From the Guidelines
The treatment for portal venous hypertension should prioritize Transjugular Intrahepatic Portosystemic Shunt (TIPS) as a crucial therapeutic option, especially for patients with refractory ascites or recurrent variceal bleeding despite medical and endoscopic therapy, as recommended by the most recent guidelines 1. The management of portal venous hypertension involves a multifaceted approach, including pharmacological therapy, endoscopic treatment, and interventional procedures.
- First-line pharmacological therapy typically includes non-selective beta-blockers such as propranolol or nadolol to reduce portal pressure by decreasing cardiac output and causing splanchnic vasoconstriction.
- For acute variceal bleeding, emergency management includes vasoactive drugs like octreotide or terlipressin, combined with endoscopic therapy such as band ligation or sclerotherapy.
- Patients with refractory ascites may require diuretics or periodic large-volume paracentesis. However, TIPS has become an essential treatment for portal hypertension, particularly for patients with complications such as ascites and variceal bleeding, as highlighted in recent guidelines 1. The decision to perform TIPS should be based on a multidisciplinary approach, involving gastroenterologists, hepatologists, and interventional radiologists, to optimize outcomes 1. Long-term management should also address the underlying cause of portal hypertension, such as alcohol cessation or antiviral therapy, to reduce portal pressure and prevent disease progression. It is essential to note that the indications, patient selection, and follow-up for TIPS have been reviewed and summarized in recent guidelines, providing a framework for clinicians to make informed decisions 1.
From the Research
Treatment Options for Portal Venous Hypertension
The treatment for portal venous hypertension typically involves a combination of medical and endoscopic therapies.
- Non-selective beta-blockers, such as propranolol and carvedilol, are commonly used to reduce portal pressure and prevent variceal bleeding 2, 3, 4.
- Variceal endoscopic band ligation is also effective in preventing bleeding, but may have procedure-related morbidity 5.
- Vasopressor drugs, such as terlipressin, and antibiotics may be used to treat acute bleeding 5.
- Transjugular intrahepatic portosystemic shunt (TIPS) may be considered for refractory bleeding or as a bridge to definitive treatment 5, 6.
Medical Therapy
Non-selective beta-blockers have been shown to reduce portal pressure and prevent variceal bleeding in patients with portal hypertension 2, 3, 4.
- Carvedilol may be more potent than propranolol in reducing portal pressure, particularly in non-responders 3.
- Beta-blockers may also have non-hemodynamic beneficial effects, such as reducing bacterial translocation and spontaneous bacterial peritonitis in cirrhosis 3.
Endoscopic Therapy
Variceal endoscopic band ligation is an effective treatment for variceal bleeding, but may have procedure-related morbidity 5.