Title: Study of Portal Hemodynamic Changes Using Doppler Ultrasound in Egyptian Cirrhotic Patients with Oesophageal Varices Treated By Band Ligation with or Without Beta Blockers
Portal Hemodynamics In Egyptian Cirrhotics
Authors: Mohamed Tamer Afifi, Ezzat Ali Ahmed, Ayman Mohamed Shamseya, Mohamed Mahmoud Elshafei, Essam Eldin Saeed Bedewy and Amr Ahmed Mahmoud Dorra
DOI: http://dx.doi.org/10.18535/jmscr/v3i10.49
Abstract
Background and aims: Egypt has the largest burden of hepatitis C infection & liver cirrhosis worldwide. Sixty percent of cirrhotic patients develop esophageal varices and thirty percent suffer variceal hemorrhage. Studying portal hemodynamics using duplex Doppler is non-invasive, reliable and relatively cheap method for evaluating portal hemodynamic changes in cirrhotic patients; also it can be used in studying the effect and prognosis of different drugs used to reduce portal hypertension. Where as Baveno Consensus conference recommends β-blockers, banding ligation or both; the experts add that combined therapy is probably the best.
Aim Of The Work: was to study portal hemodynamics in cirrhotic patients with esophageal varices admitted for band ligation with and without the administration of propranolol.
Patients And Methods: 50 patients eligible for the study (cirrhosis, esophageal varices and no contraindications for propranolol), were randomized into two groups: Group I: 25 patients on oral propranolol (non-selective β-blocker) combined with endoscopic variceal band ligation. Group II: 25 patients on endoscopic variceal band ligation alone without oral propranolol.
Results: As regards to Portal vein diameter (PVD), Portal vein flow velocity (VEL), and Congestion index (CI), there was no statistically significant difference between the two groups before the start of the treatment. After 6 months of treatment, there was statistically significant difference between the two studied groups as regards to PVD & VEL, while non-statistically significant difference for CI.
Conclusions: both band ligation and propranolol reduced portal hemodynamic parameters, but patients on combination of both showed better results.
Key-words: portal hypertension, hepatitis, sclerotherapy
References
1. Frank C, Mohamed MK, Strickland GT, et al. The role of parenteral antischistosomal therapy in the spread of hepatitis C virus in Egypt. Lancet 2000; 355: 887–91.
2. Breban R, Doss W, Esmat G, et al. Towards realistic estimates of HCV incidence in Egypt. J Viral Hepat 2013;20:294-296.
3. Mohamoud Y, Mumtaz G, Riome S, Miller D, Abu-Raddad L. The epidemiology of hepatitis C virus in Egypt: a systematic review and data synthesis. BMC Infect Dis 2013;13:288.
4. WHO. Hepatitis C Fact sheet 164. (Online at:http://www.who.int/mediacentre/factsheets/fs164/en/) 2014.
5. Walid S. Ayoub. Combination of pharmacologic and endoscopic therapy or the secondary prevention of esophageal variceal bleeding. Gastrointestinal endoscopy 2009; 70:665-7.
6. Garcia-Tsao G, Sanyal AJ, Grace ND, et al. Prevention and management f gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol 2007; 102: 2086-102.
7. De Franchis R. Evolving consensus in portal hypertension. Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2005; 43: 167-76
8. Sarin SK, Wadhawan M, Agarwal SR, Tyagi P, Sharma BC. Endoscopic variceal ligation plus propranolol versus endoscopic variceal ligation alone in primary prophylaxis of variceal bleeding. Am J Gastroenterol. 2005 Apr; 100(4):797-804.
9. Ravipati M, Katragadda S, Swaminathan PD, Molnar J, Zarling E. Pharmacotherapy plus endoscopic intervention is more effective than pharmacotherapy or endoscopy alone in the secondary prevention of esophageal variceal bleeding: a meta-analysis of randomized, controlled trials. Gastrointest Endosc. 2009 Oct; 70(4):658-664.e5.
10. Tincani E, Cioni G, D'Alimonte P, et al. Effects of propranolol compared with clonidine on portal haemodynamics: a double-blind cross-over study using duplex-Doppler ultrasonography. Eur J Gastroenterol Hepatol. 1995 Sep; 7(9):893-7.
11. Villanueva C, Aracil C. Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de la Santa Creu I Sant Pau, Autonomous University, Barcelona, Spain. Aliment Pharmacol Ther Journal compilation 2009; 29: 397–408.
12. Ana-Maria et al. Hemodynamic changes in cirrhotic patients receiving propranolol. Romanian Journal of gastroenterology. 2005; 14(2): 123-127.
13. Ahmad Abdel Bary, Riham Mohamed Elshafie, Heba Mohamed Abdella, et al. Evaluation of the effect of Propranolol on portal hemodynamics in patients with HCV-related Cirrhosis. Journal of American Science 2012; 8(3):447-456.
14. Zain-Hamid R, Ismail Z, Mahendra Raj, et al. The effect of propranolol in Malay patients with liver cirrhosis - a pharmacodynamic evaluation. Malaysian Journal of Medical Sciences 2003; 10(1):65-73.
15. McKay, Rebecca, and Nigel R. Webster. "VARICEAL BLEEDING." Continuing Education in Anaesthesia, Critical Care and Pain 2007 ;(7): 6.
16. Shi Min B, Yan XW, Mu Ling Q, Wu Huang T, XU J. Value of portal hemodynamics and hypersplenism in cirrhosis staging. World J Gastroeneterol 2005; 11(5): 708-11.
17. Moriyasu F, Nishida O, Ban N, Nakamura T, Sakai M, MiyakeT, Uchino H. Congestion index of the portal vein. AJR 1986; 146: 735-9.
18. Huang J, Yin X, Lu M, Chen J, et al. Portal hemodynamics in cirrhotics with portal hypertension using color Doppler velocity profile. Chin Med J (Engl) 1999; 112(7): 627-31.
19. Kayacetin E, Efe D, Dogan C. Portal and splenic hemodynamics in cirrhotic patients: relationship between esophageal variceal bleeding and the severity of hepatic failure. J Gastroenterol 2004; 39: 129- 667.
20. Abdel-Motelb M. et al. Effect of repeated large volume paracentesis on portal hemodynamics and risk of bleeding in patients with mixed liver cirrhosis and tense ascites. Ms Thesis, Faculty of Medicine, Alex Univ. 2002.