pituitrin and Gastrointestinal-Hemorrhage

Vasoactive agents with endoscopic therapy are used to treat acute variceal bleeding (AVB). There are two main groups of vasoactive agents: terlipressin and vasopressin (T-V), and octreotide and somatostatin (O-S). However, the benefit/harm balance is unclear. Our aim was to assess the efficacy and safety of T-V versus O-S for the management of AVB.. We performed a systematic search for randomized controlled trials (RCTs) in PubMed, Scopus, and CENTRAL. Our main outcomes were mortality and adverse events. Secondary outcomes were bleeding control, rebleeding, blood transfusion, hospital stay. We evaluated the certainty of evidence using GRADE methodology.. We included 21 RCTs. The risk of mortality (RR: 1.01; 95%CI: 0.83-1.22), bleeding control (RR: 0.96; 95%CI: 0.91-1.02; I 2 =53%), early rebleeding (RR: 0.91; 95%CI: 0.66-1.24: I 2 =0%), late rebleeding (RR: 0.94; 95 CI: 0.56-1.60; I 2 =0%), blood transfusion (MD: 0.04; 95%CI: -0.31-0.39; I 2 =68%) and hospital stay (MD: -1.06; 95%CI: -2.80-0.69; I 2 =0%) were similar between T-V and O-S groups. Only 15 studies reported adverse events, which were significantly higher in the T-V compared to the O-S group (RR 2.39; 95%CI: 1.58-3.63; I 2 =57%). The certainty of evidence was moderate for the main outcomes, and low or very low for others.. In cirrhotic patients with AVB, those treated with T-V had similar mortality risk compared to O-S. However, the use of T-V showed an increased risk of adverse events compared to O-S.

Topics: Adult; Aged; Blood Transfusion; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Length of Stay; Liver Cirrhosis; Male; Middle Aged; Octreotide; Recurrence; Somatostatin; Terlipressin; Treatment Outcome; Vasopressins

Approximately 40% to 95% of people with liver cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed within about one to three years after diagnosis. Several different treatments are available, including, among others, endoscopic sclerotherapy, variceal band ligation, somatostatin analogues, vasopressin analogues, and balloon tamponade. However, there is uncertainty surrounding the individual and relative benefits and harms of these treatments.. To compare the benefits and harms of different initial treatments for variceal bleeding from oesophageal varices in adults with decompensated liver cirrhosis, through a network meta-analysis; and to generate rankings of the different treatments for acute bleeding oesophageal varices, according to their benefits and harms.. We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until 17 December 2019, to identify randomised clinical trials (RCTs) in people with cirrhosis and acute bleeding from oesophageal varices.. We included only RCTs (irrespective of language, blinding, or status) in adults with cirrhosis and acutely bleeding oesophageal varices. We excluded RCTs in which participants had bleeding only from gastric varices, those who failed previous treatment (refractory bleeding), those in whom initial haemostasis was achieved before inclusion into the trial, and those who had previously undergone liver transplantation.. We performed a network meta-analysis with OpenBUGS software, using Bayesian methods, and calculated the differences in treatments using odds ratios (OR) and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. We performed also the direct comparisons from RCTs using the same codes and the same technical details.. We included a total of 52 RCTs (4580 participants) in the review. Forty-eight trials (4042 participants) were included in one or more comparisons in the review. The trials that provided the information included people with cirrhosis due to varied aetiologies and those with and without a previous history of bleeding. We included outcomes assessed up to six weeks. All trials were at high risk of bias. A total of 19 interventions were compared in the trials (sclerotherapy, somatostatin analogues, vasopressin analogues, sclerotherapy plus somatostatin analogues, variceal band ligation, balloon tamponade, somatostatin analogues plus variceal band ligation, nitrates plus vasopressin analogues, no active intervention, sclerotherapy plus variceal band ligation, balloon tamponade plus sclerotherapy, balloon tamponade plus somatostatin analogues, balloon tamponade plus vasopressin analogues, variceal band ligation plus vasopressin analogues, balloon tamponade plus nitrates plus vasopressin analogues, balloon tamponade plus variceal band ligation, portocaval shunt, sclerotherapy plus transjugular intrahepatic portosystemic shunt (TIPS), and sclerotherapy plus vasopressin analogues). We have reported the effect estimates for the primary and secondary outcomes when there was evidence of differences between the interventions against the reference treatment of sclerotherapy, but reported the other results of the primary and secondary outcomes versus the reference treatment of sclerotherapy without the effect estimates when there was no evidence of differences in order to provide a concise summary of the results. Overall, 15.8% of the trial participants who received the reference treatment of sclerotherapy (chosen because this was the commonest treatment compared in the trials) died during the follow-up periods, which ranged from three days to six weeks. Based on moderate-certainty evidence, somatostatin analogues alone had higher mortality than sclerotherapy (OR 1.57, 95% CrI 1.04 to 2.41; network estimate; direct comparison: 4 trials; 353 participants) and vasopressin analogues alone had higher mortality than sclerotherapy (OR 1.70, 95% CrI 1.13 to 2.62; network estimate; direct comparison: 2 trials; 438 participants). None of the trials reported health-related quality of life. Based on low-certainty evidence, a higher proportion of people receiving balloon tamponade plus sclerotherapy had more serious adverse events than those receiving only sclerotherapy (OR 4.23, 95. Based on moderate-certainty evidence, somatostatin analogues alone and vasopressin analogues alone (with supportive therapy) probably result in increased mortality, compared to endoscopic sclerotherapy. Based on moderate-certainty evidence, vasopressin analogues alone and band ligation alone probably result in fewer adverse events compared to endoscopic sclerotherapy. Based on low-certainty evidence, balloon tamponade plus sclerotherapy may result in large increases in serious adverse events compared to sclerotherapy. Based on low-certainty evidence, sclerotherapy plus somatostatin analogues may result in large decreases in symptomatic rebleed compared to sclerotherapy. In the remaining comparisons, the evidence indicates considerable uncertainty about the effects of the interventions, compared to sclerotherapy.

Topics: Adult; Bayes Theorem; Bias; Combined Modality Therapy; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Ligation; Liver Cirrhosis; Network Meta-Analysis; Nitrates; Odds Ratio; Portasystemic Shunt, Transjugular Intrahepatic; Randomized Controlled Trials as Topic; Sclerotherapy; Somatostatin; Vasopressins

Acute variceal bleeding is a potentially life-threatening complication of portal hypertension. Management consists of emergent hemostasis, therapy directed at hemodynamic resuscitation, protection of the airway, and prevention and treatment of complications including prophylactic use of antibiotics. Endoscopic treatment remains the mainstay in the management of acute variceal bleeding in combination with pharmacotherapy aimed at reducing portal pressure. This article intends to highlight only the current nonendoscopic treatment approaches for control of acute variceal bleeding.

Topics: Acute Disease; Acute Kidney Injury; Anti-Bacterial Agents; Balloon Occlusion; Blood Transfusion; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hepatic Encephalopathy; Hormones; Humans; Hypertension, Portal; Intubation, Intratracheal; Liver Cirrhosis; Portasystemic Shunt, Transjugular Intrahepatic; Somatostatin; Vasoconstrictor Agents; Vasopressins

Vasoactive medications such as vasopressin, somatostatin and their analogues (terlipressin, vapreotide and octreotide) are commonly used for the treatment of acute variceal bleeding. However, the risks and benefits of these interventions are not well understood.. To undertake a meta-analysis of the efficacy of vasoactive medications in patients having acute variceal bleeds.. Randomised controlled trials (RCTs) of vasopressin, somatostatin and their analogues, administered to patients with acute variceal bleeds were identified based on systematic searches of nine electronic databases and multiple sources of grey literature.. The search identified 3011 citations, and 30 trials with a total of 3111 patients met eligibility criteria. The use of vasoactive agents was associated with a significantly lower risk of 7-day mortality (RR 0.74; 95% CI 0.57-0.95; P = 0.02; I(2) = 0%; moderate quality of evidence), and a significant improvement in haemostasis (RR 1.21, 95% CI 1.13-1.30; P < 0.001; I(2) = 28%; very low quality of evidence), lower transfusion requirements (pooled mean difference -0.70 units of blood transfused, 95% CI -1.01 to -0.38; P < 0.001; I(2) = 82%; moderate quality of evidence), and a shorter duration of hospitalisation (pooled mean difference -0.71 days; 95% CI -1.23 to -0.19; P = 0.007; I(2) = 0%; low quality of evidence). Studies comparing different vasoactive agents did not show a difference in efficacy, although the quality of evidence was very low.. The use of vasoactive agents was associated with a significantly lower risk of acute all-cause mortality and transfusion requirements, and improved control of bleeding and shorter hospital stay. Studies comparing different vasoactive medications failed to demonstrate a difference in efficacy.

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatics; Humans; Lypressin; Octreotide; Randomized Controlled Trials as Topic; Somatostatin; Terlipressin; Vasopressins

The use of catheter-based techniques to treat upper gastrointestinal hemorrhage has evolved considerably over the past few decades. At present, the state-of-the-art interventional suites provide optimal imaging. Coupled with advanced catheter technology, the two may be used to manage and treat the patient with acute upper gastrointestinal hemorrhage. This article summarizes these techniques and, when possible, compares them with other methods such as surgery and endoscopy. The specific role of transcatheter embolotherapy is highlighted, alongside an additional discussion on pharmacologic infusion of vasopressin.

Topics: Angiography; Embolization, Therapeutic; Endoscopy, Gastrointestinal; Gastrointestinal Hemorrhage; Humans; Radiography, Interventional; Upper Gastrointestinal Tract; Vasopressins

Emergency sclerotherapy is still widely used as a first line therapy for variceal bleeding in patients with cirrhosis, particularly when banding ligation is not available or feasible. However, pharmacological treatment may stop bleeding in the majority of these patients.. To assess the benefits and harms of emergency sclerotherapy versus vasoactive drugs for variceal bleeding in cirrhosis.. Search of trials was based on The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded through January 2010.. Randomised clinical trials comparing sclerotherapy with vasoactive drugs (vasopressin (with or without nitroglycerin), terlipressin, somatostatin, or octreotide) for acute variceal bleeding in cirrhotic patients.. Outcome measures were failure to control bleeding, five-day treatment failure, rebleeding, mortality, number of blood transfusions, and adverse events. Data were analysed by a random-effects model according to the vasoactive treatment. Sensitivity analyses included combined analysis of all the trials irrespective of the vasoactive drug, type of publication, and risk of bias.. Seventeen trials including 1817 patients were identified. Vasoactive drugs were vasopressin (one trial), terlipressin (one trial), somatostatin (five trials), and octreotide (ten trials). No significant differences were found comparing sclerotherapy with each vasoactive drug for any outcome. Combining all the trials irrespective of the vasoactive drug, the risk differences (95% confidence intervals) were failure to control bleeding -0.02 (-0.06 to 0.02), five-day failure rate -0.05 (-0.10 to 0.01), rebleeding 0.01 (-0.03 to 0.05), mortality (17 randomised trials, 1817 patients) -0.02 (-0.06 to 0.02), and transfused blood units (8 randomised trials, 849 patients) (weighted mean difference) -0.24 (-0.54 to 0.07). Adverse events 0.08 (0.03 to 0.14) and serious adverse events 0.05 (0.02 to 0.08) were significantly more frequent with sclerotherapy.. We found no convincing evidence to support the use of emergency sclerotherapy for variceal bleeding in cirrhosis as the first, single treatment when compared with vasoactive drugs. Vasoactive drugs may be safe and effective whenever endoscopic therapy is not promptly available and seems to be associated with less adverse events than emergency sclerotherapy. Other meta-analyses and guidelines advocate that combined vasoactive drugs and endoscopic therapy is superior to either intervention alone.

Topics: Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatics; Humans; Liver Cirrhosis; Lypressin; Octreotide; Sclerotherapy; Somatostatin; Terlipressin; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Gastroesophageal variceal hemorrhage is a major complication of portal hypertension in 50% to 60% of patients with liver cirrhosis and is a frequent cause of mortality in these patients. The prevalence of variceal hemorrhage is approximately 5% to 15% yearly, and early variceal rebleeding has a rate of occurrence of 30% to 40% within the first 6 weeks. More than 50% of patients who survive after the first bleeding episode will experience recurrent bleeding within 1 year. Management of gastroesophageal varices should include prevention of initial and recurrent bleeding episodes and control of active hemorrhage. Therapies used in the management of gastroesophageal variceal hemorrhage may include pharmacologic therapy (vasoactive agents, nonselective b-blockers, and antibiotic prophylaxis), endoscopic therapy, transjugular intrahepatic portosystemic shunt, and shunt surgery. This article focuses primarily on pharmacologic management of acute variceal hemorrhage.

Topics: End Stage Liver Disease; Esophageal and Gastric Varices; Gastrointestinal Agents; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis; Octreotide; Primary Prevention; Prognosis; Proton Pump Inhibitors; Recurrence; Risk Factors; Sclerotherapy; Severity of Illness Index; Vasoconstrictor Agents; Vasopressins

Portal hypertension is a progressively debilitating complication of cirrhosis and a principal cause of mortality in patients who have hepatic decompensation. This article describes the classification system and pathophysiology of portal hypertension. It also discusses a practical approach to prevention of first variceal hemorrhage, general management of the acute bleeding episode, and secondary prophylaxis to prevent rebleeding. Pharmacologic, endoscopic, radiologic, and surgical modalities are all described in detail.

Topics: Algorithms; Endoscopy, Gastrointestinal; Esophageal and Gastric Varices; Gastrointestinal Agents; Gastrointestinal Hemorrhage; Hemodynamics; Humans; Hypertension, Portal; Liver Cirrhosis; Octreotide; Portal System; Primary Prevention; Secondary Prevention; Vasoconstrictor Agents; Vasopressins

Although most cases of acute gastrointestinal (GI) hemorrhage either spontaneously resolve or respond to medical management and/or endoscopic treatment, there remain a significant number of patients who require emergency evaluation and treatment by the interventional radiologist. Any angiographic evaluation should begin with selective catheterization of the artery supplying the most likely site of bleeding, as determined by the available clinical, endoscopic, and imaging data. If a source of hemorrhage is identified, superselective catheterization followed by transcatheter embolization with microcoils is the most effective means of successfully controlling hemorrhage while minimizing potential complications. This is now well-recognized as a viable and safe alternative to emergency surgery. In selected situations transcatheter intra-arterial infusion of vasopressin may also be useful in controlling acute GI bleeding. One must be aware of the various side effects and potential complications associated with this treatment, however, and recognize the high rebleeding rate. In this article, we review the current role of angiography, transcatheter arterial embolization, and infusion therapy in the evaluation and management of GI hemorrhage.

