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TRANSCRIPT
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