Wiener Medizinische Wochenschrift

, Volume 156, Issue 13–14, pp 397–403 | Cite as

Portal hypertension – old problem, new therapeutic solutions

Themenschwerpunkt

Summary

Portal hypertension is an old problem, but many solutions have been elaborated in recent years, mostly through international cooperation of several research groups. Ultimately, liver transplantation is a solution for all these problems but with the increasing need for liver transplantation and the lack of sufficient donor organs, there is still a high need for better conservative and interventional treatment solutions to portal hypertension. With the rapid improvements in specific therapies for chronic liver disease, especially viral hepatitis, there is hope that there will be a decreasing need for the treatment of the complications of advanced stage liver disease in future years.

Keywords

Ascites Hepatic encelphalopathy Hepatorenal syndrome Portal hypertension Spontaneous bacterial peritonitis Variceal bleeding 

Portale Hypertension – Frischer Wind auf eingefahrenen therapeutischen Wegen

Zusammenfassung

Unter portaler Hypertension versteht man den Anstieg des Druckgradienten zwischen der Pfortader und der abdominellen Vena cava inferior. Der Goldstandard in der Diagnostik der portalen Hypertension ist die Messung des Druckgradienten mittels indirekter Pfortaderdruckmessung mit dem Lebervenenkatheter. Dieser erlaubt nicht nur die Diagnosestellung sondern auch eine Risikostratifizierung anhand der Höhe des Messwerts und die Evaluierung des Ansprechens auf eine medikamentöse Therapie. Zu den Komplikationen der portalen Hypertension gehören die akute Varizenblutung, der Aszites, die spontan- bakterielle Peritonitis, das hepatorenale Syndrom, das hepatopulmonale Syndrom und die hepatische Enzephalopathie. In der Therapie der akuten Varizenblutung stellen vasoaktive, antibiotische und endoskopische Therapie heute den Standard dar, in der Primär- und Sekundärprävention stellt die ß-Blocker basierte medikamentöse Therapie den Standard dar, wobei die Sekundärprävention auch eine Domäne der endoskopische Therapie ist. Sowohl bei Versagen der Sekundärprävention als auch bei intraktablem Aszites ist der TIPS eine Alternative, wobei hier niemals die Lebertransplantation als Option außer Acht gelassen werden darf. Allerdings könnte sich die Rolle des TIPS durch die technischen Entwicklungen im Bereich der Stents durchaus etwas verschieben. Während die spontan-bakterielle Peritonitis eher ein diagnostisches Problem darstellt, ist die Prognose des hepatorenalen Syndroms schlecht und die Therapieoptionen diesseits der Lebertransplantation sind limitiert. Auch wenn neue, Erfolg versprechende medikamentöse Ansätze in Entwicklung sind, so liegt eine der großen Hoffnungen in der Therapie der portalen Hypertension im Fortschritt in der Therapie chronischer Lebererkrankungen, welcher die Progression dieser Erkrankungen hin zur klinisch signifikanten portalen Hypertension verhindern kann.

Schlüsselwörter

Aszites Hepatische Enzephalopathie Hepatorenales Syndrom Portale Hypertension Spontan-bakterielle Peritonitis Varizenblutung 