Topics: Acute Disease; Angiography, Digital Subtraction; Embolization, Therapeutic; Emergency Treatment; Gastrointestinal Hemorrhage; Hemostatic Techniques; Hemostatics; Humans; Infusions, Intra-Arterial; Predictive Value of Tests; Radiography, Interventional; Recurrence; Tomography, X-Ray Computed; Treatment Outcome; Vasopressins

Bleeding of oesophageal varices and hepatorenal syndrome are most dramatic complications in gastroenterology. They develop in consequence of progressively increasing blood flow entering the vasodilated splanchnic bed and the portal vein where blood flow meets intrahepatic resistance. Porto-systemic collateral veins are formed to bypass the cirrhotic liver. Intravascular pressure is very high in these collaterals, causing the venous walls to expand into esophageal varices, which eventually may rupture and bleed. This splanchnic blood pooling generates hypovolemia in the central and arterial system, initiating activation of the renin-angiotensin-aldosteron and sympathetic nervous system. These compensatory mechanisms induce renal vasoconstriction, followed by hypoperfusion of the kidneys and development of hepatorenal syndrome. Vasoconstrictors like terlipressin inhibit splanchnic blood flow, thus reducing portal and variceal pressure, which is followed by termination ofvariceal bleeding, by normalization of central and arterial blood volume and by an improvement of kidney function and hepatorenal syndrome.

Topics: Animals; Blood Circulation; Gastrointestinal Hemorrhage; Hepatorenal Syndrome; Humans; Hypovolemia; Liver Cirrhosis; Lypressin; Splanchnic Circulation; Terlipressin; Vasoconstrictor Agents; Vasopressins

Portal hypertension, a major hallmark of cirrhosis, is defined as a portal pressure gradient exceeding 5 mm Hg. In portal hypertension, porto-systemic collaterals decompress the portal circulation and give rise to varices. Successful management of portal hypertension and its complications requires knowledge of the underlying pathophysiology, the pertinent anatomy, and the natural history of the collateral circulation, particularly the gastroesophageal varices.

Topics: Collateral Circulation; Dilatation, Pathologic; Endoscopy, Gastrointestinal; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatics; Humans; Hypertension, Portal; Ligation; Portasystemic Shunt, Transjugular Intrahepatic; Pyloric Antrum; Risk Factors; Sclerotherapy; Vasopressins

Cirrhosis results in portal hypertension in many patients. The major complications of portal hypertension include development of ascites and esophageal or gastric varices. Varices lead to hemorrhage and death in a significant proportion of patients. This review focuses on the pharmacologic approach to management of portal hypertension in patients at risk of variceal hemorrhage, or those who have already had variceal bleeding. Pharmacologic therapy is used for 1) primary prevention of bleeding, 2) management of acute bleeding, and 3) prevention of recurrent bleeding (secondary prophylaxis). For acute esophageal variceal hemorrhage, a variety of pharmacologic agents are used, including somatostatin, octreotide, vapreotide, lanreotide, terlipressin, and vasopressin (with nitrates). For primary and secondary prevention of esophageal variceal hemorrhage, beta-blockers remain the mainstay therapy.

Topics: Adrenergic beta-Antagonists; Algorithms; Antihypertensive Agents; Cardiovascular Agents; Esophageal and Gastric Varices; Esophagoscopy; Gastrointestinal Hemorrhage; Hemostatics; Humans; Hypertension, Portal; Ligation; Liver Cirrhosis; Nitrates; Portasystemic Shunt, Transjugular Intrahepatic; Recurrence; Sclerotherapy; Somatostatin; Vasoconstrictor Agents; Vasopressins

Variceal bleeding is a severe complication of cirrhosis leading to significant morbidity and mortality. Treatment of acute variceal bleeding has improved dramatically since the era of the mechanical balloon tamponade. These advances include endoscopic band ligation or sclerotherapy, and vasoactive pharmacological options such as somatostatin, octreotide, vasopressin and terlipressin. Evidence from a multitude of clinical trials and meta-analyses comparing endoscopic and pharmacological treatments suggests near equivalence in efficacy for initial hemostasis, mortality and rate of rebleeding. This raises the question of whether on-call gastroenterologists should be performing emergency endoscopic treatment in the middle of the night or start pharmacological treatment and delay endoscopy until optimal patient and working conditions the next morning. The present review analyzes the available comparative data between endoscopic and pharmacological treatment options. Although the literature cannot yet definitively answer the question posed, the authors suggest that delaying endoscopic treatment until the next morning may be the most reasonable practical approach.

Topics: Critical Illness; Emergency Treatment; Esophageal and Gastric Varices; Female; Follow-Up Studies; Gastrointestinal Hemorrhage; Hemostasis, Endoscopic; Hemostatics; Humans; Ligation; Male; Octreotide; Risk Assessment; Sclerotherapy; Survival Analysis; Time Factors; Treatment Outcome; Vasopressins

Portal hypertension is one of the main consequences of cirrhosis. It results from a combination of increased intrahepatic vascular resistance and increased blood flow through the portal venous system. The condition leads to the formation of portosystemic collateral veins. Esophagogastric varices have the greatest clinical impact, with a risk of bleeding as high as 30% within 2 years of medium or large varices developing. Ascites, another important complication of advanced cirrhosis and severe portal hypertension, is sometimes refractory to treatment and is complicated by spontaneous bacterial peritonitis and hepatorenal syndrome. We describe the pathophysiology of portal hypertension and the current management of its complications, with emphasis on the prophylaxis and treatment of variceal bleeding and ascites.

Topics: Algorithms; Anti-Bacterial Agents; Ascites; Collateral Circulation; Diuretics; Endoscopy, Gastrointestinal; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hepatorenal Syndrome; Hormones; Hypertension, Portal; Liver Cirrhosis; Lypressin; Peritonitis; Portasystemic Shunt, Transjugular Intrahepatic; Sclerotherapy; Secondary Prevention; Somatostatin; Spironolactone; Terlipressin; Vascular Resistance; Vasoconstrictor Agents; Vasodilation; Vasopressins

Somatostatin and its analogues have been compared with a variety of other treatments for the treatment of variceal bleeding in cirrhotic patients. Meta-analyses of studies comparing somatostatin or octreotide with vasopressin or terlipressin have shown that somatostatin is somewhat superior to vasopressin and equivalent to terlipressin in controlling bleeding and has significantly fewer side effects; no difference in mortality was observed. Octreotide was somewhat better than vasopressin and terlipressin in controlling bleeding, with similar mortality. Meta-analysis of trials comparing somatostatin or octreotide with endoscopic sclerotherapy shows that both drugs are equivalent to sclerotherapy for bleeding control, early rebleeding and survival. Complications are much less frequent with drug treatment. Nine trials have compared endoscopic therapy with therapeutic regimens combining endoscopic treatment with somatostatin, octreotide or vapreotide. Meta-analysis show that the combined regimens increase the 5 days bleeding control rate of endoscopic treatments by over 20%, although there is no difference in mortality. Comparisons of somatostatin and octreotide with combined regimens of sclerotherapy + somatostatin and sclerotherapy + octreotide have shown that the combined regimens were better than drug treatments alone in controlling bleeding and preventing early rebleeding, while complications were significantly less frequent with drug therapy.

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Lypressin; Octreotide; Sclerotherapy; Somatostatin; Terlipressin; Vasoconstrictor Agents; Vasopressins

Topics: Acute Disease; Esophageal and Gastric Varices; Esophageal Diseases; Gastrointestinal Hemorrhage; Humans; Lypressin; Rupture, Spontaneous; Somatostatin; Terlipressin; Vasoconstrictor Agents; Vasopressins

Modern transcatheter embolization has emerged as a viable option for the treatment of lower gastrointestinal (LGI) hemorrhage. Over the last decade, steady data has accumulated showing the safety and effectiveness of superselective microcoil embolization within the colon. In light of such results, the application of microcatheter-based skills has become more important in an algorithm for managing LGI bleeding. The purpose of this article is to discuss the modern embolization technique while also reviewing traditional and experimental transcatheter methods that may prove useful in the appropriate clinical settings. While recognizing that transcatheter therapy continues to evolve, the proposed indications for these current treatments are reviewed.

Topics: Angiography, Digital Subtraction; Blood Platelets; Catheterization; Embolization, Therapeutic; Gastrointestinal Hemorrhage; Hemostatics; Humans; Lower Gastrointestinal Tract; Vasopressins

A POTENTIALLY SEVERE EVENT: Upper gastrointestinal haemorrhage in a cirrhotic patient is always extremely serious, particularly in the case of rupture of the oesophageal varices, which is the most frequent cause. THE TWO POLES OF TREATMENT: Early vasoactive treatment permits elastic ligature in optimal conditions using an endoscope. The prevention of other complications of cirrhosis is an essential element in the management of these patients.

Topics: Acute Disease; Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostasis, Endoscopic; Hemostatics; Hepatic Encephalopathy; Hormones; Humans; Hypertension, Portal; Ligation; Liver Cirrhosis; Octreotide; Recurrence; Risk Factors; Rupture; Sclerotherapy; Shock, Hemorrhagic; Somatostatin; Vasopressins

Emergency sclerotherapy is used as a first-line therapy for variceal bleeding in cirrhosis, although pharmacologic treatment stops bleeding in most patients. We performed a meta-analysis comparing emergency sclerotherapy with pharmacologic treatment.. MEDLINE (1968-2002), EMBASE (1986-2002), and the Cochrane Library (2002;4) were searched to retrieve randomized controlled trials comparing sclerotherapy with vasopressin (+/- nitroglycerin), terlipressin, somatostatin, or octreotide for variceal bleeding in cirrhosis. Outcome measures were failure to control bleeding, rebleeding, blood transfusions, adverse events, and mortality.. Fifteen trials were identified. Sclerotherapy was not superior to terlipressin, somatostatin, or octreotide for any outcome and to vasopressin for rebleeding, blood transfusions, death, and adverse events; it was superior to vasopressin for the control of bleeding in a single trial flawed by a potential detection bias. Sclerotherapy was associated with significantly more adverse events than somatostatin. In a predefined sensitivity analysis, combining all of the trials irrespective of the control treatment, risk differences (sclerotherapy minus control) and confidence intervals (CIs) were as follows: failure to control bleeding, -0.03 (-0.06 to 0.01); mortality, -0.035 (-0.07 to 0.008); adverse events, 0.08 (0.02 to 0.14). Mortality risk difference was -0.01 (-0.07 to 0.04) in good-quality trials and -0.08 (-0.14 to -0.02) in poor-quality trials.. Available evidence does not support emergency sclerotherapy as the first-line treatment of variceal bleeding in cirrhosis when compared with vasoactive drugs, which control bleeding in 83% of patients. Therefore, endoscopic therapy might be added only in pharmacologic treatment failures.

Topics: Acute Disease; Emergency Medical Services; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatics; Hormones; Humans; Liver Cirrhosis; Lypressin; Octreotide; Randomized Controlled Trials as Topic; Sclerotherapy; Somatostatin; Terlipressin; Vasoconstrictor Agents; Vasopressins

Traditionally, embolization has been reserved for treatment of upper gastrointestinal bleeding whereas lower gastrointestinal (LGI) bleeding has been controlled with vasopressin infusion. This is based on findings in older literature in which infarction frequently complicated LGI embolization. With modern embolization techniques, clinically significant bowel ischemia has become an uncommon complication. Although the efficacies of vasopressin and embolization are fairly comparable, embolotherapy has advantages in terms of quicker completion of therapy and decreased likelihood of systemic complications. Although vasopressin is still probably preferable for diffuse lesions and cases in which superselective catheterization is not technically possible, embolization should be considered a primary option for treating LGI bleeding.

Topics: Embolization, Therapeutic; Gastrointestinal Hemorrhage; Hemostatics; Humans; Infusions, Intra-Arterial; Mesenteric Arteries; Radiography, Interventional; Vasopressins

Variceal haemorrhage is a common medical emergency with a high mortality (30-50%). Adequate resuscitation is vital, and once stabilised the patient should be moved to a high-dependency area. Antibiotics reduce mortality, and the vasoactive drug terlipressin should be administered if early endoscopy is unavailable. Early endoscopy is essential both to make the diagnosis and to allow therapeutic measures to be performed. The evidence suggests that variceal band ligation is the most effective therapy for oesophageal varices. If gastric varices are found at the index endoscopy the evidence at present is inadequate to be certain which is the best treatment, but both endoscopic therapy with cyanoacrylate or thrombin and transjugular intrahepatic portosystemic stent shunt (TIPSS) have been reported to be of benefit. When initial treatments fail, rescue therapy should be initiated. Most authorities agree that TIPSS is the rescue therapy of choice. Many questions remain concerning the treatment of acute variceal bleeding, particularly the ideal therapy for gastric varices and the role of combination vasoactive and endoscopic therapy. Randomised controlled trials are required to answer these important issues.

Topics: Acute Disease; Catheterization; Endoscopy, Gastrointestinal; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatics; Hormones; Humans; Ligation; Lypressin; Octreotide; Portasystemic Shunt, Surgical; Randomized Controlled Trials as Topic; Recurrence; Sclerotherapy; Somatostatin; Terlipressin; Vasoconstrictor Agents; Vasopressins

The treatment of arterial gastrointestinal hemorrhage continues to evolve. Currently, most interventional radiologists approach bleeding both in the upper and lower gastrointestinal tract with intention to treat. Embolization has replaced local vasoconstrictive therapy as the catheter-based treatment of choice in many hospitals. Coaxial microcatheters have simplified embolotherapy and enabled lower gastrointestinal bleeding to be treated safely and effectively.

Topics: Acute Disease; Embolization, Therapeutic; Female; Gastrointestinal Hemorrhage; Hemostasis, Endoscopic; Hemostatics; Humans; Male; Mesenteric Arteries; Radiography; Vasopressins

Endoscopic therapy and in particular endoscopic variceal banding ligation, in experienced hands, is the treatment of choice for acute variceal bleeding which remains a major cause of death in patients with cirrhosis and portal hypertension. Pharmacological therapy with Glypressin or somatostatin can be useful to gain time when the endoscopic expertise is not available or to help to obtain a clearer endoscopic view. Transjugular intrahepatic porto-systemic stent shunt is currently used for endoscopic failures, producing similar results with the surgical portacaval shunts. Which one of the two should be preferred, since they both work best in relatively compensated patients, should be a balance between the available surgical and radiological expertise, the urgency of the situation and the expected course of the disease.

