Secondary Prophylaxis

Rebleeding is common after the first bleed; 50 to 80% of those who survive the first bleed rebleed within 2 years and most rebleed within 6 weeks after the first bleed. A number of options are available to prevent recurrent bleeding, including endoscopic treatment, nonselective ¡3-blockers, shunt or nonshunt surgery, TIPS, and liver transplantation. This area will be discussed in more detail in Chapter 117, "Portal Hypertension."

Recent trials comparing propranolol/nadolol with scle-rotherapy/band ligation have confirmed that both forms of treatment are similar in efficacy. Although it may appear logical to perform long term follow-up endoscopic treatment, there is no convincing evidence to suggest that long term follow-up treatment is superior to short term treatment aimed at obliteration of varices, especially if patients are maintained on ¡-blockers. Based on the limited data, it appears that addition of ¡-blockers to short term endo-scopic therapy may be superior to either treatment alone. This was to be expected since a number of patients on ¡-blockers do not attain a significant reduction in HVWP. Combination treatment may be useful especially in patients who are less likely to comply with medical treatment or in those who cannot tolerate maximal medical treatment. Currently, shunt surgery (preferably mesocaval shunt or distal splenorenal shunt) is reserved for patients with good synthetic function (Child A) and recurrent variceal bleeding who fail endoscopic and pharmacologic treatment. TIPS is very effective in preventing recurrent rebleeding, but it is associated with very high rates of shunt stenosis and occlusion. The current indication for TIPS is as a bridge to transplantation in patients with advanced cirrhosis (Child B or C) who present with recurrent rebleeding despite variceal obliteration and pharmacologic therapy. The mortality after variceal bleeding and the long term survival following the index bleed are directly related to the severity of liver disease. It is difficult to imagine that the various treatment options discussed here are likely to improve liver function and, hence, survival. Liver transplantation, with 5-year survival rate reaching 85 to 90% percent, is the treatment of choice for patients with advanced liver disease.

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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