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References

  1. Groszmann RJ, Wongcharatrawee S (2004) The hepatic venous pressure gradient: anything worth doing should be done right. Hepatology 39: 280–282PubMedCrossRefGoogle Scholar
  2. Garcia-Tsao G (2001) Current management of the complications of cirrhosis and portal hypertension: variceal hemorrhage, ascites, and spontaneous bacterial peritonitis. Gastroenterology 120: 726–748PubMedCrossRefGoogle Scholar
  3. de Franchis R (2005) Evolving consensus in portal hypertension. Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 43: 167–176PubMedCrossRefGoogle Scholar
  4. Peck-Radosavljevic M, Trauner M, Schreiber F (2005) Austrian consensus on the definition and treatment of portal hypertension and its complications. Endoscopy 37: 667–673PubMedCrossRefGoogle Scholar
  5. Groszmann RJ, Garcia-Tsao G, Bosch J, Grace ND, Burroughs AK, Planas R, Escorsell A et al (2005) Beta-Blockers to Prevent Gastroesophageal Varices in Patients with Cirrhosis. N Engl J Med 353: 2254–2261PubMedCrossRefGoogle Scholar
  6. Merkel C, Marin R, Angeli P, Zanella P, Felder M, Bernardinello E, Cavallarin G et al (2004) A placebo-controlled clinical trial of nadolol in the prophylaxis of growth of small esophageal varices in cirrhosis. Gastroenterology 127: 476–484PubMedCrossRefGoogle Scholar
  7. Imperiale TF, Chalasani N (2001) A meta-analysis of endoscopic variceal ligation for primary prophylaxis of esophageal variceal bleeding. Hepatology 33: 802–807PubMedCrossRefGoogle Scholar
  8. Schepke M, Kleber G, Nurnberg D, Willert J, Koch L, Veltzke-Schlieker W, Hellerbrand C et al (2004) Ligation versus propranolol for the primary prophylaxis of variceal bleeding in cirrhosis. Hepatology 40: 65–72PubMedCrossRefGoogle Scholar
  9. Bosch J, Abraldes JG, Groszmann R (2003) Current management of portal hypertension. J Hepatol 38 (Suppl 1): 54–68CrossRefGoogle Scholar
  10. Bosch J, Abraldes JG (2004) Management of gastrointestinal bleeding in patients with cirrhosis of the liver. Semin Hematol 41: 8–12PubMedCrossRefGoogle Scholar
  11. Bernard B, Grange JD, Khac EN, Amiot X, Opolon P, Poynard T (1999) Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology 29: 1655–1661PubMedCrossRefGoogle Scholar
  12. Moitinho E, Planas R, Banares R, Albillos A, Ruiz-del-Arbol L, Galvez C, Bosch J (2001) Multicenter randomized controlled trial comparing different schedules of somatostatin in the treatment of acute variceal bleeding. J Hepatol 35: 712–718PubMedCrossRefGoogle Scholar
  13. Bosch J, Garcia-Pagan JC (2003) Prevention of variceal rebleeding. Lancet 361: 952–954PubMedCrossRefGoogle Scholar
  14. Patch D, Sabin CA, Goulis J, Gerunda G, Greenslade L, Merkel C, Burroughs AK (2002) A randomized, controlled trial of medical therapy versus endoscopic ligation for the prevention of variceal rebleeding in patients with cirrhosis. Gastroenterology 123: 1013–1019PubMedCrossRefGoogle Scholar
  15. Villanueva C, Minana J, Ortiz J, Gallego A, Soriano G, Torras X, Sainz S et al (2001) Endoscopic ligation compared with combined treatment with nadolol and isosorbide mononitrate to prevent recurrent variceal bleeding. N Engl J Med 345: 647–655PubMedCrossRefGoogle Scholar
  16. de la Pena J, Brullet E, Sanchez-Hernandez E, Rivero M, Vergara M, Martin-Lorente JL, Garcia Suarez C (2005) Variceal ligation plus nadolol compared with ligation for prophylaxis of variceal rebleeding: a multicenter trial. Hepatology 41: 572–578PubMedCrossRefGoogle Scholar