Topics: Endoscopy; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hormones; Humans; Lypressin; Portasystemic Shunt, Transjugular Intrahepatic; Resuscitation; Sclerotherapy; Somatostatin; Terlipressin; Vasoconstrictor Agents; Vasopressins

Topics: Adrenergic beta-Antagonists; Antihypertensive Agents; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Gastroscopy; Humans; Hypertension, Portal; Lypressin; Research; Somatostatin; Terlipressin; Vasopressins

Beta-blockers are the treatment of choice to prevent the first episode of variceal bleeding and further rebleeding episodes. In acute bleeding all patients should receive pharmacological treatment with vasoconstrictors and endoscopic treatment. Failure of therapy should lead to consideration of transjugular intrahepatic portosystemic shunting.

Topics: Adrenergic beta-Antagonists; Anti-Bacterial Agents; Clinical Protocols; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Ligation; Octreotide; Portasystemic Shunt, Transjugular Intrahepatic; Sclerotherapy; Somatostatin; Vasopressins

The risk of recurrent variceal bleeding after an acute episode of bleeding has been controlled in significant with rebleeding rates as high as 80% between one and two years. Pharmacologic therapy has a definite role in the prevention of recurrent variceal bleeding and should be started as soon as the acute bleeding event has been controlled. Serial hemodynamic measurements are critical for success. Non-selective beta-blocker therapy is a reasonable first line approach followed by the addition of a long-acting nitrate for patients not achieving a 20% reduction in the hepatic venous pressure gradient. Most patients will require combination pharmacotherapy or combined endoscopic therapy with pharmacotherapy.

Topics: Acute Disease; Antihypertensive Agents; Blood Flow Velocity; Drug Therapy, Combination; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hormones; Humans; Liver Circulation; Lypressin; Nitroglycerin; Portal Pressure; Risk Factors; Somatostatin; Terlipressin; Treatment Outcome; Vasoconstrictor Agents; Vasodilator Agents; Vasopressins

The search for new pharmaceutical treatments has led to the isolation of products from a range of natural sources. Analogues synthesized from these products may possess an improved therapeutic effect over their natural counterparts. Two natural peptides, vasopressin and somatostatin, possess pronounced in vivo effects, so do their analogues terlipressin and octreotide. Vasopressin is a powerful vasopressor, reducing portal pressure, and has been used to treat gastrointestinal haemorrhages. However, a number of adverse cardiovascular effects resulting from an increase in peripheral vascular resistance have been associated with this drug. Terlipressin, however, is more effective, has an improved safety profile and is associated with fewer side effects than vasopressin. Somatostatin, a growth regulatory hormone, achieves haemostasis by decreasing splanchnic blood flow, and is effective in preventing early rebleeding. Somatostatin is effective in treating bleeding oesophageal varices (BOV) and is associated with fewer and more transient side effects than terlipressin. Octreotide, however, has greater stability and a longer half-life than somatostatin, but has a less favourable safety profile. Octreotide displays a number of therapeutic advantages over somatostatin, but not in the treatment of gastrointestinal indications. The development of terlipressin from vasopressin has demonstrated a number of clinical advantages, while the development of octreotide from somatostatin has not shown any significant advantage in the treatment of BOV.

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Lypressin; Octreotide; Somatostatin; Terlipressin; Vasoconstrictor Agents; Vasopressins

Various treatment strategies have been used to control variceal bleeding, including drugs, esophageal tamponade, endoscopic sclerotherapy (ES), endoscopic variceal ligation, transjugular intrahepatic portosystemic shunt and emergency surgery. None of these procedures are ideal and treatment frequently requires a combination of techniques. Sclerotherapy is one of the most widely used methods to control variceal bleeding; however, success is largely dependent on an experienced endoscopist. Vasoactive drugs act by decreasing pressure and blood flow in the gastroesophageal collaterals and they offer the advantage of being administered by inexperienced personnel. Drugs currently used in the treatment of variceal hemorrhage include vasopressin, terlipressin, somatostatin and octreotide. In the clinical studies to date, somatostatin was more effective than vasopressin and as effective as terlipressin in the control of bleeding esophageal varices (BEV), with an improved safety profile. In contrast, octreotide has shown conflicting results and more data are required to support the drug in this indication. More recently the ABOVE (Acute Bleeding Esophageal Variceal Episodes) study has provided further evidence that early administration of vasoactive drugs such as somatostatin is significantly more effective than placebo in the overall control of acute BEV episodes in cirrhotic patients undergoing ES. Therefore, the administration of a vasoactive drug as early as possible before emergency sclerotherapy is recommended for the effective management of BEV.

Topics: Esophageal and Gastric Varices; Esophagoscopy; Gastrointestinal Hemorrhage; Humans; Lypressin; Randomized Controlled Trials as Topic; Sclerotherapy; Somatostatin; Terlipressin; Vasoconstrictor Agents; Vasopressins

Topics: Animals; Disease Models, Animal; Gastrointestinal Agents; Gastrointestinal Hemorrhage; Hemodynamics; Hormone Antagonists; Humans; Hypertension, Portal; Octreotide; Somatostatin; Vasoconstrictor Agents; Vasopressins

Topics: Domperidone; Esophageal and Gastric Varices; Gastrointestinal Agents; Gastrointestinal Hemorrhage; Humans; Lypressin; Metoclopramide; Octreotide; Randomized Controlled Trials as Topic; Sclerosing Solutions; Sclerotherapy; Somatostatin; Terlipressin; Vasopressins

Endoscopic injection sclerotherapy and/or endoscopic variceal ligation are well accepted and established in the treatment of bleeding esophageal varices. Endoscopic treatment for bleeding gastric varices is behind in hemostatic rate by 5% ethanolamine oleate as sclerosant. However, since cyanoacrylate is employed as endoscopic injection sclerosant, hemostatic rate was greatly improved especially for the bleeding large gastric varices. In addition angiographic sclerotherapy (balloon occluded retrograde transvenous obliteration) is highly effective for large gastric fundal varices and no rebleeding is expected when successfully done. Endoscopic and angiographic sclerotherapy made great improvement in the treatment of esophagogastric varices.

Topics: Cyanoacrylates; Endoscopy, Gastrointestinal; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostasis, Endoscopic; Histamine H2 Antagonists; Humans; Ligation; Oleic Acids; Sclerosing Solutions; Sclerotherapy; Vasoconstrictor Agents; Vasopressins

Acute bleeding due to esophageal varices continues to be a life-threatening complication of liver disease. Despite the availability of improved therapy, mortality continues to be high. Octreotide has been shown to be at least as effective as vasopressin in the treatment of bleeding varices, with fewer and less severe systemic adverse effects. In addition, octreotide has also been consistently associated with a decreased need for transfusions. Octreotide has been used safely in patients without serious cardiovascular disease when administered as a continuous intravenous infusion of 25 micrograms/h for 24 hours with or without an initial 100-micrograms bolus dose. Since these trials have used small numbers of patients, the ability to detect small but clinically important differences has been limited. Additional controlled trials comparing octreotide with the combination of vasopressin and nitroglycerin are needed to more clearly determine the efficacy and cost-effectiveness of therapy. Furthermore, the optimal dosage, duration, and route of administration of octreotide in the treatment of bleeding esophageal varices has yet to be determined.

Topics: Clinical Trials as Topic; Esophageal and Gastric Varices; Gastrointestinal Agents; Gastrointestinal Hemorrhage; Hemostatics; Humans; Liver Diseases; Octreotide; Vasopressins

Bleeding from esophageal varices presents a considerable challenge to clinicians. Adequate fluid resuscitation must be undertaken before urgent endoscopy. Pharmacotherapy of acute variceal hemorrhage consists of either vasopressin plus nitroglycerin or intravenous octreotide. Vasopressin should not be used alone because of a high incidence of side effects such as cardiac and/or visceral ischemia. Band ligation appears superior to sclerotherapy primarily because of decreased rebleeding from varices and decreased esophageal stricture formation among patients undergoing band ligation. Future trials with newer sclerosant agents, such as cyanoacrylate, are anxiously awaited.

Topics: Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Hemostasis, Endoscopic; Hemostatics; Hormones; Humans; Middle Aged; Nitroglycerin; Octreotide; Sclerotherapy; Vasopressins

Topics: Enbucrilate; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostasis, Endoscopic; Hemostatics; Humans; Ligation; Lypressin; Octreotide; Portasystemic Shunt, Surgical; Sclerotherapy; Somatostatin; Stents; Terlipressin; Tissue Adhesives; Vasopressins

Management of variceal hemorrhage is complex and can be difficult. Initially, the severity of the bleeding episode must be assessed and the intravascular volume repleted. Several treatment options are available. A trial of pharmacologic therapy (eg, vasopressin) may control acute bleeding. Temporary balloon tamponade of varices is helpful if bleeding continues. Endoscopic sclerotherapy and variceal ligation appear to be equally beneficial, although fewer complications have been reported with the latter. Transjugular intrahepatic portacaval shunt (TIPS) and portal-systemic shunt surgery are alternatives when endoscopic therapy fails; TIPS is preferred in patients awaiting liver transplantation. Ultimately, the choice of treatment is based on the expertise available at each medical center.

Topics: Balloon Occlusion; Catheterization; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Ligation; Portacaval Shunt, Surgical; Portasystemic Shunt, Surgical; Sclerotherapy; Vasopressins

Topics: Adrenergic beta-Antagonists; Animals; Dogs; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Lypressin; Nitroprusside; Pituitary Hormones, Posterior; Recurrence; Somatostatin; Terlipressin; Vasopressins

Although sclerotherapy is the current standard therapy for bleeding esophageal varices, the best method for initial control is unclear. The aim of this meta-analysis was to compare the efficacy and toxicity of somatostatin and vasopressin in short-term treatment of hemorrhage from esophageal varices.. Using MEDLINE, all randomized trials comparing somatostatin with vasopressin in subjects with endoscopically documented acute esophageal variceal bleeding were identified. The quality of each study was critically and independently evaluated, and quantitative data for initial cessation of bleeding, sustained control of bleeding, and major adverse effects were abstracted. The relative risk (RR) and number needed to be treated were calculated.. The RR or likelihood of achieving initial control of bleeding with somatostatin vs. vasopressin was 1.62 (95% confidence interval [CI], 1.37-1.93), and the number needed to be treated was 3.7, i.e., between 3 and 4 patients would have to be treated with somatostatin for 1 patient to derive additional benefit over vasopressin. For trials that measured sustained control of bleeding, somatostatin was superior to vasopressin (RR, 1.28 [95% CI, 1.00-1.65]; number needed to be treated, 8.8). The risk of adverse effects was greater for subjects given vasopressin (10% vs. 0%; P = 0.00007).. This meta-analysis suggests that somatostatin is more efficacious in controlling acute hemorrhage from esophageal varices and has a lower risk of adverse effects than vasopressin.

Topics: Acute Disease; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatics; Humans; Research Design; Somatostatin; Treatment Outcome; Vasopressins

The role of angiography in acute upper GI tract bleeding is less a diagnostic than a therapeutic one because it provides a guide to selective embolization of either the left gastric artery, or the gastroduodenal artery and its two principal branches, the pancreaticoduodenal and the right gastroepiploic artery. Angiographic catheter techniques may also provide substantial diagnostic and therapeutic support for the management of acute lower GI bleeding from a variety of bleeding sources. The advantages are minimal invasion and relatively low risk. The intermittent nature of GI bleeding often interferes with the ability of angiography to demonstrate the source of bleeding. However, at times angiographic techniques provide the only reasonable means of localizing and controlling bleeding.

Topics: Adult; Aged; Aged, 80 and over; Diagnostic Imaging; Female; Gastrointestinal Hemorrhage; Humans; Male; Middle Aged; Radiology, Interventional; Vasopressins

Topics: Acute Disease; Catheterization; Endoscopy, Gastrointestinal; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis; Liver Transplantation; Portasystemic Shunt, Surgical; Radiography; Rupture, Spontaneous; Sclerotherapy; Somatostatin; Vasopressins

Topics: Adrenergic beta-Antagonists; Antihypertensive Agents; Catheterization; Clinical Trials as Topic; Diuretics; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Lypressin; Metoclopramide; Molsidomine; Octreotide; Portasystemic Shunt, Surgical; Sclerotherapy; Somatostatin; Terlipressin; Vasodilator Agents; Vasopressins

The option of using direct compression to arrest haemorrhage from an oesophageal varix was introduced by Westphal in 1930. Since then, different types of oesophageal and or gastric balloons have become available for use. The published data concerning the efficacy and complications of the balloon tamponade in the treatment of variceal haemorrhage is evaluated. METHOD-RESULTS: Balloon tamponade as a single therapy may control initial variceal haemorrhage in more than 80% of cases. However, haemostasis is usually transient and is associated with a high rate of complications. As regards the comparison of balloon tamponade with vasoactive drugs such as vasopressin alone or vasopressin + terlipressin or terlipressin + nitroglycerin, it appears that both regimens are comparable in respect to initial control of bleeding, rebleeding, mortality, and complications. There is also evidence suggesting that balloon tamponade is as equally effective as octreotide and somatostatin in the initial control of variceal haemorrhage, but early rebleeding and complications are significantly less with the administration of both drugs. Finally, it appears that balloon tamponade is inferior to endoscopic sclerotherapy in both the acute and the long-term control of variceal haemorrhage.. Balloon tamponade should be reserved for those patients with variceal haemorrhage in whom bleeding continues despite conservative treatment, or as the first form of treatment only if sclerotherapy is not available.

Topics: Balloon Occlusion; Catheterization; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Lypressin; Nitroglycerin; Recurrence; Sclerotherapy; Terlipressin; Vasopressins

Numerous conditions lead to portal hypertension with the development of esophageal varices. Treatment for acute variceal hemorrhage should progress in a logical, stepwise fashion. Therapy after fluid resuscitation includes vasopressin, somatostatin, or a Sengstaken-Blakemore tube. This is followed by treatment with sclerotherapy, variceal ligation, or a combination of both. Continued bleeding is managed by more invasive measures that include radiologic embolization or shunting, esophageal transection, distal splenorenal shunt, or liver transplantation. Beta-blockade may be useful to prevent recurrent bleeding in compliant patients without medical conditions that would preclude use of beta-blockade. Once control of the bleeding has been achieved, sclerotherapy or ligation should be used to obliterate the varices, but prophylactic use of sclerosant is not particularly beneficial.

