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Prevention of Recurrent Bleeding: Pharmacological Procedures

  • Wolfgang E. Fleig

Abstract

Based on the factors which determine the transhepatic pressure gradient and, according to Laplace’s law, wall tension of esophageal varices, the aim of pharmacological agents for the prevention of initial and recurrent variceal bleeding should be to decrease portal flow and increase the diameter of the portal vascular bed and/or decrease transmural pressure of the varices and local bood flow through the gastroesophageal collateral veins. Transmural variceal pressure should be directly related to the transhepatic pressure gradient and, in the same patient, probably is. However, when a series of patients is analyzed, no conclusive correlation between these parameters is detected [1]. The obscured relationship between portal and variceal pressure on a statistical basis is most likely the result of a wide interindividual variation in the contribution of the different portal-systemic collateral channels (i. e., gastroesophageal versus rectal, splenorenal, umbilical etc.) to total collateral flow. Although the number of patients investigated was small and the follow-up short, recurrent variceal bleeding under a regimen of chronic endoscopic sclerotherapy appeared to be related to the pre-sclerotherapy variceal pressure [2]. The intra-individual relationship between portal pressure and the risk of first variceal bleeding and thus, indirectly, between portal and variceal pressure has been convincingly demonstrated in the recent Spanish-American prophylactic β-blocker trial [3]. In this study, no patient bled from varices whose portal pressure—either spontaneously or as a consequence of beta-adrenergic blockade— fell below 12 mmHg. Therefore, reduction of portal pressure and of gastroesophageal collateral flow should be the aim of any pharmacological intervention. Several drugs such as beta-adrenergic blockers, calcium antagonists, nitrates, serotonin antagonists, and others have been evaluated hemodynamically [4]. However, sufficient data on the prevention of variceal rebleeding from prospective controlled clinical trials are available only for beta-blockers. Therefore, this section will focus on beta-adrenergic blockers. The other drug candidates for the treatment of portal hypertension are discussed in Chap. 4.

Keywords

Portal Hypertension Cirrhotic Patient Esophageal Varix Portal Pressure Hepatic Venous Pressure Gradient 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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Copyright information

© Springer Japan 1991

Authors and Affiliations

  • Wolfgang E. Fleig
    • 1
  1. 1.Medizinische Klinik I mit PoliklinikFriedrich-Alexander-Universität Erlangen-NürnbergErlangenGermany

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