Portal hypertension.

Abstract

The treatment of portal hypertensive gastrointestinal hemorrhage has seen many new and innovative advances in the past 15 years, including pharmocotherapy, sclerotherapy, transjugular intrahepatic portacaval shunt, partial portacaval shunt, and hepatic transplantation. Such an array of therapeutic options provides great flexibility for the physicians managing this complex disorder. The less invasive procedures tend to be associated with higher rates of rebleeding from esophageal varices. However, these procedures serve as excellent bridges to hepatic transplantation in poor-risk patients. Surgical portasystemic shunts offer a permanent solution to portal hypertensive bleeding but also have several drawbacks. Standard (end-to-side or side-to-side) portacaval shunts are associated with unacceptably high rates of p4rtasystemic encephalopathy because of complete diversion of portal flow away from the liver. Selective shunts, such as the distal splenorenal shunt, result in maintenance of portal perfusion, but this is not lasting in alcoholic cirrhotics. Partial shunting (small-diameter portacaval H-graft with collateral ligation) is the most recent addition to the surgical armamentarium. This allows for hepatic portal perfusion, thus minimizing encephalopathy rates, but it violates the right upper quadrant if the patient is a candidate for hepatic transplantation. This large array of treatment options, each with its own advantages and disadvantages, permits for careful selection of the best modality based on several influencing factors. These include the underlying liver disease, the prognosis, the health team's experience, the resources available to the patient and the community, and the cost-effectiveness of each treatment.