Topics: Adrenergic beta-Antagonists; Combined Modality Therapy; Embolization, Therapeutic; Esophageal and Gastric Varices; Esophagoscopy; Gastrointestinal Hemorrhage; Humans; Intubation, Gastrointestinal; Ligation; Liver Transplantation; Portasystemic Shunt, Surgical; Randomized Controlled Trials as Topic; Sclerotherapy; Somatostatin; Vasopressins

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Recurrence; Somatostatin; Vasoconstrictor Agents; Vasopressins

Topics: Drug Therapy, Combination; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemodynamics; Humans; Hypertension, Portal; Lypressin; Nitro Compounds; Sclerotherapy; Terlipressin; Vasopressins

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Octreotide; Randomized Controlled Trials as Topic; Somatostatin; Vasopressins

Topics: Clinical Trials as Topic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hospital Mortality; Humans; Ligation; Octreotide; Portasystemic Shunt, Surgical; Prognosis; Sclerotherapy; Stents; Vasopressins

Topics: Drug Therapy, Combination; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Middle Aged; Nitroglycerin; Portal Pressure; Randomized Controlled Trials as Topic; Vasopressins

Topics: Angiography; Embolization, Therapeutic; Endoscopy, Gastrointestinal; Gastrointestinal Hemorrhage; Humans; Intestine, Large; Intestine, Small; Vasopressins

We describe the case of a patient with hepatic cirrhosis treated with an intravenous infusion of vasopressin to control an upper digestive hemorrhage, who developed distance cutaneous necrosis and rhabdomyolysis. We review the other cases published in the international scientific literature and we discuss the possible pathogeny of these complications.

Topics: Gastrointestinal Hemorrhage; Humans; Infusions, Intravenous; Liver Cirrhosis, Alcoholic; Male; Middle Aged; Necrosis; Rhabdomyolysis; Skin; Vasopressins

Once the bleeding patient has been resuscitated and the diagnosis of acute variceal hemorrhage established by endoscopy, emergency injection sclerotherapy should be employed as the therapeutic option of choice. Endoscopic band ligation is a promising new technique that may prove to be as effective as sclerotherapy, with fewer complications. Pharmacologic treatment (with vasopressin and nitroglycerin) and balloon tamponade remain important alternative treatments, both as empiric temporizing therapy before sclerotherapy can be arranged and in the approximately 30% of patients who continue to bleed after a single sclerotherapy session. Continued bleeding in many of these patients can be controlled with a second session of sclerotherapy. If active acute bleeding persists after two sclerotherapy treatments, treatment should be considered a failure. Some of these patients may be suitable for surgical treatment with either staple-gun transection of the esophagus or emergency portacaval shunting.

Topics: Acute Disease; Balloon Occlusion; Catheterization; Drug Administration Schedule; Emergencies; Endoscopy, Gastrointestinal; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Ligation; Nitroglycerin; Portacaval Shunt, Surgical; Sclerotherapy; Somatostatin; Vasopressins

Variceal formation and rupture are dreaded complications of chronic liver disease and portal hypertension. The pharmacologic treatment of portal hypertension should be able to stop as well as to prevent variceal hemorrhage. There are two principal types of vasoactive drugs in the treatment of portal hypertension: vasoconstrictors and vasodilators. Vasoconstrictors reduce the splanchnic blood flow, thereby decreasing the portal blood flow and portal pressure. Vasodilators act by different mechanisms, including by relaxation of myofibroblasts in the fibrous septa and presinusoidal areas of the liver and by direct vasodilation of the collateral circulation. In addition, paradoxically, they could decrease portal flow and pressure by inducing a baroreflex-mediated mesenteric arterial vasoconstriction. A miscellaneous group of drugs is also available. These drugs reduce the blood flow and pressure in the gastroesophageal variceal system by mechanisms other than vasoconstriction or vasodilation. The success of these pharmacologic agents is limited once the varices have ruptured. The use of beta-blockers in the prophylaxis of the first variceal bleeding has been proven of benefit in this respect. Future research should be aimed at elucidating the role that humoral and endothelial factors play in development of the hyperdynamic circulatory state that characterizes patients with portal hypertension. Once these etiologic factors have been identified and new knowledge is acquired about their role in the complications of chronic liver disease, the challenge will rest on developing novel pharmacologic therapies specifically targeting these factors.

Topics: Adrenergic beta-Antagonists; Animals; Calcium Channel Blockers; Clonidine; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Metoclopramide; Molsidomine; Nitrates; Nitroglycerin; Serotonin Antagonists; Somatostatin; Vasoconstrictor Agents; Vasodilator Agents; Vasopressins

Successful pharmacological arrest of haemorrhage might avoid the risk of aspiration associated with tamponade and early studies have suggested that the vasoactive agent somatostatin may be as effective and perhaps safer than tamponade in controlling variceal haemorrhage. In our view, vasopressin has not established a role in management but we retain an open mind regarding the potential use of terlipressin in combination with nitroglycerin. It is unlikely that any of these agents can improve significantly our ability to control variceal haemorrhage when compared to balloon tamponade but they may reduce the incidence of pulmonary complications and thereby reduce subsequent mortality. Tamponade has proved successful in controlling acute haemorrhage from oesophageal varices in our hands. Late complications continue to give cause for concern but until effective safe alternatives to tamponade are developed, we continue to advocate its use for emergency control of acute variceal haemorrhage. Our own studies have shown that the high mortality seen in this patient population may reflect the severity of the underlying liver disease rather than failure of a management policy employing oesophageal tamponade for the initial control of acute variceal haemorrhage.

Topics: Antihypertensive Agents; Balloon Occlusion; Catheterization; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Propranolol; Recurrence; Somatostatin; Splanchnic Circulation; Vasoconstrictor Agents; Vasopressins

Variceal bleeding is the most important complication of portal hypertension. Mortality due to the first variceal bleeding is very high (50%) and of those surviving a variceal bleeding episode, up to 80% may rebleed. Proper management of the acute variceal bleeding episode, the prevention of rebleeding and primary prophylaxis for variceal haemorrhage are therefore mandatory in order to improve the morbidity and mortality of cirrhotic patients with variceal bleeding. Injection sclerotherapy would be the treatment of choice for acute variceal bleeding. Drug treatment in the form of either a combined vasopressin-nitroglycerin regimen or somatostatin may be used as an alternative. Patients not responding to these treatments should be referred for surgery. For the prevention of variceal rebleeding, non-selective beta-blockers should be tried first, reserving long-term injection sclerotherapy for patients with contraindications or intolerance to beta-blockers or in whom beta-blocker therapy has failed. Surgical rescue in the form of either shunt surgery or lever transplantation should be considered if either treatment fails. A new technique, transjugular intrahepatic portosystemic stent-shunt (TIPSS) may replace shunt surgery in the future. Beta-blockers is the treatment of choice for primary prophylaxis of variceal haemorrhage and has a role in preventing acute and chronic bleeding from congestive gastropathy. However, the above sequential approach from the least invasive to the more invasive therapeutic options may not be appropriate for all cirrhotic patients with variceal bleeding.

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Lypressin; Sclerotherapy; Somatostatin; Terlipressin; Vasopressins

The goals of therapy in acute variceal bleeding are to arrest haemorrhage and to prevent deterioration of liver function and complications related to bleeding. The measures used to stop acute bleeding should, ideally, also prevent the very early rebleeding that is frequently seen with bleeding varices. Variceal bleeding should be managed by a gastrointestinal bleeding team with intensive nursing care. Diagnostic endoscopy is mandatory once initial resuscitation has been achieved, and allows immediate injection sclerotherapy of varices. Drug therapy can be used as the first treatment in patients admitted with variceal bleeding since it can be given immediately. Of the available drugs, somatostatin has the least side effects and is as effective as vasopressin, terlipressin and the combination of vasopressin and an organic nitrate vasodilator. The role of drugs needs to be studied in combination with sclerotherapy. Sclerotherapy remains the mainstay of management as it achieves the twin goals of stopping active bleeding and preventing early rebleeding. Injection of tissue adhesive and endoscopic ligation or 'banding' are new endoscopic techniques that have shown promise in preliminary trials and are currently being assessed more widely. Balloon tamponade is a temporary measure used to prevent exsanguination. Surgery should be reserved for those patients in whom sclerotherapy is unsuccessful or cannot be carried out. Oesophageal staple transection is the most used operation. The new interventional radiological technique of transjugular intrahepatic portosystemic shunting will probably replace surgery in the future, but its role in acute variceal bleeding has yet to be fully defined.

Topics: Acute Disease; Animals; Balloon Occlusion; Catheterization; Drug Therapy, Combination; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Lypressin; Nitroglycerin; Sclerotherapy; Somatostatin; Terlipressin; Vasopressins

Following the demonstration that somatostatin lowered portal pressure in cirrhotic patients with portal hypertension, 2 uncontrolled reports suggested that the hormone might be useful in the control of acute variceal haemorrhage. Subsequently, a number of randomised controlled trials have indicated that somatostatin may have an efficacy as good as or better than either vasopressin or combined vasopressin and nitroglycerin therapy and is associated with fewer side effects. Somatostatin has an efficacy comparable to balloon tamponade, histamine-2-receptor antagonists and injection sclerotherapy. One double-blind randomised controlled trial demonstrated a significant benefit of somatostatin over placebo in the control of variceal bleeding whereas a second did not show any significant difference between treatments. In all the controlled trials, the average control rate achieved with somatostatin administration was 69% and it was not associated with any major side effects. Somatostatin administration has also been shown in uncontrolled series to be very effective in controlling postinjection sclerotherapy bleeding from the varices per se, and from oesophageal ulcers and oesophagitis. Few data are available on the long acting analogue of somatostatin, octreotide, but preliminary data suggest that it may be as effective and safe as the native hormone in controlling the acute variceal bleeding and postinjection sclerotherapy haemorrhage. It is concluded that there may be a case for instituting somatostatin therapy as soon as the patient enters hospital to facilitate sclerotherapy, and for continuing treatment for 5 days after sclerotherapy when the risk of recurrent bleeding is highest.

Topics: Acute Disease; Balloon Occlusion; Catheterization; Combined Modality Therapy; Double-Blind Method; Drug Therapy, Combination; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Nitroglycerin; Octreotide; Sclerotherapy; Somatostatin; Vasopressins

Bleeding from esophagogastric varices carries a high mortality rate. Active variceal bleeding can usually be temporarily controlled medically with a combination of intravenous vasopressin and nitroglycerin, with balloon tamponade, or with endoscopic sclerotherapy. Because of the high likelihood of recurrence, long-term treatment, such as repeated sclerotherapy, propranolol therapy, or shunt surgery, is necessary. The proper selection of such measures requires consideration of the site of variceal bleeding, local availability of specialized techniques, and patient factors. Only liver transplantation reverses the liver damage and offers hope of improved long-term survival. As success at identifying high-risk patients by endoscopic features improves, propranolol or other pharmacologic prophylaxis may become an acceptable treatment.

Topics: Balloon Occlusion; Catheterization; Clinical Protocols; Education, Medical, Continuing; Endoscopy, Gastrointestinal; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Liver Transplantation; Nitroglycerin; Propranolol; Recurrence; Sclerotherapy; Somatostatin; Vasopressins

Variceal bleeding has a high mortality, as the majority of patients have cirrhosis, with hepatic coma, renal failure, ascites and clotting deficiencies as complicating factors. Bleeding varices must therefore be treated as an emergency. Resuscitation, endoscopic diagnosis and haemostasis are the cornerstones of treatment. Once bleeding varices have been identified, attempts to stop the bleeding must be made at once as this will lessen the chances of hepatic failure developing. Endoscopic sclerotherapy at the time of diagnosis is the best available treatment at present, although profusely bleeding varices can be difficult to see and inject. In these circumstances the passage of a Sengstaken tube should stop the bleeding, allowing later sclerotherapy to be successful. If rebleeding recurs and cannot be controlled, oesophageal transection with a stapling gun may be life-saving, although the varices may later recur and long-term endoscopic follow-up will be necessary. Portacaval shunting and the distal splenorenal shunt involve arduous surgery and are followed by a significant incidence of hepatic encephalopathy; they should be reserved for those few cases when simpler measures have failed, although shunts do lead to permanent decompression of the portal system. The acute variceal bleed may also be dealt with pharmacologically. Vasopressin, used in combination with nitroglycerin to lessen the harmful side-effects, is cheaper and as effective as terlipressin or somatostatin and its synthetic analogue octreotide. Several courses of injection sclerotherapy will be required to eliminate oesophageal varices. Thereafter, long-term follow-up will be necessary to deal with any recurrence. The place of non-selective beta-blockers is still contentious, but they do reduce portal pressure and may lessen the chance of rebleeding. There is also a growing role for hepatic transplantation, which not only eliminates the varices but also restores liver function to normal and greatly reduces the risk of subsequent hepatoma development.

Topics: Catheterization; Emergencies; Esophageal and Gastric Varices; Esophagus; Gastrointestinal Hemorrhage; Hemostasis, Endoscopic; Humans; Lypressin; Resuscitation; Sclerosing Solutions; Sclerotherapy; Somatostatin; Terlipressin; Vasopressins

Topics: Catheterization; Clinical Trials as Topic; Endoscopy, Gastrointestinal; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Lypressin; Nitroglycerin; Portacaval Shunt, Surgical; Sclerotherapy; Somatostatin; Survival Rate; Terlipressin; Vasopressins

The main aim of conservative treatment of upper gastrointestinal bleeding in portal hypertension is aim to treat and prevent esophageal variceal hemorrhage. Controlled trials show that the hemostasis rate following vaso-active therapy (vasopressin and analogues, somatostatin) is only slightly superior to the spontaneous hemostasis rate. Complications caused by vasopressin treatment can be avoided by concomitant application of nitroglycerin or by alternative treatment with somatostatin. Balloon tamponade is slightly superior to vasopressin for arresting variceal hemorrhage. Injection sclerotherapy influences acute bleeding most positively. Analysis of controlled trials favors sclerotherapy for prophylaxis of rebleeding, but beta-adrenoceptor blockers appear to be almost equally good.

Topics: Adrenergic beta-Antagonists; Balloon Occlusion; Catheterization; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Sclerotherapy; Somatostatin; Vasodilator Agents; Vasopressins

Topics: Antihypertensive Agents; Drug Evaluation; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Infusions, Intra-Arterial; Lypressin; Mesenteric Arteries; Propranolol; Terlipressin; Vasopressins

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Resuscitation; Vasopressins

A continuous IV infusion of vasopressin was administrated to a patient with cirrhosis of the liver and acute gastrointestinal bleeding from esophageal varices. In the first 24 hours, the patient developed rhabdomyolysis and cutaneous necrosis. Stopping vasopressin infusion resulted in relief of these lesions. The rarity of these complications suggests an idiosyncratic reaction of susceptible individuals that may be related to previous vascular disease or a failure in baroreceptor regulation.

