Skip to main content
SpringerLink
Log in

Ösophagusvarizenblutung: Management und Tipps zum transjugulären intrahepatischen portosystemischen Shunt

Esophageal variceal bleeding: management and tips on transjugular intrahepatic portosystemic shunt

  • Leitthema
  • Published:
Der Chirurg Aims and scope Submit manuscript

Zusammenfassung

Hintergrund

Die Ösophagusvarizenblutung ist eine lebensbedrohliche Komplikation bei Patienten mit Leberzirrhose, welche pathophysiologisch durch die vorhandene portale Hypertension zu erklären ist. Die Inzidenz einer solchen Blutung korreliert mit der Schwere der Lebererkrankung.

Fragestellung

Ziel der vorliegenden Arbeit ist es, die aktuellen Therapiekonzepte bei akuter Ösophagusvarizenblutung, deren Management in der Akutsituation sowie die Indikationen zur Therapie der ursächlichen portalen Hypertension mittels transjugulärem intrahepatischem portosystemischem Shunt (TIPS) darzulegen.

Ergebnisse

Nach Diagnose der Leberzirrhose oder anderer für eine portale Hypertension ursächlichen Krankheitsbilder ist zunächst eine Ösophagogastroduodenoskopie als Staginguntersuchung zwecks Festlegung des Stadiums der Varizen und der resultierenden erforderlichen Therapie notwendig. Zudem ist eine Bestimmung des hepatisch-venösen Druckgradienten hilfreich. Eine medikamentöse oder endoskopische Blutungsprophylaxe wird zusätzlich anschließend initiiert. Nach einem akuten Blutungsereignis ist unter klar definierten Voraussetzungen eine TIPS-Implantation zur Therapie des portalen Hypertonus in Erwägung zu ziehen. Diese ist die einzig effektive Therapie zur Senkung des portalen Hypertonus.

Schlussfolgerungen

Die TIPS-Implantation ist durch die Senkung des portalen Hypertonus bei gegebener Indikation eine effektive Therapie zur Prophylaxe einer Rezidivvarizenblutung. Die resultierende Verbesserung der portalen Hämodynamik führt einerseits zu einer Verbesserung der Nierenfunktion, andererseits jedoch auch zu einer Verschlechterung der Leberfunktion mit konsekutiver Entwicklung oder Verschlechterung einer bereits vorhandenen hepatischen Enzephalopathie.

Abstract

Background

Esophageal variceal bleeding is a life-threatening complication in patients with liver cirrhosis, which is pathophysiologically explained by the presence of portal hypertension. The incidence of such bleeding greatly depends on the severity of the underlying liver disease.

Objective

The aim of this article is to present the current treatment concepts for acute esophageal variceal bleeding, the management in acute situations and the indications for treatment of the causal portal hypertension with a transjugular intrahepatic portosystemic shunt (TIPS).

Results

In patients with liver cirrhosis or any other disease causing portal hypertension, a staging examination by esophagogastroduodenoscopy is first carried out for determination of the stage of the varices and the resulting necessary treatment. In addition, determination of the portal pressure gradient is useful. In patients with varices a medicinal or endoscopic bleeding prophylaxis should subsequently additionally be initiated. After an acute variceal bleeding event, under clearly defined prerequisites an evaluation for TIPS implantation should be considered. This is the only effective treatment for reducing portal hypertension.

Conclusion

With appropriate indications implantation of a TIPS is an effective strategy to lower portal hypertension and therefore prevent recurrent variceal bleeding. The resulting improvement of the portal hemodynamics leads to an improvement in kidney function; however, it also leads to deterioration of liver function with subsequent development or deterioration of a previously existing hepatic encephalopathy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3
Abb. 4
Abb. 5
Abb. 6
Abb. 7

Literatur

  1. Berres ML, Asmacher S, Lehmann J et al (2015) CXCL9 is a prognostic marker in patients with liver cirrhosis receiving transjugular intrahepatic portosystemic shunt. J Hepatol 62:332–339

