Hipertensión portal

  1. M.V. Catalina-Rodríguez 1
  2. D. Pérez-Valderas 1
  3. L. Ibáñez-Samaniego 1
  4. R. Bañares 1
  1. 1 Hospital General Universitario Gregorio Marañón
    info

    Hospital General Universitario Gregorio Marañón

    Madrid, España

    ROR https://ror.org/0111es613

Revista:
Medicine: Programa de Formación Médica Continuada Acreditado

ISSN: 0304-5412

Año de publicación: 2016

Título del ejemplar: Enfermedades del aparato digestivo (XI) Enfermedades hepáticas. Cirrosis hepática

Serie: 12

Número: 11

Páginas: 606-616

Tipo: Artículo

DOI: 10.1016/J.MED.2016.05.011 DIALNET GOOGLE SCHOLAR

Otras publicaciones en: Medicine: Programa de Formación Médica Continuada Acreditado

Resumen

Definición La hipertensión portal se desarrolla progresivamente en el curso natural de la enfermedad hepática crónica y es el factor pronóstico principal de la misma. Sus consecuencias (hemorragia por rotura de varices esofágicas o gástricas, ascitis, síndrome hepatorrenal, peritonitis bacteriana espontánea, encefalopatía hepática y síndrome hepatopulmonar, entre otras) representan la principal causa de muerte y de trasplante hepático en los pacientes cirróticos. Manifestaciones clínicas Las manifestaciones clínicas de la hipertensión portal pueden aparecer cuando el gradiente de presión portal aumenta por encima del umbral de 10 mm Hg, valor que define la hipertensión portal clínicamente significativa. Tratamiento El tratamiento de elección en la hemorragia aguda por varices es la combinación de tratamiento endoscópico, preferiblemente ligadura endoscópica con bandas y tratamiento farmacológico vasoconstrictor, con somatostatina o terlipresina. La hemorragia por varices esofágicas tiene una alta mortalidad, superior al 20%, por lo que es fundamental establecer tratamientos preventivos, tanto primarios como de recidiva.

