinking, those with Child-Pugh class
into or adjacent to esophageal varices. The most commonly B cirrhosis who were stabilized with vasoactive and endoscopic
used sclerosants are ethanolamine oleate, sodium tetradecyl therapy were randomized to either urgent TIPS within 72 hours
sulfate, sodium morrhuate, and ethanol. Cyanoacrylate, a glue after initial stabilization or therapy with a β-adrenergic recep-
that effectively stops bleeding when injected into esophageal or tor blocking agent and endoscopic band ligation as maintenance
gastric varices, is difficult to use and not approved by the FDA. therapy, and those who underwent a TIPS had a lower rate of
Various techniques are used; their common goals are to achieve rebleeding and improved 1-year survival. 230 The findings may
initial hemostasis and reduce the risk of rebleeding by performing not be as applicable to patients with nonalcoholic cirrhosis (see
sclerotherapy on a scheduled basis until the varices are obliter- also Chapter 92).
ated. Esophageal varices are much more amenable than gastric
varices to eradication with endoscopic therapy. Portosystemic Shunt Surgery
Prospective randomized trials have suggested that immedi- A variety of portosystemic shunt operations have been per-
ate hemostasis is improved and the risk of acute rebleeding is formed to reduce portal venous pressure. When compared
reduced with sclerotherapy compared with medical therapy with sclerotherapy, surgical shunts decrease the rebleeding
alone for bleeding esophageal varices. 217-220 Hemostasis can be rate significantly but do not improve survival. 221,231-234 Surgical
achieved in 85% to 95% of cases, with a rebleeding rate of 25% shunts may be associated with hepatic encephalopathy and can
to 30%. 221 Complications of endoscopic variceal sclerotherapy make future LT technically more difficult, but they have an
include esophageal ulcers that can bleed or perforate, esophageal advantage over endoscopic variceal therapy in reducing portal
strictures, mediastinitis, pleural effusions, aspiration pneumonia, hypertension and treating gastric variceal bleeding. Surgical
acute respiratory distress syndrome, chest pain, fever, and bac- shunts are performed infrequently now but are considered for
teremia and account, in part, for the use of esophageal variceal selected patients who have failed endoscopic therapy and are
band ligation as the preferred endoscopic therapy for variceal not expected to become candidates for LT (see Chapters 92
bleeding. and 97).