All of the following therapies are considered appropriate during the management of an acute variceal hemorrhage EXCEPT?
Variceal bleeding is the leading cause of morbidity and mortality in those with portal venous hypertension. Approximately 30% of patients with compensated cirrhosis and 60% of those with decompensated cirrhosis will have varices, and one-third of these patients will experience a variceal bleed. These episodes carry a 20 to 30% risk of mortality. Prevention of variceal bleeding may be accomplished through administration of nonselective β-blockers (eg, propranolol) and routine endoscopic surveillance and variceal band ligation. In the case of acute variceal bleeding, patients should be admitted to an ICU for resuscitation and management. While prompt resuscitation is critical, administration ofboth blood products and crystalloid should be done with care. A target of hemoglobin of 8 g/ dL is appropriate, and administration of platelets and fresh frozen plasma may be considered for patients with thrombocytopenia or severe coagulopathy. However, overresuscitation with both blood products and crystalloid solution has been associated with increased risk of re-bleeding and morbidity. Use of recombinant factor VIla has not been shown to be better than standard therapy, and is not recommended. Patients with cirrhosis who experience a variceal bleed are at high risk for developing bacterial infection, including spontaneous bacterial peritonitis (~5O% of infectious complications), pneumonia, and urinary tract infection. These bacterial infections not only carry their own risk of morbidity and mortality, but also are associated with increased risk of re-bleeding. For this reason short-term antibiotic prophylaxis (eg, ceftriaxone) is recommended for patients with acute variceal bleeding. Management of the bleeding can be accomplished with vasoactive medications, including vasopressin and somatostatin analogues (eg, octreotide). These therapies cause splanchnic vasoconstriction and slow the flow of blood to the varices. Though vasopressin is the most potent vasoconstrictor, it is limited by its systemic effects. Thus, somatostatin analogues are the preferred agent. Further therapy for bleeding varices should include endoscopy with variceal band ligation.
A cirrhotic patient is admitted with variceal bleeding. The bleeding is controlled with pharmacologic therapy, and the patient recovers from the acute episode. Assuming they receive no other therapies to treat their varices or their underlying cause, what is the likelihood that they will experience a recurrent variceal bleed within 2 years:
The risk of re-bleed for patients is 70% over 2 years if they receive no further treatment. Patients who recover from an episode of variceal bleeding should be treated with follow-up endoscopy and variceal band ligation. In appropriate patients, transjugular intrahepatic portosystemic shunt (TIPS) or orthotopic liver transplant should be considered.
Which of the following INCORRECTLY matches a grading scale for patients with liver disease and one of its components?
The Child-Turcotte- Pugh (CTP) was initially derived for use in predicting the risk of portocaval shunt procedures, and comprises five components: bilirubin, albumin, INR, presence of encephalopathy, presence of ascites. The Model for End-Stage Liver Disease (MELD) score was developed as a model to predict mortality after TIPS, but has been adapted and validated for use as the method of organ allocation for orthotopic liver transplantation (OLT) in the United States. It is a linear regression model based on the serum creatinine, total bilirubin, and INR.
Which of the following INCORRECTLY pairs the CTP class with overall risk of mortality following an intraabdominal operation?
The overall mortality for patients with cirrhosis undergoing intra-abdominal surgery has consistently been shown to correlate with the CTP classification. The estimated mortality is 10%, 30% and 75 to 80% for those with CTP class A, B, and C cirrhosis, respectively. MELD score also predicts postoperative mortality in cirrhotic patients, and has been shown to correlate well with estimates based on CTP classification. In general, those patients with a MELD below 10 should be considered appropriate for surgery, while those with scores above 15 should not be considered for elective procedures.
What is the most common complication following TIPS?
TIPS is a percutaneous procedure used for treatment of patients who have gastroesophageal varices in the setting of portal hypertension. It has largely replaced surgical portosystemic shunts due to the fact that it is both safe and effective while also providing a minimally invasive alternative to major abdominal surgery. TIPS functions by creating an intrahepatic shunt between the portal and systemic circulation which causes a reduction in the portal pressure and ultimately in the blood flow through varices. It is accomplished by endovascular access through the jugular vein to a hepatic vein radical and subsequent creation of a needle tract that connects it to a branch of the portal vein. After dilation of the tract, a metallic stent is deployed to hold the new portosystemic connection open. Because this shunt reduces first pass metabolism of the liver, the most common complication of TIPS is encephalopathy which occurs in 25 to 30% of patients. Other complications such as hepatic ischemia, infection, renal failure, and hemorrhage may occur, but are rare.