Referencias bibliográficas

  • McCuskey RS. Morphological mechanisms for regulating blood flow through hepatic sinusoids. Liver. 2000;20:3-7.
  • Rockey DC, Fouassier L, Chung JJ, Carayon A, Vallee P, Rey C, et al. Cellular localitation of endothelin-1 and increased production in liver injury in the rat: potential for autocrine and paracrine effects on stellate cells. Hepatology. 1998;27:472-80.
  • Wiest R, Groszmann RJ. The paradox of nitric oxide in cirrhosis and portal hypertension:too much, not enough. Hepatology. 2002;35:478-91.
  • D’Amico G, García-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol. 2006;44:217-231.
  • Groszmann RJ, García-Tsao G, Bosch J, Grace ND, Burroughs AK, Planas R, et al. Beta-blockers to prevent gastroesophageal varices in patients with cirrosis. N Engl J Med. 2005;353:2254-61.
  • Bosch J, Berzigotti A, García-Pagán JC, Abraldes JG. The management of portal hipertensión: racional basis, available treatments and future op-tions. J Hepatol. 2008;48:68-92.
  • De Franchis R, Primignani M. Natural history of portal hypertension in patients with cirrosis. Clin Liver Dis. 2001;5:645-63.
  • Ripoll C, Groszmann RJ, García-Tsao G, Grace N, Burroughs A, Planas R, et al. Hepatic venous pressure gradient predicts clinical decompensation in patients with compensated cirrhosis. Gastroenterology. 2007;133: 481-8.
  • Ripoll C, Groszmann RJ, García-Tsao G, Bosch J, Grace N, Burroughs A, et al. Hepatic venous pressure gradient predicts development of hepatocellular carcinoma independently of severity of cirrhosis. J Hepatol. 2009;50:923-8.
  • D’Amico G, Morabito A. Noninvasive markers of esophageal varices: another round, not the last. Hepatology. 2004;39:30-34.
  • Bosch J, Abraldes J, Albillos A, Aracil C, Bañares R, Berzigotti A, et al. Hipertensión portal: recomendaciones para su evaluación y tratamiento. Documento de consenso auspiciado por la AEEH y el CIBERehd. Gastroenterol Hepatol. 2012;35:421-50.
  • De Franchis R, on behalf of the Baveno VI Faculty. Expanding consensus in portal hypertension. Report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care of portal hy-pertension. J Hepatol. 2015:63:743-52.
  • Giannini E, Botta F, Borro P, Risso D, Romagnoli P, Fasoli A, et al. Pla-telet count/spleen diameter ratio: proposal and validation of a non-inva-sive parameter tto predict the presence of esophageal varices in patients with liver cirrhosis. Gut. 2003;52:1200-5.
  • Vizzuti F, Arena U, Romanelli RG, Rega L, Foschi M, Colagrande S, et al. Liver stiffness measurement predicts severe portal hypertension in patients with HCV-related cirrhosis. Hepatology. 2007;45:1290-7.
  • Bureau C, Metivier S, Peron JM, Selves J, Rovic MA, Gourraud PA, et al. Transient elastography accurately predicts presence of significant portal hypertension in patients with chronic liver disease. Aliment Pharmacol Ther. 2008;27:1261-8.
  • Pritchett S, Cardenas A, Manning D, Curry M, Afdhal NH. The optimal cut-off for predicting large oesophageal varices using transient elastography is disease specific. J Viral Hepat. 2011;18:75-80.
  • Berzigotti A, Seijo S, Arena U, Abraldes JG, Vizzutti F, García-Pagán JC, et al. Elastography, spleen size and platelet count identify portal hyper-tension in patients with compensated cirrhosis. Gastroenterology. 2013;144:102-11.
  • The North Italian Endoscopic Club for the study and treatment of esophageal varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study. N Engl J Med. 1988;319:983-9.
  • Merkel C, Marin R, Angeli P, Zanella P, Felder M, Bernardinello E, et al. A placebo-controlled clinical trial of nadolol in the prophylaxis of growth of small esophageal varices in cirrhosis. Gastroenterology. 2004;127: 476-84.
  • García-Pagán JC, Bosch J. Monitoring HVPG during pharmacological therapy: evidence in favour of the prognostic value of a 20% reduction. Hepatology. 2004;39:1746-7.
  • D’Amico G, Plagliaro L, Bosch J. Pharmacological treatment of portal hipertensión: an evidence-based approach. Semin Liver Dis. 1999;19: 475-505.
  • Chen S, Wang JJ, Wang QQ, Hu JW, Dong S, Hu LJ, et al. The effect of carvedilol and propranolol on portal hypertension in patients with cirr-hosis: a meta-analysis. P Patient Prefer Adherence. 2015;9:961-70.