Topics: Aged; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Infusions, Intravenous; Liver Cirrhosis; Male; Necrosis; Rhabdomyolysis; Skin Diseases; Vasopressins

Topics: Clinical Trials as Topic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Lypressin; Metoclopramide; Somatostatin; Terlipressin; Vasoconstrictor Agents; Vasopressins

Vasopressin is a potent vasoconstrictor which greatly reduces mesenteric blood flow. In patients with portal hypertension this results in decreased portal venous flow and portal pressure. Because of this property, vasopressin has been used for years in the therapy of variceal haemorrhage. A few controlled trials show that vasopressin causes a decrease in bleeding but has no effect on survival. It has been shown that intravenous vasopressin is just as effective as intra-arterial, and is associated with fewer complications. The inability to influence the outcome of variceal haemorrhage significantly may be related to suboptimal dosing due to the occurrence of systemic complications at higher doses. The combination of vasopressin with either sodium nitroprusside or nitroglycerin (glyceryl trinitrate) has resulted in a further decline of portal pressure, along with amelioration of most of the adverse haemodynamic effects of vasopressin. Whether or not clinical efficacy is increased when vasopressin is combined with sodium nitroprusside or nitroglycerin remains to be proven. Analogues of vasopressin, such as terlipressin, held early promise as agents which would be as effective as vasopressin, without the cardiac adverse effects. Recent data have not supported this and at present there is little to suggest any advantage of terlipressin over vasopressin. Virtually no adequate studies have yet been performed to support the use of vasopressin in the treatment of non-variceal haemorrhages. There is reason to suspect that vasopressin can effectively control bleeding from haemorrhagic gastritis, but the subsequent results of inducing gastric ischaemia in an already damaged gastric mucosa are unknown. In summary, vasopressin appears to have little effect on the mortality of patients with variceal haemorrhage. It may, however, help control the haemorrhage in some patients by lowering the portal pressure. Cardiovascular complications limit the dose that can be used but it is hoped that by combining vasopressin with nitroglycerin, a more effective and safe therapy will be available for variceal haemorrhages.

Topics: Gastrointestinal Hemorrhage; Humans; Vasopressins

Topics: Gastrointestinal Hemorrhage; Hemostatic Techniques; Humans; Liver Cirrhosis; Sclerosing Solutions; Surgical Sponges; Vasopressins

Portal hypertension may be caused by portal venous outflow obstruction, an increased portal venous inflow due to a hyperdynamic circulation or both. Portal venous collaterals usually develop above a threshold portal venous pressure of 10 to 12 mm Hg. Only about one third of patients with esophageal varices eventually bleed. However, the mortality in patients who do bleed is high (around 50%) mostly because patients frequently die prior to hospital admission. Immediate endoscopy for precise location of site of bleeding is essential. Bleeding then may be controlled by drugs which lower portal pressure, balloon-tube tamponade or emergency injection sclerotherapy. Of these therapeutic options sclerotherapy probably has the highest success rate for the acute control of variceal bleeding. It can in addition be combined with the initial endoscopic diagnostic procedure, and repeated injection sclerotherapy can reduce the incidence of recurrent variceal bleeding. Portasystemic shunts, transection and devascularisation operations are nowadays only used in patients in whom repeated sclerotherapy had failed. Beta-blocking agents may be an alternative for long-term management after variceal bleeding, although the results are controversial. The data regarding prophylaxis of first variceal hemorrhage are conflicting. Prophylactic regimens should only be carried out in the form of controlled trials.

Topics: Balloon Occlusion; Catheterization; Combined Modality Therapy; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Liver Cirrhosis; Propranolol; Sclerotherapy; Vasopressins

Arginine vasopressin preparations have been used in the treatment of diabetes insipidus for many years. Compared with older antidiuretic agents, the synthetic analog desmopressin is more potent, longer acting and easier to use. It is available for intravenous, subcutaneous and intranasal administration. Desmopressin may be useful in the treatment of hemostatic disorders such as von Willebrand's disease and hemophilia A. It has also been used for nocturnal enuresis. The vasopressor effects of arginine vasopressin preparations have been exploited for use as a temporizing measure in controlling acute gastrointestinal bleeding. Side effects such as hyponatremia and water intoxication are uncommon when these drugs are used with proper precautions.

Topics: Deamino Arginine Vasopressin; Diabetes Insipidus; Enuresis; Gastrointestinal Hemorrhage; Hemorrhagic Disorders; Humans; Vasopressins

Although controversial, pharmacological therapy aimed at controlling acute variceal bleeding is widely used. A combination of intravenous vasopressin and nitroglycerin or glypressin alone with the aim of lowering portal pressure is currently recommended. Immediate endoscopy is mandatory to confirm that the patient is bleeding from varices. When variceal bleeding is detected, the patient should be immediately submitted to sclerotherapy, if expert treatment is available, or have the bleeding controlled by balloon tamponade or by pharmacological means, with subsequent performance of sclerotherapy with the use of a flexible endoscope within 6 to 24 hours, or transportation of the patient to a special center during this time. If bleeding has stopped, sclerotherapy can be performed immediately, or the patient can be observed while appropriate long-term management is planned. Patients who do not respond to immediate or delayed emergency sclerotherapy should be identified early and their suitability for a shunt or devascularisation procedure assessed. There is no question that at least after one or two early or even late recurrences of variceal hemorrhage, surgery should be planned and initiated. Although sclerotherapy is the favored form of emergency treatment, a nonshunting procedure or a portosystemic shunt operation should be recommended and thoroughly evaluated in order to determine whether this may be a preferable therapeutic option in a minority of patients, representing about 20% of all patients bleeding from esophageal varices referred to our institution.

Topics: Balloon Occlusion; Catheterization; Esophageal and Gastric Varices; Esophagoscopy; Gastrointestinal Hemorrhage; Humans; Lypressin; Sclerotherapy; Terlipressin; Vasopressins

The management of both acute and recurrent variceal bleeding continues to be a significant challenge to the clinician. The cause and pathogenesis of portal hypertension has been described. Alcoholic cirrhosis is the most common cause of intrahepatic sinusoidal and postsinusoidal obstruction in the United States. Long term survival depends on rapid institution of an established protocol of surgical management for variceal hemorrhage. A patient who presents with variceal bleeding must be rapidly stabilized with fluid resuscitation, and specific measures, such as the use of vasopressin and balloon tamponade, must be instituted to control hemorrhage so that endoscopy can be used to establish the diagnosis. Sclerotherapy achieves a high rate of success in the acute situation, but if hemorrhage cannot be controlled, percutaneous transhepatic embolization or emergent shunting must be performed, depending on the condition of the patient. Angiography, prior to surgical treatment, is necessary to define venous anatomy and determine portal hemodynamics, both of which provide information vital in choosing the type of shunt. If bleeding is massive and the patient is unstable, H-grafts are most appropriate, for they are technically easier and give excellent short term results. In a stable Child's A or B patient with minor ascites as well as suitable anatomy and hepatopedal flow, DSRS is the procedure of choice because it produces the smallest degree of HE postoperatively and increases the survival rate for nonalcoholics. If this is not feasible or if the surgeon lacks the technical expertise to perform DSRS, PCS is the logical alternative. In view of the data from the series observed in the United States, ablative procedures cannot be recommended at the present for the treatment of variceal bleeding. In the Child's C poor-risk patient, the operative mortality rate is prohibitive, and only nonsurgical means should be used to establish control of bleeding. In the elective situation, the surgical options change. The efficacy of ES as a definitive procedure to control recurrent variceal bleeding is unproved, and rebleeding can be significant; therefore, it cannot be recommended. H-grafts have a prohibitively high rate of long term thrombosis and are also not recommended, and the Linton or proximal splenorenal shunt offers no advantages over conventional portacaval shunting. Moreover, arterialization of the hepatic stumps of the portal vein does not prevent hepatic encephal

Topics: Acute Disease; Clinical Trials as Topic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hepatic Encephalopathy; Humans; Hypertension, Portal; Liver Cirrhosis, Alcoholic; Portacaval Shunt, Surgical; Radiography; Recurrence; Sclerosing Solutions; Vasopressins

Topics: Clinical Trials as Topic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Lypressin; Somatostatin; Terlipressin; Vasopressins

Vasopressin has been in clinical use for more than two decades in the treatment of upper gastrointestinal haemorrhage, especially bleeding oesophageal varices. However the haemostatic effect in controlled clinical trials is far from impressive, and no double-blind placebo controlled trial has shown even a trend in favour of vasopressin. These studies, the effects, side-effects, and clinical use of vasopressin and its long-acting analogue triglycylvasopressin, glypressin, are reviewed.

Topics: Animals; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Lypressin; Somatostatin; Terlipressin; Vasopressins

Topics: Catheterization; Embolization, Therapeutic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Ligation; Lypressin; Portacaval Shunt, Surgical; Portasystemic Shunt, Surgical; Propranolol; Resuscitation; Sclerosing Solutions; Somatostatin; Splenorenal Shunt, Surgical; Terlipressin; Vasopressins

Topics: Aged; Angiography; Antacids; Blood Cell Count; Blood Chemical Analysis; Blood Transfusion; Emergency Medical Services; Female; Fluid Therapy; Gastric Juice; Gastric Lavage; Gastrointestinal Hemorrhage; Gastroscopy; Gravity Suits; Hematemesis; Hemostatic Techniques; Histamine H2 Antagonists; Humans; Intubation, Gastrointestinal; Male; Medical History Taking; Middle Aged; Oxygen Inhalation Therapy; Patient Admission; Physical Examination; Prognosis; Propranolol; Resuscitation; Transportation of Patients; Vasopressins

Topics: Acute Disease; Adrenergic beta-Antagonists; Animals; Drug Therapy, Combination; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Lypressin; Nitroglycerin; Nitroprusside; Recurrence; Risk; Somatostatin; Terlipressin; Vasopressins

Drugs used to treat portal hypertension cause constriction of mesenteric arterioles, reducing inflow to the portal venous system, portal pressure, and flow through portasystemic collaterals (such as esophageal varices). Vasopressin and somatostatin are direct vasoconstrictors. Propranolol acts by blocking vasodilatory beta 1 receptors and reducing cardiac output. A major side effect of vasopressin therapy is impaired cardiac performance secondary to coronary vasoconstriction and increased work against high arterial pressure. Infusion of vasopressin together with a cardiac inotrope or a vasodilator, and administration of vasopressin as an inactive "hormonogen" which is slowly released in vivo, may lessen adverse effects. Somatostatin appears to act selectively in the mesenteric circulation. Controlled trials indicate that vasopressin may be useful for controlling hemorrhage from esophageal varices and that somatostatin works at least as well as vasopressin. Propranolol treatment has been used to prevent variceal bleeding; however, controlled trials of its effectiveness have produced conflicting results.

Topics: Animals; Clinical Trials as Topic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemodynamics; Humans; Hypertension, Portal; Liver Cirrhosis; Portal System; Propranolol; Somatostatin; Vasopressins

Topics: Acute Disease; Endoscopy; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hypertension, Portal; Nadolol; Propranolol; Somatostatin; Vasopressins

Topics: Acute Disease; Adult; Cholestasis; Cystic Fibrosis; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Infant; Sclerosing Solutions; Splenomegaly; Vasopressins

In recent years the technique of selective portasystemic shunting (Warren procedure) and sclerotherapy, and also the possibility of lowering portal pressure with beta-blockers, have changed the approach to management of patients with bleeding esophageal varices. Treatment of these patients is reviewed in the light of experience of 204 cases and the literature. The advantages and disadvantages of vasopressin, balloon tamponade, sclerotherapy, transhepatic embolization and various shunt and non-shunt operations in the acute phase are presented. For elective cases the discussion centers mainly on treatment by distal splenorenal shunt and sclerotherapy.

Topics: Acute Disease; Clinical Trials as Topic; Embolization, Therapeutic; Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Lypressin; Portasystemic Shunt, Surgical; Prospective Studies; Recurrence; Sclerosing Solutions; Terlipressin; Vasopressins

Bleeding from esophageal varices remains a difficult clinical problem, carrying a high likelihood both of rebleeding and of mortality. The initial approach requires adequate but not overly vigorous volume replacement with blood and other fluids. Once the patient is resuscitated, upper gastrointestinal endoscopy should be performed to establish the source of bleeding. Both endoscopic variceal sclerotherapy and balloon tamponade appear to be effective in achieving temporary control of acute ongoing hemorrhage from esophageal varices. The value of intravenous vasopressin remains controversial. Rebleeding can be prevented in most patients by shunt surgery. However, surgery carries both considerable early morbidity and mortality (related mainly to the severity of the underlying liver disease) and substantial longer-term morbidity and mortality from hepatic encephalopathy and liver failure. The role of pharmacologic agents (eg, propranolol) intended to prevent variceal hemorrhage by reducing portal pressure remains to be established. At present, we recommend use of endoscopic variceal sclerotherapy for the control of active variceal bleeding, with employment of balloon tamponade and intravenous vasopressin if sclerotherapy is successful. Emergency shunt surgery should be reserved only for those patients whose bleeding cannot be controlled by these other means. For prevention of rebleeding in Child class C patients, we attempt to obliterate the varices by repeated endoscopic sclerotherapy. Patients who have two to three episodes of rebleeding despite this approach are considered for shunt surgery. For better-risk patients who do not have ascites, which is difficult to control, we are currently recommending a distal splenorenal shunt. Alternatively, repeated endoscopic variceal sclerotherapy is used for these better-risk patients (Child class A or B) in some centers, with shunt surgery reserved for patients who continue to rebleed. Which approach to preventing rebleeding in the better-risk patient is more effective, as well as the role of pharmacologic therapy with propranolol or other agents, remains to be settled by well-controlled randomized clinical trials.

Topics: Airway Obstruction; Catheterization; Esophageal and Gastric Varices; Fluid Therapy; Gastrointestinal Hemorrhage; Hemostatic Techniques; Humans; Hypertension, Portal; Liver Diseases, Alcoholic; Propranolol; Sclerosing Solutions; Vasopressins

Topics: Anesthesia; Angiotensin II; Animals; Blood Pressure; Capillary Permeability; Digitalis Glycosides; Gastrointestinal Hemorrhage; Gastrointestinal Hormones; Histamine; Homeostasis; Intestinal Mucosa; Intestines; Kidney; Microcirculation; Oxygen Consumption; Prostaglandins; Receptors, Histamine H1; Receptors, Histamine H2; Regional Blood Flow; Serotonin; Splanchnic Circulation; Substance P; Vasoconstriction; Vasodilation; Vasopressins

Topics: Adrenergic beta-Antagonists; Blood Pressure; Endoscopy; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Recurrence; Sclerosing Solutions; Somatostatin; Vasopressins

Somatostatin (SST) has been shown by several controlled studies to be effective in halting acute severe bleeding from ulcerative and erosive lesions of the upper intestinal tract. Its efficacy for the treatment of bleeding esophageal varices is less certain, and more controlled studies are necessary. Intravenous administration of SST or subcutaneous application of the new synthetic SST-analogues produces a decrease in serum hormone levels and abolition of symptoms in patients with endocrine-active tumors such as vipoma, glucagonoma and carcinoid. SST has no effect on the outcome of acute pancreatitis, and experience with SST in treating intestinal fistulas is very limited.

