hipertension portal y sangrado gastrico

MIP ALEJANDRO MEJIA VILLEGAS

27 DE SEPTIEMBRE 2013

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

SANGRADO VARICES

ESOFAGICAS

VARICES DUODENALES

SANGRADO DE ESTOMAGO

SANGRADO EN COLON

GASTROPATIA HIPERTENSIVA

PORTAL

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

Prevención de la primera hemorragia variceal

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

Al momento del diagnostico

50% de los pacientes cirróticos

presentan VE

90% la presentara

n

Mortalidad del 7-

15%

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

Diametro

Signos de wale

Función hepática

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

> 5 mm

< 5 mm

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

5% incidencia anual.

•1.5 año 21%

•3 años 45%

•4.5 anos 66%

Un estudio con 258 pacientes

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

Varices pequeñas seguimiento 1-2 años.

Sin varicesexamen de seguimiento 2-3 años

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

β- Bloqueadores

Escleroterapia

Ligadura

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

No previene formación de varices

Previene ampliación de varices pequeñas

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

Varices >

5mm

30-35%hemorragia

Tx reduce 50% el riesgode sangrado

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

Escleroterapia

Derivación

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

RIESGO DE SANGRADO NO ES DIFERENTE AL DE LA POBLACION NO TRATADA

INTERRUPCION

EFECTOS SECUNDARIOS

20%

World J Gastroenterol 2013 August 21; 19(31): 5035ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

REDUCE EL RIESGO DE HEMORRAGIA

REDUCE LA MORTALIDAD

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

B-BLOQUEADORES

LIGADURA

MISMO RESULTADO

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

Tratamiento primera linea

Pacientes con contraindicaciones de B-Bloqueadores

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

1.- sangrado activo al momento de endoscopia

2.- varices sin evidencia de sangradocon sangre presente en esófago y estomago sin otra fuente de sangrado

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

40% MUEREN

INFECCIONES

INSUFICIENCIA

HEPATICA

SANGRADO

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

ESTABILIZ

ARHEMODINAMICAMENTE

TRATAMIENTO

VASOPRESORES

TRATAMIENTO

ANTIBIOTICOTERAPIA

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

• Disminuye mortalidad

• Disminuye probabilidad de resangrado

ANTIBIOTICOS

• Mantener 7-8 g/dl

TRANSFUSIÓN

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

TERLIPRESINA

SOMATOSTAINA

VASOPRESINA

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

COMPLICACIONES

Isquemia mesentericainfarto

Vasopresina

Nitratos

Disminuye complicaciones

Control de hemorragiano modifica mortalidad World J Gastroenterol 2013 August 21; 19(31): 5035-5050

ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

• Menos eventos adversos

• Impacto en mortalidadefecto

• 80% y 67%

• 48 horas y %5 Dias.Hemorragia

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

2 MG CADA 4 HORAS EN LAS PRIMERAS 48 HORAS

SE CONTINUA CON 1 mg CADA 4 HORAS POR 5 DIAS

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

• vasopresina

• + nitrato

+

• Terlipresina

similar• somatostatina

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

Mejor perfil de seguridad

Su combinacion con terlipresina no la hace superior

Beneficio similar a terlipresina

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

80-90%

•Se controlan con endoscopia.

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

Ethoxysklerol Cianoacrilato

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

•Tratamiento de segunda línea

•Cuando falla la ligadura

•complicaciones

•Ulceras superficial y estenosis esofágica.

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

FINALMENTE

ES UN PUENTE HASTA TERAPIA DEFINITIVA DISPONIBLE

REDUCIRS COMPLICACIONES

Desinflar en 6 horas Aplicación son flouroscopio

COMPLICACIONES

Necrosis + rotura de esofago + Neumonia por aspiracion

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

Alternativa al Balón, no necesita flouroscopio

Dura hasta 2 semanas

Es un procedimiento de reserva para hemorragia refractaria a Tx medico-endoscópico

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

Indicado en pacientes con falla en Tx anteriores

8-18% de resangradoanual

Riesgo de encefalopatía hepatica

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

63 pacientes child B o C

STENnormalPTFE

Recidiva97%50%

Mortalidad86%61%

politetrafluoroetileno

Derivacion •Portosistemica

Trasnseccion •Del esófago

mortalidas • 80%

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

Sobrevivencia a 1er episodio

60% de recidiva

Mortalidad de 33%

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

ESCLEROTERAPIA

B-BLOQUEADORES

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

LIGADURA

ESCLEROTERAPIA

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

B-BLOQ +

NITRATOSLIGADURA

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

SI EL PACIENTE TOLERA EL TRATAMIENTO MEDICO

TERAPIA DE COMBINACION.

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

•Curvatura menor

TIPO I

•Curvatura mayor

TIPO II

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

Diagnostico por endoscopia o Doppler

20% de pacientes con hipertensionportal la presentan

Riesgo de sangrado depende de ubicación de la variz

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

53%•FONDO GASTRICO

19%•CURVATURA MAYOR

6%•CURVATURA MENOR

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

Inyeccion cianoacrilato

Seguro y eficas en profilaxis primaria

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

NO EFICACIA

SEGURO Y EFICAZ

NO HAY ESTUDIOS

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

INCIDENCIA

80% DE CIRROTICOS 8% HTDA NO VARICEAL

HALLAZGO

Piel de serpiente Patron de eritema

DIAGNOSTICO

endoscopia

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

RESULTADOS

9 PACIENTES 3 PACIENTES

ESTUDIO DOBLE CIEGO

ENDOSCPIA

24 PACIENTES

PROPANOLOL PLACEBO

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

HEMORRAGIA

CESÓ 2N 13 PACIENTES 93%

EN TRES DIAS

14 PACIENTES CON HTP Y SANGRADO DIFUSO

PROPANOLOL 24 A 480 mg POR DIA

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

PROFILAXIS

PRIMARIA

INNECESARIA

SECUNDARIA

PROPANOLOL

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

DILATACION DE VASOS DE LA MUCOSA GASTROINTEESTINALFUERA DEL ESOFAGO Y ESTOMAGO

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

RESPONSABLE DEL 1-5% DEL SANGRADO

ENDOSCOPIA DIGESTIVA ALTA NEGATIVA

RESLIZAR COLONOSCOPIA

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.

1.- ESCLEROTERAPIA

2.- CIRUGIA

3.- TX. MEDICO

World J Gastroenterol 2013 August 21; 19(31): 5035-5050ISSN 1007-9327 (print) ISSN 2219-2840 (online)© 2013 Baishideng. All rights reserved.