  17. Lo GH, Lai KH, Cheng JS, Chen MH, Huang HC, Hsu PI, Lin CK (2000) Endoscopic variceal ligation plus nadolol and sucralfate compared with ligation alone for the prevention of variceal rebleeding: a prospective, randomized trial. Hepatology 32: 461–465PubMedCrossRefGoogle Scholar
  18. Monescillo A, Martinez-Lagares F, Ruiz-del-Arbol L, Sierra A, Guevara C, Jimenez E, Marrero JM et al (2004) Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology 40: 793–801PubMedCrossRefGoogle Scholar
  19. Runyon BA (2004) Management of adult patients with ascites due to cirrhosis. Hepatology 39: 841–856PubMedCrossRefGoogle Scholar
  20. Arroyo V, Gines P, Gerbes AL, Dudley FJ, Gentilini P, Laffi G, Reynolds TB et al (1996) Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. International Ascites Club. Hepatology 23: 164–176PubMedGoogle Scholar
  21. Gines P, Guevara M, De Las Heras D, Arroyo V (2002) Review article: albumin for circulatory support in patients with cirrhosis. Aliment Pharmacol Ther 16 (Suppl 5): 24–31PubMedCrossRefGoogle Scholar
  22. Gines P, Cardenas A, Arroyo V, Rodes J (2004) Management of cirrhosis and ascites. N Engl J Med 350: 1646–1654PubMedCrossRefGoogle Scholar
  23. Rimola A, Garcia-Tsao G, Navasa M, Piddock LJ, Planas R, Bernard B, Inadomi JM (2000) Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. International Ascites Club. J Hepatol 32: 142–153PubMedCrossRefGoogle Scholar
  24. Sort P, Navasa M, Arroyo V, Aldeguer X, Planas R, Ruiz-del-Arbol L, Castells L et al (1999) Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis [see comments]. N Engl J Med 341: 403–409PubMedCrossRefGoogle Scholar
  25. Gines P, Guevara M, Arroyo V, Rodes J (2003) Hepatorenal syndrome. Lancet 362: 1819–1827PubMedCrossRefGoogle Scholar
  26. Duvoux C, Zanditenas D, Hezode C, Chauvat A, Monin JL, Roudot-Thoraval F, Mallat A et al (2002) Effects of noradrenalin and albumin in patients with type I hepatorenal syndrome: a pilot study. Hepatology 36: 374–380PubMedCrossRefGoogle Scholar
  27. Ferenci P, Lockwood A, Mullen K, Tarter R, Weissenborn K, Blei AT (2002) Hepatic encephalopathy-definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congress of Gastroenterology, Vienna, 1998. Hepatology 35: 716–721PubMedCrossRefGoogle Scholar
  28. Weissenborn K, Ennen JC, Schomerus H, Ruckert N, Hecker H (2001) Neuropsychological characterization of hepatic encephalopathy. J Hepatol 34: 768–773PubMedCrossRefGoogle Scholar
  29. Kircheis G, Wettstein M, Timmermann L, Schnitzler A, Haussinger D (2002) Critical flicker frequency for quantification of low-grade hepatic encephalopathy. Hepatology 35: 357–366PubMedCrossRefGoogle Scholar
  30. Kircheis G, Nilius R, Held C, Berndt H, Buchner M, Gortelmeyer R, Hendricks R et al (1997) Therapeutic efficacy of L-ornithine-L-aspartate infusions in patients with cirrhosis and hepatic encephalopathy: results of a placebo-controlled, double-blind study. Hepatology 25: 1351–1360PubMedCrossRefGoogle Scholar
  31. Stauch S, Kircheis G, Adler G, Beckh K, Ditschuneit H, Gortelmeyer R, Hendricks R et al (1998) Oral Lornithine-L-aspartate therapy of chronic hepatic encephalopathy: results of a placebo-controlled doubleblind study. J Hepatol 28: 856–864PubMedCrossRefGoogle Scholar
  32. Riggio O, Efrati C, Catalano C, Pediconi F, Mecarelli O, Accornero N, Nicolao F et al (2005) High prevalence of spontaneous portal-systemic shunts in persistent hepatic encephalopathy: a case-control study. Hepatology 42: 1158–1165PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  1. 1.Division of Gastroenterology and Hepatology, Department of Internal Medicine IVMedical University of Medicine of ViennaViennaAustria

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