Topics: Acute Disease; Cimetidine; Clinical Trials as Topic; Double-Blind Method; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Intestinal Fistula; Pancreatic Fistula; Pancreatitis; Paraneoplastic Endocrine Syndromes; Peptic Ulcer Hemorrhage; Prospective Studies; Random Allocation; Ranitidine; Secretin; Somatostatin; Vasopressins

Bleeding from esophageal varices is a feared complication of liver cirrhosis with high mortality. Pharmacotherapy of the acute bleeding episode with vasopressin has been shown to be effective in controlled studies, but side effects of this therapy are high and therefore replacement of vasopressin with somatostatin is under investigation. Another potential lead is the combination of vasopressin with vasodilators such as nitroglycerin. While acute pharmacotherapy of the patient with esophageal varices is well accepted, chronic or prophylactic pharmacotherapy is still in the investigative stage. Prophylactic therapy with beta-blockers, e.g. propranolol, has been shown to be effective in compensated patients with alcoholic cirrhosis. In patients with more advanced stages of the disease, or with cirrhosis of other etiology, the effectiveness of propranolol has not been proven. The mechanism of propranolol is similar to that of vasopressin, i.e. it lowers portal pressure by reducing portal flow. To maintain function of the affected organ, an alternative approach--namely lowering of portal pressure through reduction of the pathologically elevated resistance--should be actively investigated.

Topics: Acute Disease; Adrenergic beta-Antagonists; Chronic Disease; Clinical Trials as Topic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Propranolol; Random Allocation; Somatostatin; Vasopressins

Topics: Endoscopy; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Liver Circulation; Portacaval Shunt, Surgical; Pressure; Sclerosing Solutions; Splenorenal Shunt, Surgical; Vasopressins

Topics: Colectomy; Colonic Diseases; Colonoscopy; Gastrointestinal Hemorrhage; Humans; Rectum; Vasopressins

Topics: Electrocoagulation; Embolization, Therapeutic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Laser Therapy; Propranolol; Sclerosing Solutions; Somatostatin; Tampons, Surgical; Vasopressins

Interventional radiology is defined as a radiologic subspecialty and the services provided are tabulated in this article; those services relevant to internists are described in greater detail. This article is intended as a survey, and the authors encourage the reader to consult the references provided for a more in-depth review.

Topics: Abscess; Angiography; Angioplasty, Balloon; Arterial Occlusive Diseases; Arteriovenous Malformations; Biopsy, Needle; Cholestasis; Drainage; Embolization, Therapeutic; Fibrinolytic Agents; Gastrointestinal Hemorrhage; Hemoptysis; Humans; Neoplasms; Peptic Ulcer; Radiography; Vasopressins

Angiography has become an integral tool in the management of patients with gastrointestinal bleeding. It is used for localizing the site of bleeding and then for controlling the bleeding when more conservative methods of treatment are unsuccessful.

Topics: Angiography; Blood Vessels; Endoscopy; Erythrocytes; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatic Techniques; Humans; Intestine, Small; Mesenteric Veins; Peptic Ulcer Hemorrhage; Postoperative Complications; Sulfur; Technetium; Technetium Tc 99m Sulfur Colloid; Varicose Veins; Vasopressins

Patients with endoscopically proven variceal bleeding that continues despite conservative management require invasive emergency measures to stop hemorrhage and improve survival. Injection sclerotherapy is the simplest and most effective means currently available. The relative merits of the various techniques and sclerosants remain controversial.

Topics: Combined Modality Therapy; Esophageal and Gastric Varices; Esophagoscopy; Gastrointestinal Hemorrhage; Humans; Sclerosing Solutions; Vasopressins

Topics: Blood Transfusion; Central Venous Pressure; Cimetidine; Emergencies; Esophageal and Gastric Varices; Esophagoscopy; Esophagus; Fluid Therapy; Gastrointestinal Hemorrhage; Hemostasis, Surgical; Humans; Hypertension, Portal; Liver Cirrhosis, Alcoholic; Prognosis; Sclerosing Solutions; Vasopressins; Vitamin K

Topics: Blood Flow Velocity; Embolization, Therapeutic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Liver Circulation; Liver Cirrhosis; Portasystemic Shunt, Surgical; Propranolol; Receptors, Adrenergic, alpha; Sclerosing Solutions; Somatostatin; Vasopressins

Topics: Acute Disease; Embolization, Therapeutic; Esophageal and Gastric Varices; Esophagus; Gastrointestinal Hemorrhage; Hemostatic Techniques; Humans; Hypertension, Portal; Intubation; Intubation, Gastrointestinal; Liver Cirrhosis; Sclerosing Solutions; Vasopressins

Topics: Angiography; Diverticulitis, Colonic; Embolization, Therapeutic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Intestinal Diseases; Peptic Ulcer Hemorrhage; Vasopressins

Topics: Embolization, Therapeutic; Emergencies; Endoscopy; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatic Techniques; Humans; Portasystemic Shunt, Surgical; Recurrence; Sclerosing Solutions; Stomach; Varicose Veins; Vasopressins

The aim of the emergency management of bleeding varices is to stop the hemorrhage nonoperatively if possible, avoiding emergency shunt surgery, an operation that has a higher mortality than elective shunt surgery. Patients with an upper gastrointestinal hemorrhage should undergo endoscopy immediately to verify the diagnosis of bleeding varices. They can then be categorized according to whether they stop bleeding spontaneously (group 1), continue to bleed slowly (group 2) or continue to bleed rapidly (group 3). Group 1 patients are discussed in the second part of this two-part series. Group 2 patients are initially treated with vasopressin given intravenously; those who fail to respond should undergo emergency angiography and receive vasopressin intra-arterially. If this fails, patients at low surgical risk should undergo urgent shunt surgery; those at high risk do better with endoscopic sclerotherapy. Group 3 patients are also given an intravenous infusion of vasopressin. Patients at low surgical risk who continue to bleed then receive tamponade with a Sengstaken--Blakemore tube. If this fails, they undergo emergency creation of an H-shaped mesocaval shunt. Patients at high surgical risk who fail to respond to vasopressin given intravenously are next treated intra-arterially. If this fails they are given either endoscopic or transhepatic sclerotherapy.

Topics: Angiography; Esophageal and Gastric Varices; Esophagoscopy; Gastrointestinal Hemorrhage; Hemostatic Techniques; Humans; Liver Circulation; Portal System; Portasystemic Shunt, Surgical; Sclerosing Solutions; Vasopressins

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Laser Therapy; Portacaval Shunt, Surgical; Sclerosing Solutions; Tampons, Surgical; Vasopressins

Topics: Angiography; Arteriovenous Malformations; Catheterization; Embolization, Therapeutic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemorrhage; Humans; Neoplasms; Regional Blood Flow; Vasopressins; Wounds and Injuries

Topics: Angiography; Animals; Dogs; Embolization, Therapeutic; Gastrointestinal Hemorrhage; Humans; Vasopressins

The use of diagnostic and therapeutic angiography for postoperative bleeding which began with its application for bleeding following GI surgery can be ezpanded to almost all other areas of the body. Severe postoperative hemorrhage that previously required a second operation can now be successfully managed by the use of intraarterial or intravenous vasoconstrictors or transcatheter occlusion, thus significantly reducing patient morbidity and mortality. In those patients where a reexploration becomes necessary, diagnostic angiogarphy is a useful guide and helps to tailor the operative procedures.

Topics: Aged; Angiography; Catheterization; Embolization, Therapeutic; Esophageal Diseases; Gastrointestinal Hemorrhage; Gelatin; Hemorrhage; Hip; Humans; Intestine, Small; Kidney Diseases; Male; Pelvic Neoplasms; Postoperative Complications; Stomach Diseases; Tissue Adhesives; Vasopressins

Topics: Angiography; Embolization, Therapeutic; Gastrointestinal Hemorrhage; Humans; Vasopressins

During the last 25 years, there have been important developments in visualising the portal vein, in examining its contents, and in measuring the pressure of blood flowing within it. Radiologists have set the scene and now is the time of the scanner. These technical advances have been applied to the diagnosis and treatment of patients with portal hypertension, and many ingenious surgical techniques have been proposed. The problem of successful treatment of the patient with bleeding oesophageal varices and cirrhosis of the liver, however, has not yet been solved. This report discusses the portal vein in terms of pressure, flow, and regeneration factors. Portal hypertension is classified and methods of relief are discussed.

Topics: Catheterization; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Liver Regeneration; Portal Vein; Radiography; Regional Blood Flow; Ultrasonography; Vasopressins; Venous Pressure

Topics: Aged; Angiography; Catheterization; Epinephrine; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Stomach; Vasopressins

Topics: Aged; Angiography; Diverticulum, Colon; Embolization, Therapeutic; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Injections, Intravenous; Male; Middle Aged; Peptic Ulcer Hemorrhage; Vasopressins

Topics: Catheterization; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hepatic Veins; Humans; Hypertension, Portal; Liver Circulation; Liver Cirrhosis; Portacaval Shunt, Surgical; Portal Vein; Prospective Studies; Radiography; Regional Blood Flow; Vasopressins; Venous Pressure

Topics: Anti-Bacterial Agents; Blood Transfusion; Cryotherapy; Drainage; Esophageal and Gastric Varices; Esophageal Perforation; Gastrointestinal Hemorrhage; Hemostasis; Hepatic Encephalopathy; Humans; Hypertension, Portal; Intubation, Gastrointestinal; Liver Cirrhosis; Myocardial Infarction; Peptic Ulcer; Pneumonia, Aspiration; Portacaval Shunt, Surgical; Sclerosing Solutions; Therapeutic Irrigation; Ulcer; Vasopressins; Vitamin K

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemodynamics; Humans; Liver Cirrhosis; Vasopressins

Topics: Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Injections, Intravenous; Ligation; Mesenteric Veins; Methods; Portacaval Shunt, Surgical; Radiography; Renal Veins; Splenic Vein; Suture Techniques; Vasopressins; Venae Cavae

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hyperaldosteronism; Liver Cirrhosis; Potassium; Rest; Sodium; Vasopressins; Vitamins

Topics: Abdomen; Aged; Crohn Disease; Duodenal Diseases; Duodenal Ulcer; Esophageal Achalasia; Esophagitis; Follow-Up Studies; Gastrectomy; Gastritis; Gastrointestinal Hemorrhage; Hematoma; Hernia, Diaphragmatic; Humans; Intestine, Small; Methods; Obesity; Peptic Ulcer Hemorrhage; Postoperative Complications; Stomach Neoplasms; Stomach Ulcer; Vagotomy; Vasopressins; Zollinger-Ellison Syndrome

Topics: Acute Disease; Animals; Dogs; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Pituitary Hormones, Posterior; Tampons, Surgical; Vasopressins

Topics: Bile; Biliary Tract Diseases; Cholelithiasis; Cholesterol; Gastric Juice; Gastrointestinal Diseases; Gastrointestinal Hemorrhage; Humans; Obesity; Peptic Ulcer; Phosphatidylcholines; Pylorus; Research; Stress, Physiological; Urinary Diversion; Vagotomy; Vasopressins; Vitamin A

Topics: Age Factors; Blood Transfusion; Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis; Middle Aged; Peptic Ulcer Hemorrhage; Tampons, Surgical; Vagotomy; Vasopressins

Topics: Adrenal Cortex Hormones; Ascites; Bilirubin; Blood Pressure; Esophageal and Gastric Varices; Gastrectomy; Gastrointestinal Hemorrhage; Humans; Hypothermia, Induced; Osmosis; Plasmapheresis; Portacaval Shunt, Surgical; Portal Vein; Postoperative Care; Serum Albumin; Stomach; Tampons, Surgical; Vasopressins; Water-Electrolyte Balance

Acute variceal bleeding is a serious complication of liver cirrhosis, which has an attendant mortality of approximately 60% over two years, and a variety of treatments, such as balloon tamponade, endoscopic varix ligation, sclerotherapy, histoacryl injection and vasoactive drugs, have been used. The aims of the present trial were to compare the effectiveness and complications of somatostatin and vasopressin in the treatment of acute variceal bleeding.. Forty-three cirrhotic patients, with endoscopically proven acute variceal bleeding, were included in this trial. Both drugs were given as continuous intravenous infusions for 48 hours. Twenty patients received the somatostatin (250 mcg per hr after a bolus of 50 mcg) and twenty-three the vasopressin (0.4 units per min).. There were no significant differences between the two groups in relation to age, sex, etiology of cirrhosis, Child-Pugh classification, characteristics of bleeding episode, laboratory findings before randomization and units of transfused blood during therapy. Rebleeding, within 6 hours after beginning of therapy, was regarded as failure to control initial bleeding, and was observed in 3 (13.0%) of the patients who received vasopressin and in 1 (5.0%) treated with somatostatin (p > 0.05). Five patients in both the somatostatin (25.0%) and vasopressin (21.7%) groups rebled during the first 5 days following the initial therapy (p > 0.05). Meaningful complications related to the use of vasopressin were observed in 5 patients (chest pain or abdominal pain requiring nitroglycerin), but no complications were associated with the use of somatostatin (p < 0.05). The mortalities during hospitalization were similar in both the treatment groups. Two of the vasopressin and 1 of the somatostatin group died due to the uncontrolled rebleeding, and 1 of the vasopressin group died due to hepatic failure (2 weeks later after therapy).. This study showed no differences in the effectiveness of somatostatin and vasopressin, but the somatostatin group had a lower risk of the complications.

Topics: Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Hemostatics; Humans; Infusions, Intravenous; Liver Cirrhosis; Male; Middle Aged; Prospective Studies; Somatostatin; Treatment Outcome; Vasopressins

Portal hypertensive gastropathy is an important complication of liver cirrhosis and it contributes to acute gastric bleeding. Effective management of this condition remains a clinical challenge. We assessed and compared the efficacy of octreotide, vasopressin, and omeprazole in the treatment of acute bleeding in patients with portal hypertensive gastropathy.. Sixty-eight patients with portal hypertensive gastropathy were randomized into Octreotide, Vasopressin, and Omeprazole groups. Bleeding was monitored by observing the contents of the nasogastric tube. Blood transfusion requirements and side-effects of drugs were recorded. Repeat endoscopies were scheduled 2 weeks after treatment.. Complete bleeding control after 48 h of drug infusion was achieved in all patients receiving octreotide (100%), 14/22 patients receiving vasopressin (64%), and 13/22 patients receiving Omeprazole (59%). Octreotide required much less time and significantly fewer blood transfusions to control bleeding. Patients receiving vasopressin experienced more side-effects than those receiving octreotide and omeprazole. In the 17 patients whose bleeding was not controlled within 48 h by either vasopressin or omeprazole, complete bleeding control was achieved by combined use of these two agents. Follow-up endoscopy showed dramatic improvement in gastric mucosal erosions, superficial ulceration and erythema.. Octreotide appeared to be more effective in controlling acute bleeding in patients with hypertensive gastropathy, with significantly rapid action, smaller transfusion requirements, and minor side-effects. Simultaneous administration of vasopressin and omeprazole appeared to have additive effects.

