Updated strategies in the management of acute variceal haemorrhage.
Updated strategies in the management of acute variceal haemorrhage.
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DOI：
10.1097/mog.0000000000000723
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发表时间：
2021-05-01
影响因子：
2.5
通讯作者：
Rockey DC
中科院分区：
文献类型：
--
作者：
Edelson J;Basso JE;Rockey DC
本文回顾了有关急性食管静脉曲张出血治疗的最新研究。新的随机对照试验和荟萃分析证实了早期 TIPS 在处理 Child-Pugh C (10-13) 和 B 级活动性出血患者的急性静脉曲张出血中的作用。最近一项关注血管活性治疗持续时间的随机对照试验显示，2 天和 5 天的奥曲肽治疗之间没有差异。一项随机试验显示，与标准护理相比，使用 TEG 引导的方法（与传统参数相比）可减少用于纠正凝血病的血液制品的使用，并且出血率降低。荟萃分析发现，对于静脉曲张出血的抢救，自膨式金属支架比球囊填塞更有效、更安全。此外，研究表明 Child-Pugh C 级患者和 HVPG>20 的患者治疗失败的风险最高，而 MELD 高度预测院内死亡率。对于患有严重凝血障碍和无法控制的出血的患者，建议采用基于 TEG 的输血策略。所有出现上消化道出血的肝硬化患者均应使用抗生素，但应根据当地的耐药模式进行调整。高危患者的早期 TIPS 已被证明具有显着的生存益处。静脉曲张出血治疗的某些方面仍然缺乏研究，例如早期 TIPS 在 Child-B 患者中的作用以及非 TIPS 候选患者的抢救治疗策略，需要进一步研究。
This article reviews the most recent studies regarding the management of acute esophageal variceal hemorrhage. New randomized control trials and meta-analyses confirmed the role of early TIPS in the management of acute variceal hemorrhage in Child-Pugh C (10–13) and B patients with active bleeding. A recent randomized controlled trial focused on the duration of vasoactive therapy showed no difference between 2 days and 5 days of octreotide. A randomized trial showed decreased use of blood products for the correction of coagulopathy using a TEG-guided approach (vs. conventional parameters) as well as decreased bleeding rates when compared to standard of care. A metanalysis found that for rescue of variceal bleeding, self-expanding metallic stents were more efficacious and safer than balloon tamponade. Additionally, studies showed that Child-Pugh C patients and those with HVPG>20 were at the highest risk of treatment failure, while MELD was highly predictive of in-hospital mortality. In patients with severe coagulopathy and uncontrolled bleeding, TEG-based transfusion strategies are recommended. Antibiotics should be used for all cirrhotic patients presenting with upper GI bleeding, but should be tailored in accordance to local resistance patterns. Early TIPS for high-risk patients has been shown to have a significant survival benefit. Certain aspects of the management of variceal bleeding remain poorly studied such as the role of early TIPS in Child-B patients as well as strategies for rescue therapy in patients who are not TIPS candidates, and require further investigation.