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Preventing Bleeding Varices: A Liver Transplant Must

April 21, 2009

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Information about preventing a complication of advanced Hepatitis C infection is now available. Learn why scientists are considering beta blockers to be the best line of defense against bleeding varices, a condition prohibitive of a liver transplant and one that can also be life threatening.

by Nicole Cutler, L.Ac.

In the United States, Hepatitis C is the most prevalent cause of chronic liver disease and the most common reason for a liver transplant. Reserved for those who have run out of options, a liver transplant is the last resort for a person battling the most advanced stages of Hepatitis C infection. For one in need of a liver transplant, many obstacles must be overcome, including preventing bleeding varices.

There are many steps to be taken before a liver transplant can begin. Of the many hurdles leading to this surgery, below are three essential considerations:

1. Risky – A liver transplant is a major operation accompanied by many risks, and is therefore only considered when a person’s liver is no longer capable of sustaining life. Even though it is the most common reason to receive a liver transplant, a majority of Hepatitis C patients experience viral recurrence with their new liver.

2. Donor Matching – Being approved to be a recipient places someone on the donor list, a list that may involve a very long waiting period. Only a select few of those on the list are lucky enough to find an appropriate donor. Even though it is a last resort for those with liver disease, thousands of people are put on a liver donor recipient list every day.

3. Preventing Bleeding Varices – A flare-up of this common advanced liver disease problem will prohibit liver transplant surgery. When waiting for a new liver, one must work with his/her physician to prevent variceal bleeding in order to maintain transplant eligibility.

Bleeding Varices
Varices are dilated blood vessels typically located in the esophagus or stomach. If these vessels rupture and bleed, a dangerous situation is on hand. As a result of fibrosis from advanced liver disease, blood flow is inhibited in the liver. The circulatory inhibition that ensues causes pressure to build up in the vein carrying blood to the liver. Known as portal hypertension, this blood circulation backup causes the vessels to balloon, putting them at risk of rupturing and bleeding. A life-threatening complication of portal hypertension, bleeding from these varices is typically evidenced by blood in the vomit or stool.

Medical Intervention
Because bleeding varices can be a medical emergency, Western medicine relies on a handful of interventions to stop the bleeding. Among those are:

· Banding – By placing small rubber bands directly over the dilated blood vessels, this procedure can stop the bleeding and reduce the vessel’s dilation.

· Sclerotherapy – By injecting the dilated blood vessel with a blood-clotting solution, this method stops dangerous bleeding.

· Stent – By re-routing the blood vessels under pressure, a hollow tube is surgically inserted into the affected vasculature to reduce the high blood pressure.

· Devascularization – This surgical procedure literally removes the bleeding varices. This procedure is done when the other choices are not an option.

Prevention
While stopping the crisis of bleeding varices saves lives, preventing them is just as important. People living with an advanced case of Hepatitis C can benefit from taking prophylactic steps to avoiding a bleeding varices crisis.

According to a study published in the March 2006 edition of the American Journal of Gastroenterology, certain medications offer bleeding varices prevention. The authors concluded that pharmacologic reduction of portal hypertension is associated with a dramatic decrease in the risk of variceal bleeding in cirrhotic patients with esophageal varices.

According to an article published in the September 2007 issue of Liver Transplantation, beta blocker drugs should be the first choice treatment for preventing variceal bleeding in people with cirrhosis and portal hypertension. To compare the safety and efficacy of the two most popular therapies in preventing bleeding varices, banding and the use of beta blockers, Italian researchers conducted a randomized controlled trial among patients awaiting liver transplantation.

The researchers found that, while banding is similarly effective as beta blockers in reducing the incidence of bleeding varices, it can have fatal complications and is more expensive compared with the beta blocker, propranolol. Both propranolol and banding were found to reduce the expected incidence of bleeding by approximately 30 percent after one year. Although some patients in each group experienced adverse events related to their treatment, only banding had a fatal outcome. The authors concluded that although banding should be used when beta blockers are contraindicated, beta blockers should remain the first choice of prophylactic therapy in candidates for liver transplantation.

Even though the complications of portal hypertension must be kept under control to permit a liver transplant, anyone with advanced liver disease should aim for preventing a variceal bleed. Those with Hepatitis C who have advanced to cirrhosis with esophageal or gastric varices must speak with their physician about the best way to prevent a bleeding episode. Although beta blockers may not be the solution for everyone, they can reduce the risk of bleeding varices, a risk most people with liver disease cannot afford to take.

References:

www.clevelandclinic.org, Bleeding Varices, The Cleveland Clinic Department of Patient Education and Health Information, 2007.

www.hivandhepatitis.com, Prevention of Variceal Bleeding in Candidates Awaiting Liver Transplantation, hivandhepatitis.com, September 2007.

www.medscape.com, Long-Term Prophylaxis Can Prevent Variceal Bleeding in Cirrhotic Patients, Reteurs Ltd. 2006.

www.sciencedaily.com, Preventing Variceal Bleeding, John Wiley & Sons, Inc., ScienceDaily LLC, September 2007.

Posted by Editors at April 21, 2009 2:11 PM