v arises

Curriculum VitaeNamaLahirAlamatIstriAnak/Mantu/CucuPendidikan

Pekerjaan

Pendidikan Tambahan

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I Gede ArintonSingaraja, 1 Januari 1950Jl. Pramuka 249 Purwokerto15/3/31. dr. umum FK. UNUD 19772. dr. SpPD FK. UNDIP 19873. MKom STIBBi Jkt 19994. MMR UNSUD 20055. KGEH FK. UI 2007 6. Doktor Ilmu Kedokteran UNDIP 2008Bag. Penyakit. Dalam RSUD. Margono

Soekarjo/FKIK Unsud Purwokerto1. Pelatihan Endoscopy di RSU dr. Hasan

Sadikin Bandung. 2. International Endoscopy Workshop

2007, Jakarta 5 – 7 April 2007.3. Training Endoscopy Showa University

Yokohama 2009

Varices in Liver Cirrhosis

Dr.dr. I Gede Arinton,SpPD-KGEH

The Internal Medicine of FKIK Unoed

Purwokerto

2012

Introduction

• Prevalence CH - increased from 9%

(1996)-18.5% (2006)

• Longitudinal studies VE &/or gastric

varices - eventually- in all cirrhotic

patients

• Once developed- tend :

• to increase in size

• to bleed.

Introduction

Baveno IV - Status classification of cirrhosis :

• Stage 1: no varices, no ascites

• Stage 2: varices, no ascites;

• Stage 3: ascites±varices

• Stage 4: bleeding±ascites.

Introduction

• Mortality : ± 20%

• Risk of rebleeding if no Th/ ± 60%

--- strategies Dx, prophylaxis I (first

bleed) & II(rebleeding).

--- to identify the patients at risk of

bleeding

The mechanisms variceal formation & rupture

The mechanisms variceal formation & rupture

Abraldes & Bosch,2005

Martell et al, 2010

The natural history

• DEVELOPMENT OF VE :

• HVPG >10 mmHg- strong predictor

• No other factors

The natural history • PROGRESSIONSMALL-LARGE

• Once developed- small to large(5-

30%/yr)

• Factors :

• Child–Pugh score

• E/ alcoholic

• Red wale markings

• HVPG

The natural history • FIRST BLEEDING

• 25%/2 yr

• Predictive factors :

• Variceal size-HVPG

• The Child–Pugh classification

• Red wale marks

Prophylaxis

• Primary•Secondary

ProphylaxisSplanchnic vasocon. :•vasopressin & ana.• somatostatin & ana• NSBB

Venodilators • nitratesShunting

STEEVL

Pre-Primary

1. Pre-primary prophylaxis

(prevention of the formation of

varices)- Baveno V :

• An important area of research

• Predictive HVPG>10 mm Hg

Primary

1. Pre-primary prophylaxis

• Experimental studies NSBB -

reduce portal pressure but

insufficient evidence

Groszmann et al,2005

Primary

2. Primary prophylaxis :

• All cirrhotic patients should be

screened for varices at diagnosis :

• Endos.- gold standard

• Non invasive

Endoscopic Dx

The risk of bleeding is related to:

• the size of varices

• the presence of ‘‘red signs”

• Child-Pugh score

the size of

varices

(the Italian

Liver

Cirrhosis

Project)

Small <25% lumen

Medium25-50% lumen

Large>50% lumen

red wale

markings

Baveno IV :

• All CH endos. - screened VE.

• 2–3 yrs intervals VE. <->

• 1–2 yrs small varices

However-endoscopy :

• High costs

• Invasive - low compliance

• Clinical

• Laboratory

• USG

non-invasive alternatives

poor validation - none

recommended in

everyday clinical

practice

31.Giannini et al,200332. Giannini et al,2006.33. Thabut et al, 200644. Burton et al, 2007.

45.Berzigotti et al, 2008

Biochemical & US parameters

34. Kazemi et al,200646.Vizzutti et al, 2007.

Transient elastography

35. Kim et al, 2007.40.Kim et al, 2007.

47. Perri et al, 2008.

CT scanning

36. Eisen et al, 2006.37.Lapalus et al, 2006.38.Groce et al, 2007.

39.de Franchis et al, 2008.48.Pena et al, 2008.

Video capsule endoscopy

• Primary prophylaxis

1.Prevention of the Growth of Small

Varices to Large Ones

2.Prevention of First Bleeding-

risk :

• Red mark or

• CP - C score

CONCLUSION: This trial suggests that propranolol administration cannot be recommended for the prevention of the development of large oesophageal varices in patients with cirrhosis; thus other studies are needed in selected subgroups of patients.

Baveno V -- NSBB

Prevention of First Bleeding

Baveno V

• Either NSBB or endoscopic band

ligation (EBL)

• Carvedilol alternative

• NSBB+ISMN+spironolactone

Conclusion:

1.EVL >superior BB

2.Mortality - differerence <->

Primary Prophylaxis

ConclusionsPatients with contraindications, intolerance or not responding to beta-blockers treated with band ligation achieve protection from variceal bleeding comparable to that of good responders to beta-blockers.

Secondary Prophylaxis

• If untreated- risks of :

• Rebleeding 63%

• Death 33%

- recommendation -

Secondary Prophylaxis

Baveno V :

• Time to start - as soon as possible from day

6 of the index variceal episode

• BB+EVL > Th/ alone

• EVL unable/unwiling - BB+ISMN

• Fail endos.+ pharmaco. Th/ :

• Transjugular Intra-hepatic Porto-systemic Shunt

(TIPS).

• Transplantation

Algorithm

de Franchis,2010

Summary

• VE bleeding - C/ PH

• E/death 1/3 cirrhotic pts.

• Patients with a high risk of

bleeding need to be identified-

prophylaksis.

Summary

• The most important predictors:

• Variceal size

• The presence of red wale markings

• The severity of liver

dysfunction(Child–Pugh score)

Summary

• Endoscopic variceal ligation--

alternative to NSBB

• Pharma. & endos. Th/ - fail--

TIPS or transplantation

Thank You