Topics: Adult; Aged; Drug Evaluation; Enzyme Inhibitors; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Gastroscopy; Hemostatics; Humans; Hypertension, Portal; Male; Middle Aged; Octreotide; Omeprazole; Prospective Studies; Treatment Outcome; Vasopressins

Topics: Catheterization; Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatics; Humans; Liver Cirrhosis; Portacaval Shunt, Surgical; Survival Rate; Vasopressins

Despite urgent sclerotherapy, active variceal hemorrhage has a 70%-90% mortality rate in patients with advanced age, sepsis, renal or pulmonary compromise, tense ascites, or deep coma. The aim of this study was to test the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) performed semiemergently and preceded by stabilization by balloon tamponade in such patients.. Patients with actively bleeding esophageal or contiguous gastric varices despite sclerotherapy were assessed for risk of dying after emergent portacaval shunt. Those considered to be at high risk were stabilized by balloon tamponade and vasopressin/nitroglycerin and TIPS placed semiurgently within 12 hours. Balloon tamponade and pharmacological therapy were discontinued within 24 hours after TIPS in all cases.. Thirty-two patients met entry criteria, and 2 were excluded due to portal vein thrombosis. TIPS was successfully placed in 29 of 30 patients and achieved hemostasis in all. Thirty-day and 6-week survival rates were 63% and 60%, respectively; in those without aspiration, the 6-week survival rate was 90%. After a median follow-up period of 920 days, 46% of the original cohort was alive. Only 2 episodes of early rebleeding and 4 late rebleeds occurred. Eight patients developed encephalopathy. Stent stenosis requiring dilation occurred in 6 of 11 patients within 6 months.. TIPS is highly effective as salvage therapy in high-risk patients with active variceal hemorrhage despite endoscopic sclerotherapy.

Topics: Adult; Aged; Balloon Occlusion; Catheterization; Combined Modality Therapy; Emergencies; Esophageal and Gastric Varices; Female; Follow-Up Studies; Gastrointestinal Hemorrhage; Hemostatics; Humans; Male; Middle Aged; Nitroglycerin; Portasystemic Shunt, Surgical; Prognosis; Prospective Studies; Salvage Therapy; Sclerotherapy; Survival Rate; Vasopressins

Topics: Acute Disease; Double-Blind Method; Gastric Mucosa; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Liver Cirrhosis; Lypressin; Perfusion; Stomach Diseases; Terlipressin; Vasoconstrictor Agents; Vasopressins

A prospective randomized trial was conducted in unselected, consecutive patients with bleeding esophageal varices resulting from cirrhosis comparing (1) emergency portacaval shunt performed within 8 hr of initial contact (21 patients) with (2) emergency medical therapy (intravenous vasopressin and esophageal balloon tamponade) followed in 9 to 30 days by elective portacaval shunt in survivors (22 patients). All patients underwent the same diagnostic workup within 3 to 6 hr of initial contact, and received identical supportive therapy initially. All patients were followed up for at least 10 yr. The protocol contained no escape or cross-over provisions. There were no statistically significant differences between the two treatment groups in the incidence of any of the clinical variables, results of laboratory tests or degree of portal hypertension. Child's risk classes in the shunt group were A-2 patients, B-8 patients and C-11 patients, whereas in the medical group they were A-10 patients, B-5 patients, and C-7 patients, a significant difference (p < 0.01) that might have favored emergency medical treatment. Bleeding was controlled initially and permanently by emergency shunt in every patient, but by medical therapy in only 45% (p < 0.001). Mean requirement for blood transfusion was 7.1 +/- 2.6 units in the shunt group and 21.4 +/- 2.6 units in the medical group (p < 0.001). Eighty-one percent of the patients in the shunt group were discharged alive compared with 45% in the medical group (p = 0.027). Five- and 10-yr observed survival rates were 67% and 57%, respectively, after emergency shunt compared with 18% and 18%, respectively, after the combination of emergency medical therapy and elective shunt (p < 0.01). These survival rates produced by emergency shunt performed within 8 hr of initial contact confirm the effectiveness of this procedure observed in our previous unrandomized studies.

Topics: Adult; Aged; Balloon Occlusion; Catheterization; Emergencies; Esophageal and Gastric Varices; Esophagus; Follow-Up Studies; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis; Male; Middle Aged; Portacaval Shunt, Surgical; Prospective Studies; Quality of Life; Survival Rate; Vasopressins

Between 1988 and 1990 an unblinded, randomized trial of terlipressin or vasopressin plus transdermal nitroglycerin, as part of a treatment strategy including emergency sclerotherapy for actively bleeding varices, was conducted during 165 admissions in 137 patients with cirrhosis and upper digestive bleeding. Eighty-four patient admissions were assigned to terlipressin (2 mg every 6 h) and 81 to vasopressin (0.4 to 0.8 unit per min) plus transdermal nitroglycerin (20 to 80 mg). The two groups were comparable for relevant clinical data, but there were slightly more patients with hepatocellular carcinoma or terminal conditions in the terlipressin group. After the 24-h study period, failure to control bleeding was 20/84 (25%) in the vasopressin and 14/81 (17%) in the terlipressin group (p = 0.19). Corresponding figures for patients bleeding from varices (emergency sclerotherapy in 43 and 45, respectively) were 13/55 (24%) and 5/56 (9%; p = 0.035), from other sources 5/16 (31%) and 2/15 (13%; p = 0.23), from undefined sources 2/10 (20%) and 7/13 (54%; p = 0.1). In a logistic multivariate regression model the odds ratio for terlipressin adjusted for prognostic factors was 0.45 (p = 0.07). There were seven major side effects requiring treatment discontinuation in the vasopressin and one in the terlipressin group. These results suggest that terlipressin alone is as effective as vasopressin plus transdermal nitroglycerin, with less severe side effects, in 24-h control of upper gastrointestinal bleeding in patients with cirrhosis.

Topics: Administration, Cutaneous; Adult; Aged; Drug Therapy, Combination; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis; Lypressin; Male; Middle Aged; Nitroglycerin; Terlipressin; Vasopressins

Gastric mucosal perfusion is increased in portal-hypertensive gastropathy, and this may contribute to gastric bleeding from these lesions. Therefore drugs reducing gastric mucosal perfusion may be beneficial in the treatment of overt bleeding from portal-hypertensive gastropathy. In this study gastric mucosal perfusion was assessed in 28 cirrhotic patients with portal-hypertensive gastropathy under basal conditions and after double-blind intravenous administration of vasopressin (0.4 U/min), glypressin (2-mg injection) or placebo, with laser-Doppler flowmetry and reflectance spectrophotometry. Vasopressin and glypressin induced a significant increase in blood pressure and a decrease in heart rate. These effects were more pronounced in the vasopressin group. Both vasopressin and glypressin induced a sustained and similar reduction in gastric mucosal perfusion as assessed by laser-Doppler flowmetry (-36% +/- 8% and -34% +/- 6%, respectively; p < 0.05 with respect to basal values and with respect to the control group), whereas placebo had no effect. Both drugs significantly reduced the oxygen content of the gastric mucosa; however, the impairment in mucosal oxygenation was greater (p < 0.05) in the vasopressin group (-17% +/- 3%) than in the glypressin group (-6% +/- 0.1%). We conclude that the increased gastric perfusion in cirrhotic patients with portal-hypertensive gastropathy may be reduced by either vasopressin or glypressin. These findings support the use of these drugs in clinical trials treating bleeding portal-hypertensive gastropathy. The lower reduction in gastric mucosal oxygen content observed with glypressin could decrease the incidence of ischemic adverse events associated with the use of vasopressin.

Topics: Double-Blind Method; Female; Gastric Mucosa; Gastrointestinal Hemorrhage; Gastroscopy; Humans; Hyperemia; Hypertension, Portal; Laser-Doppler Flowmetry; Liver Cirrhosis; Lypressin; Male; Middle Aged; Oxygen; Regional Blood Flow; Spectrophotometry; Stomach Diseases; Terlipressin; Vasopressins

Following the demonstration that somatostatin lowered portal pressure in cirrhotic patients with portal hypertension, 2 uncontrolled reports suggested that the hormone might be useful in the control of acute variceal haemorrhage. Subsequently, a number of randomised controlled trials have indicated that somatostatin may have an efficacy as good as or better than either vasopressin or combined vasopressin and nitroglycerin therapy and is associated with fewer side effects. Somatostatin has an efficacy comparable to balloon tamponade, histamine-2-receptor antagonists and injection sclerotherapy. One double-blind randomised controlled trial demonstrated a significant benefit of somatostatin over placebo in the control of variceal bleeding whereas a second did not show any significant difference between treatments. In all the controlled trials, the average control rate achieved with somatostatin administration was 69% and it was not associated with any major side effects. Somatostatin administration has also been shown in uncontrolled series to be very effective in controlling postinjection sclerotherapy bleeding from the varices per se, and from oesophageal ulcers and oesophagitis. Few data are available on the long acting analogue of somatostatin, octreotide, but preliminary data suggest that it may be as effective and safe as the native hormone in controlling the acute variceal bleeding and postinjection sclerotherapy haemorrhage. It is concluded that there may be a case for instituting somatostatin therapy as soon as the patient enters hospital to facilitate sclerotherapy, and for continuing treatment for 5 days after sclerotherapy when the risk of recurrent bleeding is highest.

Topics: Acute Disease; Balloon Occlusion; Catheterization; Combined Modality Therapy; Double-Blind Method; Drug Therapy, Combination; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Nitroglycerin; Octreotide; Sclerotherapy; Somatostatin; Vasopressins

This randomized controlled trial was conducted to compare the efficacy of intravenous infusion of octreotide (a synthetic long-acting somatostatin analogue) with vasopressin in 48 cirrhotic patients with endoscopically proven bleeding esophageal varices. Twenty-four patients received a continuous infusion of octreotide 25 micrograms/h for 24 h after an initial bolus of 100 micrograms and another 24 patients received a continuous infusion of vasopressin 0.4 U/min for 24 h. Bleeding was initially controlled after 6 h of drug infusion in 88% (21/24) and 54% (13/24) of the patients treated with octreotide and vasopressin respectively (p = 0.03). Complete control of bleeding after 24 h of drug infusion was achieved in 15 (63%) patients receiving octreotide and in 11 (46%) patients receiving vasopressin (p > 0.05). Side effects during drug infusion such as headache, chest pain and abdominal pain were significantly lower in the octreotide group (3/24) than in the vasopressin group (11/24). Serum gastrin and insulin levels fell significantly following octreotide infusion, but plasma glucose levels remained unchanged. Mortality related to bleeding esophageal varices was no different between the two groups. This report showed that octreotide infusion was more effective and had fewer side effects than vasopressin in initial controlling of acute esophageal variceal bleeding until an elective endoscopic sclerotherapy could be performed.

Topics: Aged; Blood Glucose; Esophageal and Gastric Varices; Female; Gastrins; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Injections, Intravenous; Insulin; Liver Cirrhosis; Male; Middle Aged; Octreotide; Vasopressins

To study the hemostatic effect of Sandostatin, a long-acting analogue of somatostatin, in acute variceal bleeding, a prospective randomized controlled trial comparing it with Vasopressin was conducted in 41 cirrhotic patients with esophageal variceal bleeding. Initial hemostasis was achieved within 6 hours in 75% of patients treated with Sandostatin and in 61.9% treated with Vasopressin. Recurrent bleed developed in 20% of patients in Sandostatin group and 46.2% in Vasopressin group following initial hemostasis. Complete control of bleeding for 24 hours was attained in 60% of the Sandostatin group and in 33.3% of the Vasopressin group. There was no statistically significant difference in both the rate of initial hemostasis and complete bleeding control. Hospital mortality was also similar in both groups. However, transfusion requirements were less (P less than 0.05) and side effects tended to be milder in patients treated with Sandostatin. In conclusion, Sandostatin is at least as effective as Vasopressin in the treatment of acute variceal bleeding, and carries less severe complications than Vasopressin does.

Topics: Adult; Aged; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Male; Middle Aged; Octreotide; Prospective Studies; Vasopressins

Somatostatin (ST) and vasopressin (VP) infusions were compared in the treatment of actively bleeding esophageal varices. Fifty-four patients with liver cirrhosis were included in the study. Thirty-two were given ST 4.2 micrograms/min, and 22 patients were given VP 0.4 IU/min for 72 h after endoscopic diagnosis. The role of alcoholic cirrhosis was similar in both groups. Initial control of bleeding was achieved significantly more often (p = 0.0281) when ST was used (84.4%) than during VP treatment (57.1%). Rebleeding occurred in 18.8% and 4.8%, respectively. Side effects of treatment were significantly more common when VP was used than during ST treatment (p = 0.0021). Overall mortality was high in both groups, being 34% in the ST group and 36% in the VP group. ST infusion seems to be more effective and safer than VP in the treatment of acute variceal bleeding. However, the high frequency of rebleeding during ST treatment means that, after primary hemostasis with ST infusion, other methods, such as surgery or sclerotherapy, are needed to prevent the serious complications of rebleeding.

Topics: Adult; Aged; Aged, 80 and over; Esophageal and Gastric Varices; Female; Finland; Gastrointestinal Hemorrhage; Humans; Male; Middle Aged; Random Allocation; Recurrence; Somatostatin; Vasopressins

Effects of hemostatic and various side effects were compared between glypressin and pitressin. Fifty-five episodes of esophageal variceal bleeding in 29 patients were studied. Although the glypressin group included more patients in Pugh's classification C than the pitressin group, the result of hemostasis was not influenced. The effect of hemostasis was evaluated in 24 episodes receiving either glypressin or pitressin. The hemostatic effects of glypressin and pitressin were 6/11, 54.5% and 7/13, 53.8% respectively. Eighteen episodes in six patients, with multiple episodes, were used to observe the effect of these two drugs in the same person. No difference was observed. The number of side effects in the glypressin group and the pitressin group were 5 and 10 respectively. Although the side effects of glypressin might be fewer than those of pitressin, chest pain was observed in patients receiving glypressin treatment. The use of glypressin in the patients with cardiac diseases should be studied further. Glypressin is more convenient in clinical use. However, pitressin doses is easily modified. Both drugs might be selected in the control of variceal bleeding.