  • Reiberger T, Ulbrich G, Ferlitsch A, Payer BA, Schwabl P, Pinter M, et al. Vienna Hepatic Hemodinamic Lab. Carvedilol for primary prophylaxis of variceal bleeding in cirrhotic patients with haemody-namic non-response to propranolol. Gut. 2013;62:1634-41.
  • Mandorfer M, Bota S, Schwabl P, Bucsics T, Pfisterer N, Kruzik M, Hag-mann M et al. Nonselective b blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis. Gastroenterology. 2014:146:1680-90.
  • Bosch J, García-Tsao G. Pharmacological versus endoscopic therapy in the prevention of variceal hemorrhage: and the winner is. Hepatology. 2009;50:674-7.
  • Villanueva C, Colomo A, Bosch, Concepción M, Hernández-Gea V, Ara-cil C,et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2103;368:11-21.
  • Cardenas A, Gines P, Uriz J, Bessa X, Salmeron JM, Mas A, et al. Renal failure after upper gastrointestinal bleeding in cirrosis:incidence, clinical course, predictive factors, and short-term prognosis. Hepatology. 2001; 34:671-6.
  • Bernard B, Cadranel JF, Valla D, Escolano S, Jarlier V, Opolon P. Prognostic significance of bacterial infection in bleeding cirrhotic patients: a prospective study. Gastroenterology. 1995;108:1828-34.
  • Fernández J, Navasa M, Gómez J, Colmenero J, Vila J, Arroyo V, et al. Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis. Hepatology. 2002;35:140-8.
  • Fernández J, Ruiz del Árbol L, Gómez C, Durandez R, Serradilla R, Guarner C, et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroentero-logy. 2006;131:1049-56.
  • Bañares R, Albillos A, Rincon D, Alonso S, Gonzalez M, Ruiz del Árbol L, et al. Endoscopic treatment versus endoscopic plus pharmacologic treatment for acute variceal bleeding: a meta-analysis. Hepatology. 2002;35:609-15.
  • Moitinho E, Planas R, Bañares R, Albillos A, Ruiz-del-Arbol L, Gálvez C, et al. Multicenter randomized controlled trial comparing different schedules of somatostatin in the treatment of acute variceal bleeding. J Hepa-tol. 2001;35:712-8.
  • Escorsell A, Pavel O, Cardenas A, Morillas R, Llop E, Villanueva C, et al. Esophageal balloon tamponade Vs esophageal stent in controlling acute refractory variceal bleeding: a multicenter RCT. Hepatology. En prensa 2015.
  • Bañares R, Casado M, Rodríguez-Láiz JM, Camuñez F, Matilla A, Echenagusia A, et al. Urgent transjugular intrahepatic portosystemic shunt for control of acute variceal bleeding. Am J Gastroenterol. 1998;93:75-9.
  • Bureau C, García-Pagán JC, Otal P, Pomier-Layrargues G, Chabbert V, Cortez C, et al. Improved clinical outcome using polytetrefluoroethyle-ne-coated stents for TIPS: results of a randomized study. Gastroentero-logy. 2004;126:469-75.
  • Monescillo A, Martínez-Lagares F, Ruiz del Arbol L, Sierra A, Guevara C, Jiménez E, et al. Influence of portal hipertensión and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepa-tology. 2004;40:793-801.
  • García-Pagán JC, Caca K, Bureau C, Laleman W, Appenrodt B, Luca A, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010;362:2370-9.
  • García-Pagán JC, Barrufet M, Cardenas A, Escorsell A. Management of gastric varices. Clinical Gastroenterology and Hepatology 2014;12:919-928.
  • Bernard B, Lebrec D, Mathurin P, Opolon P, Poynard T. Beta-adrenergic antagonists in the prevention of gastrointestinal rebleeding in patients with cirrhosis: a meta-analysis. Hepatology. 1997;25:63-70.
  • Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding. A metaanalysis. Ann Intern Med. 1995;123:280-7.
  • González R, Zamora J, Gómez-Camarero J, Molinero LM, Bañares R, Albillos A. Meta-analysis: Combination endoscopic and drug therapy to prevent variceal rebleeding in cirrhosis. Ann Intern Med. 2008;149:109-22.
  • Abraldes JC, Albillos A, Bañares R, Turnes J, González R, García-Pagán JC, et al. Simvastatin lowers portal pressure in patients with cirrhosis and portal hypertension: a randomized controlled trial. Gastroenterology. 2009;136:1651-8.
  • Papatheodoridis GV, Goulis J, Leandro G, Patch D, Burroughs AK. Tran-sjugular intrahepatic portosystemic shunt treatment for prevention of variceal rebleeding: a meta-analysis. Hepatology. 1999;30:612-22.
  • Sauerbruch T, Mengel M, Dollinger M, Zipprich A, Rössle M, Panther E, et al. Prevention of rebleeding from esophageal varices in patients with cirrhosis receiving small-diameter stents versus hemodynamically contro-lled medical therapy. Gastroenterology. 2015;149:660-8.
Fuente de los datos: Dialnet