hipertension portal y sangrado gastrico
TRANSCRIPT
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
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40% MUEREN
INFECCIONES
INSUFICIENCIA
HEPATICA
SANGRADO
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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
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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
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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
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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
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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
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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
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