    Article  CAS  PubMed  Google Scholar 

  2. Berres ML, Lehmann J, Jansen C et al (2016) Chemokine (C-X-C motif) ligand 11 levels predict survival in cirrhotic patients with transjugular intrahepatic portosystemic shunt. Liver Int 36:386–394

    Article  CAS  PubMed  Google Scholar 

  3. Boyer TD, Haskal ZJ (2010) The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension: Update 2009. Hepatology 51:306

    Article  PubMed  Google Scholar 

  4. Burroughs AK, Thalheimer U (2010) Hepatic venous pressure gradient in 2010: Optimal measurement is key. Hepatology 51:1894–1896

    Article  PubMed  Google Scholar 

  5. Burroughs AK, Triantos CK (2008) Predicting failure to control bleeding and mortality in acute variceal bleeding. J Hepatol 48:185–188

    Article  CAS  PubMed  Google Scholar 

  6. D’Amico G, Morabito A (2004) Noninvasive markers of esophageal verices: Another round, not the last. Hepatology 39:30–34

    Article  PubMed  Google Scholar 

  7. De Franchis R (2015) Expanding consensus in portal hypertension Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 63:743–752

    Article  PubMed  Google Scholar 

  8. Fidelman N, Kwan SW, LaBerge JM et al (2012) The transjugular intrahepatic portosystemic shunt: An update. AJR Am J Roentgenol 199:746–755

    Article  PubMed  Google Scholar 

  9. Garcia-Pagan JC, Heydtmann M, Raffa S et al (2008) TIPS for Budd-Chiari syndrome: Long-term results and prognostics factors in 124 patients. Gastroenterology 135:808–815

    Article  PubMed  Google Scholar 

  10. Garcia-Pagan JC, Di Pascoli M, Caca K et al (2013) Use of early-TIPS for high-risk variceal bleeding: Results of a post-RCT surveillance study. J Hepatol 58:45–50

    Article  PubMed  Google Scholar 

  11. Garcia-Tsao G, Groszmann RJ, Fisher RI et al (1985) Portal pressure, presence of gastroesophageal varices and variceal bleeding. Hepatology 5:419–424

    Article  CAS  PubMed  Google Scholar 

  12. Garcia-Tsao G, Sanyal AJ, Grace N et al (2007) Prevention and management of gastroesophageal varices and variceal hemorhhage in cirrhosis. Am J Gastroenterol 102:2086–2102

    Article  PubMed  Google Scholar 

  13. Götz M, Anders M, Biecker E et al (2017) S2k Leitlinie Gastrointestinale Blutung. https://www.awmf.org/uploads/tx_szleitlinien/021028l_S2k_Gastrointestinale_Blutung_2017-07.pdf. Zugegriffen: 23. Febr. 2019

    Book  Google Scholar 

  14. Henderson JM, Boyer TD, Kutner MH et al (2016) Distal splenorenal shunt versus transjugular Intrahepatic portal systematic shunt for variceal bleeding: A randomized trail. Gastroenterology 130:1643–1651

    Article  Google Scholar 

  15. Hogan BJ, O’Beirne JP (2016) Role of self-expanding metal stents in the management of variceal haemorrhage: Hype or hope? World J Gastrointest Endosc 8:23–29

    Article  PubMed  PubMed Central  Google Scholar 

  16. Lebrec D, Nouel O, Corbic M et al (1980) Propranolol-a medical treatment for portal hypertension? Lancet 2:180–182

    Article  CAS  PubMed  Google Scholar 

  17. Lebrec D, Hillon P, Munoz C et al (1982) The effect of propranolol on portal hypertension in patients with cirrhosis; a hemodynamic study. Hepatology 2:523–527

    Article  CAS  PubMed  Google Scholar 

  18. Luca A, Miraglia R, Maruzzelli L et al (2016) Early liver failure after transjugular intrahepatic portosystemic shunt in patients with cirrhosis with model for end-stage liver disease score of 12 or less: Incidence, outcome, and prognostic factors. Radiology 280:622–629

    Article  PubMed  Google Scholar 

  19. Malinchoc M, Kamath PS, Gordon FD et al (2000) A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 31:864–871

    Article  CAS  PubMed  Google Scholar 

  20. Narahara Y, Kanazawa H, Fukuda T et al (2011) Transjugular intrahepatic portosystemic shunt versus paracentesis plus albumin in patients with refractory ascites who have good hepatic and renal function: A prospective randomized trial. J Gastroenterol 46:78–85

