Page 203 - Medicine and Surgery

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Chapter 5: Disorders of the liver 199

blood flow, so that there is a lower risk of en- from the lowest point of the oesophagus. Urgent blood
cephalopathy afterwards. samples should be sent for full blood count, group and
3 Insertion of a transjugular intrahepatic portosys- cross-matchforatleast6units,U&Es,glucose,liverfunc-
temic shunt (TIPSS) can be performed without tion tests and clotting profile.
general anaesthesia and laparotomy. A transjugu-
lar approach is used to pass a guidewire through the Management
hepatic vein piercing the wall to the intrahepatic Resuscitation:
branches of the portal vein, a stent is then passed At least two large bore peripheral cannulae should
over the guidewire. The risk of encephalopathy is be sited for fluid resuscitation. Packed red blood cells
the same as for other shunts, but operative morbid- should be given as soon as possible, O −ve blood may
ity and mortality is improved. be required before cross-matched blood is available.
Liver transplantation offers the only hope of cure. Anyabnormalities in prothrombin time or platelet

count should be corrected.
Careful fluid balance assessment is essential and may
Bleeding oesophageal varices
require urinary catheterisation and central venous
Definition pressure measurements.
Oesophageal varices are dilated vessels at the junction Elective intubation may be required in severe uncon-
between the oesophagus and the stomach and occur in trolled variceal bleeding, severe encephalopathy, in
portal hypertension. They may rupture and cause an patients unable to maintain oxygen saturation above
acute and severe upper gastrointestinal bleed. 90%, or in patients with evidence of an aspiration
pneumonia.
Incidence/prevalence Further management:
30–50% of patients with portal hypertension will bleed An upper gastrointestinal endoscopy should be per-
from varices. formed as soon as the patient is haemodynamically
stable.Varicealbandligationisthetreatmentofchoice.
Aetiology If banding is not possible, the varices should be in-
Varicesresult from portal hypertension, the most com- jected with a sclerosant.
moncauseofwhichiscirrhosis.Factorspredictingbleed- If endoscopy is unavailable, vasoconstrictors, such as
ing in varices include pressure within the varix, variceal octreotide or glypressin, or a Sengstaken tube may be
size and severity of the underlying liver disease. used while more definitive therapy is arranged.
In case of bleeding that is difficult to control, a

Clinical features Sengstakentubeshouldbeinserteduntilfurtherendo-
Patients with acute upper gastrointestinal bleeding scopic treatment, transjugular intrahepatic portosys-
present with haematemesis, which is usually a large vol- temic shunting (TIPSS) or surgical treatment is per-
ume of fresh blood. Melaena may also be present. Se- formed.
vere blood loss results in hypovolaemic shock. Signs of Infection may occur following a variceal haemorrhage
chronic liver disease may be present (jaundice, pallor in cirrhotic patients resulting in significant morbidity
spider naevi, liver palms, opaque nails, clubbing). Other and mortality. All patients should receive a course of
features of portal hypertension may be seen. broad-spectrum antibiotics as prophylaxis.
Secondary prophylaxis following a variceal bleed in cir-
Investigations rhosis:
The diagnostic investigation is endoscopy, which may Following control of active bleeding the varices
also be therapeutic during an acute bleed. The varices should be eradicated using endoscopic band liga-
must be confirmed to be the source of bleeding, because tion (sclerotherapy if banding unavailable). Following
up to 20% of patients with varices also have peptic ulcers successful eradication of the varices repeated upper
and/orgastritis.Thevaricesareseenastortuouscolumns gastrointestinal endoscopy is required to screen for
in the lower third of the oesophagus. They usually bleed recurrence.