An AASLD symposium on the final day of DDW® 2017 brought together experts from around the world to discuss pharmacological therapies, endoscopic therapies, interventional procedures and the surgical management of portal hypertension (PH) in patients with alcoholic liver disease (ALD).
“Beta blockers are still the mainstay of pharmacological therapy for portal hypertension,” said Christina Ripoll, MD, from Martin Luther University, Halle (Saale), Germany.
The nonselective beta blockers propranolol and carvedilol are the best studied therapies for PH. Carvedilol has been shown to be more effective and is the beta blocker of choice in compensated PH patients, Dr. Ripoll said.
Clinically significant PH predicts decompensation in compensated patients, she explained. The placebo-controlled Predesci study demonstrated that beta blockers can reduce the incidence of decompensation and/or death in PH patients, she added.
In patients with Child-Pugh class A or B cirrhosis, the addition of simvastatin to beta-blocker therapy has been shown to increase survival, although it did not reduce bleeding, Dr. Ripoll said. Anticoagulant therapy with enoxaparin can help prevent portal vein thrombosis, reduce the incidence of decompensation and death, and may reduce fibrosis, she said.
Andres Cardenas, MD, MMSc, PhD, AGAF, FAASLD, clinical professor of gastroenterology and hepatology at the Hospital Clinic and University of Barcelona, Spain, discussed endoscopic therapies for variceal bleeding, including endoscopic band ligation and stents.
In patients with variceal bleeding, endoscopy should be performed in the first 12 hours after hospital admission, Dr. Cardenas said. Sclerotherapy for variceal bleeding was commonly used in the past and is still used for about 19 percent of patients with major bleeding, but endoscopic band ligation is more effective and leads to fewer complications, he said.
Placing six or seven bands is generally enough to stop the bleeding, Dr. Cardenas explained. Balloon tamponade is commonly used for rescue therapy, but it is associated with a high risk of perforation.
Covered metallic stents represent the latest therapy for variceal bleeding. The stents should be removed seven days after placement, Dr. Cardenas said. Bleeding control is superior with the use of stents compared with other methods, and stents are easier to place than bands, he added.
Riad Salem, MD, MBA, chief of interventional radiology and vice chair of image-guided therapy at Northwestern University, Chicago, IL, described portal vein recanalization transjugular intrahepatic portosystem shunt (PVR TIPS) for chronic portal vein thrombosis (PVT) in cirrhotic patients.
“The prevalence of portal vein thrombosis in cirrhotics ranges from 5 to 26 percent. It is thought to be primarily due to reduced portal flow,” Dr. Salem said. “Analysis of data from the UNOS registry and the Scientific Registry of Transplant Recipients shows that PVT is an independent risk factor for post-transplant mortality.”
The goal of PVT treatment is recanalization of the portal vein to allow end-to-end anastomosis and portal flow at the time of liver transplantation, Dr. Salem explained. The pre-transplant options for PVT include anticoagulation, which is often only effective in acute PVT patients and can prevent chronic PVT; and TIPS, which allows for portal flow to prevent recurrent thrombosis, but can be technically difficult to perform.
“Complete elimination of PVT is not necessary at the time of TIPS placement,” Dr. Salem said. “PVT establishes flow for clot clearance. Short TIPS can be placed to maximize unstented portal vein flow for liver transplantations.
“PVR TIPS should be considered in patients with chronic PVT eligible for transplant,” he continued. “The trans-splenic approach to TIPS has become our preferred approach for portal vein recanalization.”
Alternatives to TIPS for variceal bleeding include balloon-occluded retrograde transvenous obliteration of gastric varices, coil-assisted retrograde transvenous obliteration and vascular plug-assisted retrograde transvenous obliteration, Dr. Salem said.
Julie Heimbach, MD, surgical director of liver transplantation at the Mayo Clinic, Rochester, MN, examined the role of surgery, including shunt procedures, devascularization procedures and transplantation, in PH patients with variceal bleeding.
Surgical shunts are either selective or nonselective. Selective shunts divert gastrosplenic portal flow. Specific procedures include distal splenorenal (Warren) shunts, mesentericoportal (Rex) shunts and mesoarterial shunts, Dr. Heimbach said.
Warren shunts are used for recurrent variceal bleeding, extrahepatic portal hypertension and Child-Pugh class A or B cirrhosis. Rex shunts are used for well-compensated cirrhosis or extrahepatic portal hypertension after failed endoscopic treatment or isolated gastric varices. Mesoarterial shunts are used for Budd-Chiari syndrome with caval involvement and with or without PVT.
Nonselective shunt procedures include mesocaval shunts, portocaval shunts (end-to-end or side-to-side) and proximal splenorenal shunts. Portocaval shunts are indicated for Budd-Chiari syndrome and variceal hemorrhaging in cirrhosis patients in the presence of ascites.
Mesocaval shunts are used for PVT, Budd-Chiari syndrome patients with enlarged caudate and portal vein atresia in children. Proximal splenorenal shunts are indicated for patients with PVT.
Shunt surgery is indicated for cirrhotic patients with variceal bleeding who fail beta blockers or sclerotherapy.
Devascularization is rarely performed for PH except in patients with extensive mesenteric thrombosis, Dr. Heimbach said.
Transplantation is limited by organ availability. It involves a major surgical procedure and long-term immunosuppression, and is the treatment of choice for patients with decompensated cirrhosis, she said.