    Article  CAS  PubMed  Google Scholar 

  21. Panes J, Teres J, Bosch J et al (1988) Efficacy of balloon tamponade in treatment of bleeding gastric and esophageal varices. Results in 151 consecutive episodes. Dig Dis Sci 33:454–459

    Article  CAS  PubMed  Google Scholar 

  22. Richter GM, Palmaz JC, Nölge G et al (1989) The transjugular portosystemic stent-shunt. A new nonsurgical percutaneous method. Radiologe 8:406–411

    Google Scholar 

  23. Rössle M, Richter GM, Nöldge G et al (1989) New non-operative treatment for variceal haemorrhage. Lancet 2(8655):153

    Article  PubMed  Google Scholar 

  24. Rösch J, Hanafee W, Snow H (1969) Transjugular portal venography and radiologic portocaval shunt: An experimental study. Radiology 92:1112–1114

    Article  PubMed  Google Scholar 

  25. Strunk H, Marinova M (2018) Transjugular intrahepatic portosystemic shunt (TIPS): Pathophysoiologic basics, actual indications and results with review of the literature. Rofo 190(08):701–711

    Article  PubMed  Google Scholar 

  26. Tan HK, James PD, Snidermann KW et al (2015) Long-term clinical outcome of patients with cirrhosis and refractory ascites treated with transjugular intrahepatic portosystemic shunt insertion. J Gastroenterol Hepatol 30:389–395

    Article  CAS  PubMed  Google Scholar 

  27. The Nord Italian Endoscopic Club for the Study, Treatment of Esophageal Varices (1988) Prediction of the first variceal haemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicentre study. N Engl J Med 319:983–989

    Article  Google Scholar 

  28. Trebicka J (2016) Emergency TIPS in a Child-Pugh B patient: When does the window of opportunity open and close? J Hepatol 66:442–450

    Article  PubMed  Google Scholar 

  29. Triantos CK, Kalafateli M (2014) Endoscopic treatment of esophageal varices in patients with liver cirrhosis. World J Gastroenterol 20:13015–13026

    Article  PubMed  PubMed Central  Google Scholar 

  30. Tripathie D, Stanley AJ, Hayes PC et al (2015) U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut 64:1680–1704

    Article  Google Scholar 

  31. Villanueva C, Colomo A, Bosch A et al (2013) Transfuion strategies for acute upper gastrointestinal bleeding. N Engl J Med 368:11–21

    Article  CAS  PubMed  Google Scholar 

  32. Wannhoff A, Hippchen T, Weiss CS et al (2016) Cardiac volume overload and pulmonary hypertension in long-term follow-up of patients with transjugular intrahepatic portosystemic shunt. Aliment Pharmacol Ther 43:955–965

    Article  CAS  PubMed  Google Scholar 

  33. Wolter K, Decker G, Kuetting D et al (2018) Interventional treatment of acute portal vein thrombosis. Rofo 190:740–746

    Article  PubMed  Google Scholar 

  34. Zheng M, Chen Y, Bai J et al (2008) Transjugular intrahepatic portosystemic shunt versus endoscopic therapy in the secondary prophylaxis of variceal rebleeding in cirrhotic patients. J Clin Gastroenterol 42:507–516

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Klinik und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum der Rheinischen Friedrich-Wilhelms-Universität Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Deutschland

    S. Manekeller MHBA & J. C. Kalff

Authors
  1. S. Manekeller MHBA
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J. C. Kalff
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to S. Manekeller MHBA.

Ethics declarations

Interessenkonflikt

S. Manekeller und J.C. Kalff geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Manekeller, S., Kalff, J.C. Ösophagusvarizenblutung: Management und Tipps zum transjugulären intrahepatischen portosystemischen Shunt. Chirurg 90, 614–620 (2019). https://doi.org/10.1007/s00104-019-0949-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00104-019-0949-6

Schlüsselwörter

Keywords

Search

Navigation