Varicies

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Clinical Trial Related : Major Complications of Cirrhosis

Predicting the Risk of Future Bleeding in Patients with Varices and Portal

Hypertension

Kurt J. Isselbacher

Treatment with beta blockers has become an accepted medical practice for

patients who have bled from esophageal varices. Studies have shown that the

risk of bleeding is almost eliminated if the hepatic venous pressure

gradient (HVPG) is reduced to 12 mmHg. Therefore, pressure measurements can

provide useful prognostic data; however, the drawback is that they require

repeated invasive hemodynamic studies. For this reason, other methods have

been sought that might be less invasive but provide meaningful data. A

recent, alternative approach has been to measure the transmural pressure of

varices during endoscopy by using a miniature pressure-sensitive capsule

attached to the end of the endoscope. This technique has been shown in the

past to be capable of reproducible measurements of variceal pressure. A

recent study by Escorsell and colleagues (2000) compares the results of HVPG

measurements with pressures obtained with a less invasive endoscopic

technique in 55 patients with cirrhosis (Child's class A and B cirrhosis),

24 of whom had previously bled from varices. Follow-up studies were obtained

on propanolol 2811 months later. Of these 55 patients, 16 subsequently bled

from varices. However, if variceal pressures had declined by more than 20

percent, variceal bleeding in the 3-year follow-up period was only 7

percent, compared with a rebleeding rate of 46 percent in those patients

whose esophageal pressures decline by <20 percent. This study, therefore,

confirms previous reports in which reductions in HVPG >20 percent were also

associated with a low risk of rebleeding. Both variceal pressure and HVPG

were independent predictors of variceal bleeding during the follow-up

period.

Variceal pressure measurements were not always similar to the HVPG and the

endoscopic approach was somewhat more difficult technically (accurate

measurements could not be obtained in 25 percent of patients because they

had small varices). However, the combination of the two measurements had an

85 percent sensitivity and 93 percent specificity in identifying patients

who did not have recurrent variceal bleeding over the 3-year follow-up. The

report by Escorsell and colleagues (2000) is very encouraging but,

obviously, more studies with the endoscopic measurement of esophageal

variceal pressure are needed.

Reference

Escorsell A et al: Predictive value of the variceal pressure response to

continued pharmacological therapy in patients with cirrhosis and portal

hypertension. Hepatology 31:1061, 2000 [PMID 10796880]