Therapy and Prophylaxis of Variceal Bleeding in Patients with Cirrhosis and Portal Hypertension
Variceal hemorrhage represents a severe complication of portal hypertension in patients with liver cirrhosis. Current guidelines recommend either non-selective β-blockers (NSBB) or endoscopic band ligation (EBL) for primary prophylaxis of the first variceal bleeding episode. Traditionally, propanolol and nadolol are used for primary prophylaxis of variceal hemorrhage. Carvedilol is a novel alternative with additional anti-alpha1 adrenergic activity that results in a more effective decrease in portal hypertension.
Secondary prophylaxis refers to the prevention of recurrent variceal hemorrhage, which has a major impact on mortality. The recommended strategy for secondary prophylaxis is a combination of NSBB and EBL since this combination has been reported to be more effective at controlling recurrent variceal hemorrhage than respective monotherapies (i.e. EBL or NSBB alone).
In this doctoral thesis, I aim to characterize a cohort of patients with cirrhosis and portal hypertension who underwent EBL for primary and secondary prophylaxis of variceal bleeding. I will analyze data on the efficacy of EBL in primary and secondary prophylaxis for variceal bleeding in daily clinical practice obtained from two large liver centers in Vienna (Medical University of Vienna and Krankenanstalt Rudolfstiftung).
I will assess transplant-free survival in patients undergoing EBL for primary and secondary prophylaxis of variceal bleeding between NSBB users versus non-NSBB users.
My second aim is to assess efficacy, mortality and rebleeding rates in patients undergoing EBL for secondary prophylaxis of variceal bleeding between additional propanolol therapy versus additional carvedilol therapy.Finally, I will analyze the efficacy of self-expanding esophageal stents (Danis® stents) versus balloon tamponade (Sengstaken-Blakemore® tube) for acute variceal bleeding.Methods: This project represents as a retrospective multicenter- study including patients from two large Liver centers, the Vienna General Hospital of the Medical University of Vienna and the Krankenanstalt Rudolfstiftung in Vienna. Patients undergoing EBL for esophageal varices between January/2000 and June/2015 will be identified and considered for this retrospective cohort study.
The main analyses comprise the longitudinal retrospective assessment of (re-)bleeding rates and mortality in patients with liver cirrhosis and esophageal varices. Transplant-free survival will be compared in patients undergoing EBL for primary and secondary prophylaxis of variceal bleeding between NSBB users versus non-NSBB users. In secondary prophylaxis, including patients undergoing EBL and NSBB therapy, I will compare the efficacy of propanolol versus carvedilol.
Methods and Skills:
Clinical studies; endoscopy
Mandorfer M, Bota S, Schwabl P, Bucsics T, Pfisterer N, Summereder C, Hagmann M, Blacky A, Ferlitsch A, Sieghart W, Trauner M, Peck-Radosavljevic M, Reiberger T. Proton pump inhibitor intake neither predisposes to spontaneous bacterial peritonitis or other infections nor increases mortality in patients with cirrhosis and ascites. PLoS One 9: e110503, 2014
Mandorfer M, Bota S, Schwabl P, Bucsics T, Pfisterer N, Kruzik M, Hagmann M, Blacky A, Ferlitsch A, Sieghart W, Trauner M, Peck-Radosavljevic M, Reiberger T. Nonselective β blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis. Gastroenterology 146: 1680-1690, 2014