Prevention of Recurrent Variceal Hemorrhage Pharmacologic and Endoscopic Therapy

Once the acute bleed has been managed, the focus of treatment shifts to preventing rebleeding. As previously mentioned, rebleeding occurs in 70% of patients surviving their initial bleed, so all patients need to receive treatment aimed at preventing rebleeding. The approach to and goals of treatment are similar to the treatment aimed at preventing a first variceal bleed. First line treatment is either initiation of a nonselective p-blocker or endoscopic variceal ligation. Nonselective p-blockers decrease rebleeding by 33% and mortality by 26%. In patients who have not achieved an adequate response to a p-blocker alone, the addition of ISMN may result in a significant lowering of the HVPG. If ISMN is to be used in combination therapy to prevent rebleeding, HVPG measurement should be performed to guide therapy. Endoscopic sclerotherapy and endoscopic variceal ligation are also both effective in preventing rebleeding, but as discussed above, endoscopic variceal ligation is the preferred approach. Despite therapy, however, rebleeding still occurs in 30 to 50% of patients at 2 years. In patients who fail treatment with one modality, combination therapy with a non-selective p-blocker and endoscopic variceal ligation may result in lower rates of rebleeding.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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