[Therapeutic endoscopy in portal hypertension. When, how and how far in 1998]

Portal hypertension hemorrhage (PHH) due to esophageal varices (EV) rupture in nearly 80% of cases, or gastric varices (GV) in the remaining 20%, account for one-fifth of the GI tract bleedings in a general hospital. Its frequency, but more importantly, its magnitude, that causes up to one-third of the cirrhotic casualties, deserves constant update in its management. Diverse inherent patient factors influence the course of any PHH, i.e., a) remaining liver function, which is determinant; b) variceal size; c) sepsis, and d) alcohol intake. Mortality due to PHH is 27% during the first week, 41% within 6 weeks and 75% by one year of follow-up after the index hemorrhage. Time of intervention is then of utmost importance. All these key circumstances determine the ultimate course of the bleeding event, in many cases to a greater degree than the opportunity and quality of the specific treatment itself. This diversity of influential factors also jeopardizes adequate patient randomization in trials designed to compare treatment modalities. During the last decade, EV sclerosis, when compared to conventional medical treatment (non-beta blockers), has proved useful to stop active bleeding in 71 vs. 31% of cases, decreasing early and late recurrence from 70 to 40%, and direct bleeding-related mortality from 24 to 9%, even when global mortality remains around 14% per year. Disappointing as it seems, remaining liver function is the determinant issue, but a biased underestimation factor may also play a role, due to greater surgical rescue of patients in the medical branch compared to EV sclerosis, 6 vs. 28%. Minor morbidity in 14% of sclerosis treatment has given way to endoscopic ligation with similar results and less morbidity. Prophylactic EV sclerosis was prohibited by prospective controlled trials, which demonstrated significant increase in bleeding and mortality, even though there might be a subgroup of patients with large varices or endoscopic prognostic signs of bleeding that decrease by 10% their incidence expected 35%/year bleeding. GV bleeding remains a challenge; where cyanoacrylate may be needed to improve immediate control and prevent recurrence of PHH. These patients, as well as those failures to endoscopic treatment are candidates for intrahepatic portosystemic shunt (TIPS), although long-lasting control is achieved, in most cases, by liver transplant.