Topics: Adult; Aged; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Hemostatics; Humans; Lypressin; Male; Middle Aged; Terlipressin; Vasopressins

The management of both acute and recurrent variceal bleeding continues to be a significant challenge to the clinician. The cause and pathogenesis of portal hypertension has been described. Alcoholic cirrhosis is the most common cause of intrahepatic sinusoidal and postsinusoidal obstruction in the United States. Long term survival depends on rapid institution of an established protocol of surgical management for variceal hemorrhage. A patient who presents with variceal bleeding must be rapidly stabilized with fluid resuscitation, and specific measures, such as the use of vasopressin and balloon tamponade, must be instituted to control hemorrhage so that endoscopy can be used to establish the diagnosis. Sclerotherapy achieves a high rate of success in the acute situation, but if hemorrhage cannot be controlled, percutaneous transhepatic embolization or emergent shunting must be performed, depending on the condition of the patient. Angiography, prior to surgical treatment, is necessary to define venous anatomy and determine portal hemodynamics, both of which provide information vital in choosing the type of shunt. If bleeding is massive and the patient is unstable, H-grafts are most appropriate, for they are technically easier and give excellent short term results. In a stable Child's A or B patient with minor ascites as well as suitable anatomy and hepatopedal flow, DSRS is the procedure of choice because it produces the smallest degree of HE postoperatively and increases the survival rate for nonalcoholics. If this is not feasible or if the surgeon lacks the technical expertise to perform DSRS, PCS is the logical alternative. In view of the data from the series observed in the United States, ablative procedures cannot be recommended at the present for the treatment of variceal bleeding. In the Child's C poor-risk patient, the operative mortality rate is prohibitive, and only nonsurgical means should be used to establish control of bleeding. In the elective situation, the surgical options change. The efficacy of ES as a definitive procedure to control recurrent variceal bleeding is unproved, and rebleeding can be significant; therefore, it cannot be recommended. H-grafts have a prohibitively high rate of long term thrombosis and are also not recommended, and the Linton or proximal splenorenal shunt offers no advantages over conventional portacaval shunting. Moreover, arterialization of the hepatic stumps of the portal vein does not prevent hepatic encephal

Topics: Acute Disease; Clinical Trials as Topic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hepatic Encephalopathy; Humans; Hypertension, Portal; Liver Cirrhosis, Alcoholic; Portacaval Shunt, Surgical; Radiography; Recurrence; Sclerosing Solutions; Vasopressins

In a prospective, randomized clinical trial, immediate injection sclerotherapy was compared with treatment by a combined infusion of vasopressin (0.4 unit per min) and nitroglycerin (40 to 400 micrograms per min) in 50 consecutive patients with 64 episodes of endoscopy-proven variceal hemorrhage. Control of bleeding was assessed over a 12-hr period following entry into the trial. Patients in the vasopressin + nitroglycerin group were then treated by sclerotherapy, as were those in the sclerotherapy group who continued to bleed. At 12 hr, bleeding was controlled in 29 (88%) of the 33 episodes treated by sclerotherapy compared with 20 (65%) of 31 episodes treated by vasopressin + nitroglycerin (p less than 0.05). Recurrence of variceal bleeding occurred at the same frequency (31%). Although admission mortality was less in those initially treated by sclerotherapy compared to those managed by vasopressin + nitroglycerin, this did not reach statistical significance (27 and 39%, respectively, p greater than 0.20). Sclerotherapy carried out as the first treatment of the active variceal hemorrhage proved both safe and effective, even in the presence of major hemorrhage, and as compared to combined vasopressin and nitroglycerin it proved superior.

Topics: Clinical Trials as Topic; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Male; Middle Aged; Nitroglycerin; Prospective Studies; Random Allocation; Recurrence; Sclerosing Solutions; Vasopressins

The aim of this study was to evaluate, using a double-blind technique, the efficacy of the association of transdermal nitroglycerin to vasopressin infusion for the treatment of variceal bleeding. Sixty-nine cirrhotic patients with active variceal bleeding were randomly allocated to receive vasopressin (0.4 to 0.8 unit per min until variceal bleeding has been controlled for 12 hr) associated with nitroglycerin administered transdermically in a slow-release preparation (10 mg in 24 hr) or placebo. An initial control of variceal hemorrhage was achieved in 83% of the patients receiving vasopressin-nitroglycerin and in 74% in the vasopressin-placebo group. Owing to a lower frequency of recurrent bleeding during therapy (18 vs. 42%, p = 0.11), vasopressin-nitroglycerin achieved a definitive control of bleeding in a higher proportion of patients than vasopressin-placebo (73 vs. 54%, p = 0.13). The group treated with the drug combination showed favorable results in relation to transfusion requirements (2.9 +/- 0.4 vs. 4.2 +/- 0.5 units, p = 0.05), total dose of vasopressin required (453 +/- 47 vs. 587 +/- 50 units, p less than 0.05), need of balloon tamponade (6 vs. 15, p less than 0.05) and requirement for emergency surgery (0 vs. 4, p = 0.07). There were no significant differences in the undesirable effects associated with treatment, observed in 37 and 49% of cases, respectively. Hospital mortality was similar (33 vs. 25%). This study demonstrates that transdermal nitroglycerin improves the effectiveness of vasopressin for controlling variceal hemorrhage.

Topics: Administration, Cutaneous; Adult; Blood Pressure; Clinical Trials as Topic; Double-Blind Method; Drug Therapy, Combination; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Heart Rate; Humans; Infusions, Intravenous; Liver; Male; Middle Aged; Nitroglycerin; Placebos; Vasopressins; Venous Pressure

Topics: Clinical Trials as Topic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Lypressin; Somatostatin; Terlipressin; Vasopressins

We have evaluated the haemodynamic effects of intravenous (iv) nitroglycerin (NG) and vasopressin (VP) alone and in combination, in 12 patients with cirrhosis and recent variceal haemorrhage (two to seven days). Nitroglycerin infusion alone (200 micrograms/min) produced a significant fall in portal pressure (WHVP-FHVP) (from 16.4 (0.6) to 13.3 (1.2) mmHg; p less than .001) associated with hypotension (mean arterial pressure from 95 (7) to 78 (9) mmHg; p less than 0.005). Vasopressin alone (0.4 IU/min) reduced portal pressure (20.7 (1.3) to 14.0 (1.3) mmHg; p less than 0.001), but there was considerable variation in the systemic haemodynamic changes with increased cardiac output in four of six patients. The combination of vasopressin and nitroglycerin corrected all systemic haemodynamic disturbances produced by either agent alone. This combination led, however, to a further reduction in portal pressure (from 13.7 (0.9) to 11.7 (0.7) mmHg p less than 0.01). These results show that: (1) intravenous nitroglycerin reduces portal pressure, and (2) the combination of nitroglycerin and vasopressin reverses systemic haemodynamic disturbances produced by either agent alone and leads to a further decrease in portal pressure.

Topics: Drug Therapy, Combination; Female; Gastrointestinal Hemorrhage; Hemodynamics; Humans; Hypertension, Portal; Injections, Intravenous; Liver Circulation; Liver Cirrhosis; Male; Nitroglycerin; Vasopressins

A multicenter double-blind clinical trial was undertaken to evaluate the efficacy of a short-term somatostatin treatment versus a short-term vasopressin treatment on acute hemorrhage from esophageal varices in patients with liver cirrhosis and portal hypertension. Forty-nine patients with massive hemorrhage and endoscopic diagnosis of bleeding esophageal varices completed the study. Patients were randomly assigned to somatostatin treatment (24 patients: 250 micrograms/hr i.v. for 48 hrs) or vasopressin treatment (25 patients: 0.1 U/min i.v. for 48 hrs). The Sengstaken-Blakemore tube was utilized, when needed, for a six hour period. In case of failure the patients were crossed-over to the other treatment. Patients in whom the bleeding stopped at 48 hrs, were randomly assigned to somatostatin (250 micrograms/hr i.v.) or placebo for seven days. Bleeding stopped in 68% of patients treated with somatostatin and in 28% of patients treated with vasopressin (p less than 0.0013). Mortality rate was lower, but not significantly so, in the somatostatin group compared to the vasopressin group. No differences were noted between somatostatin and placebo in preventing bleeding recurrences. These data suggest that somatostatin, when combined if necessary with a 6 hour period of balloon tamponade, is more effective than vasopressin at low doses in controlling severe hemorrhage from esophageal varices in patients with liver cirrhosis and portal hypertension. A clinical use of somatostatin seems to be indicated in these patients.

Topics: Clinical Trials as Topic; Double-Blind Method; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Random Allocation; Somatostatin; Time Factors; Vasopressins

Drugs used to treat portal hypertension cause constriction of mesenteric arterioles, reducing inflow to the portal venous system, portal pressure, and flow through portasystemic collaterals (such as esophageal varices). Vasopressin and somatostatin are direct vasoconstrictors. Propranolol acts by blocking vasodilatory beta 1 receptors and reducing cardiac output. A major side effect of vasopressin therapy is impaired cardiac performance secondary to coronary vasoconstriction and increased work against high arterial pressure. Infusion of vasopressin together with a cardiac inotrope or a vasodilator, and administration of vasopressin as an inactive "hormonogen" which is slowly released in vivo, may lessen adverse effects. Somatostatin appears to act selectively in the mesenteric circulation. Controlled trials indicate that vasopressin may be useful for controlling hemorrhage from esophageal varices and that somatostatin works at least as well as vasopressin. Propranolol treatment has been used to prevent variceal bleeding; however, controlled trials of its effectiveness have produced conflicting results.

Topics: Animals; Clinical Trials as Topic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemodynamics; Humans; Hypertension, Portal; Liver Cirrhosis; Portal System; Propranolol; Somatostatin; Vasopressins

This report presents results of surgery for bleeding esophageal varices in 80 patients. A prospective randomized study addresses the efficacy of the distal splenorenal shunt (DS) versus the mesocaval shunt (MS) in 50 patients undergoing elective surgery. An additional 30 patients underwent emergency MS for uncontrollable hemorrhage. In the elective series, patients averaged "B" according to Child's Classification. Operative mortality rates were similar (5%). Incidences of encephalopathy were also similar (10%). Those patients undergoing MS experienced an overall operative mortality of 9 per cent, which included emergency shunts (operative mortality 13%). This latter figure is the lowest in the world's literature. Our technique of mesocaval shunting emphasizes short (mean, 3.8-cm) and wide (mean, 21.5-mm) cloth prostheses. Utilizing this approach, we have been able to reduce operative portal venous pressure from a mean (x +/- SE) of 40.1 +/- 1.9 to 13.1 +/- 0.6 cm H2O. The latter value correlated inferior vena caval pressure, 11.8 +/- 0.6 and central venous pressure (recorded by the anesthesiologist) 11.4 +/- 0.5 cm H2O. This is the highest reduction (67%) in portal pressure thus far recorded and reflects our emphasis upon meticulous and extensive dissection of the involved structures. The former minimizes blood loss, which in our hands has been minimal (0.45 +/- 0.18 units per case), reducing the threat of further liver damage; the latter facilitates the "optimal shunt," one which returns portal venous pressure to normal.

Topics: Blood Vessel Prosthesis; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Hemodynamics; Humans; Infusions, Parenteral; Male; Mesenteric Veins; Middle Aged; Portal Vein; Portasystemic Shunt, Surgical; Prospective Studies; Random Allocation; Splenorenal Shunt, Surgical; Vasopressins; Vena Cava, Inferior; Venous Pressure

In recent years the technique of selective portasystemic shunting (Warren procedure) and sclerotherapy, and also the possibility of lowering portal pressure with beta-blockers, have changed the approach to management of patients with bleeding esophageal varices. Treatment of these patients is reviewed in the light of experience of 204 cases and the literature. The advantages and disadvantages of vasopressin, balloon tamponade, sclerotherapy, transhepatic embolization and various shunt and non-shunt operations in the acute phase are presented. For elective cases the discussion centers mainly on treatment by distal splenorenal shunt and sclerotherapy.

Topics: Acute Disease; Clinical Trials as Topic; Embolization, Therapeutic; Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Lypressin; Portasystemic Shunt, Surgical; Prospective Studies; Recurrence; Sclerosing Solutions; Terlipressin; Vasopressins

Twenty two patients were entered into a randomised controlled clinical trial comparing the efficacy of somatostatin and vasopressin in controlling acute variceal haemorrhage. Somatostatin was significantly more successful in controlling acute variceal haemorrhage than vasopressin (p = 0.003). Furthermore, no complications were observed during treatment with somatostatin.

Topics: Adult; Aged; Clinical Trials as Topic; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Male; Middle Aged; Random Allocation; Recurrence; Somatostatin; Vasopressins

Somatostatin (SST) has been shown by several controlled studies to be effective in halting acute severe bleeding from ulcerative and erosive lesions of the upper intestinal tract. Its efficacy for the treatment of bleeding esophageal varices is less certain, and more controlled studies are necessary. Intravenous administration of SST or subcutaneous application of the new synthetic SST-analogues produces a decrease in serum hormone levels and abolition of symptoms in patients with endocrine-active tumors such as vipoma, glucagonoma and carcinoid. SST has no effect on the outcome of acute pancreatitis, and experience with SST in treating intestinal fistulas is very limited.

Topics: Acute Disease; Cimetidine; Clinical Trials as Topic; Double-Blind Method; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Intestinal Fistula; Pancreatic Fistula; Pancreatitis; Paraneoplastic Endocrine Syndromes; Peptic Ulcer Hemorrhage; Prospective Studies; Random Allocation; Ranitidine; Secretin; Somatostatin; Vasopressins

Bleeding from esophageal varices is a feared complication of liver cirrhosis with high mortality. Pharmacotherapy of the acute bleeding episode with vasopressin has been shown to be effective in controlled studies, but side effects of this therapy are high and therefore replacement of vasopressin with somatostatin is under investigation. Another potential lead is the combination of vasopressin with vasodilators such as nitroglycerin. While acute pharmacotherapy of the patient with esophageal varices is well accepted, chronic or prophylactic pharmacotherapy is still in the investigative stage. Prophylactic therapy with beta-blockers, e.g. propranolol, has been shown to be effective in compensated patients with alcoholic cirrhosis. In patients with more advanced stages of the disease, or with cirrhosis of other etiology, the effectiveness of propranolol has not been proven. The mechanism of propranolol is similar to that of vasopressin, i.e. it lowers portal pressure by reducing portal flow. To maintain function of the affected organ, an alternative approach--namely lowering of portal pressure through reduction of the pathologically elevated resistance--should be actively investigated.

Topics: Acute Disease; Adrenergic beta-Antagonists; Chronic Disease; Clinical Trials as Topic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Propranolol; Random Allocation; Somatostatin; Vasopressins

Of four reported studies of vasopressin therapy in acute upper gastrointestinal tract hemorrhage, three found vasopressin to be effective and one did not. The studies differed with regard to population, design, and methods. The one study that found vasopressin to be ineffective in controlling gastrointestinal tract hemorrhage may have been better controlled with regard to duration of therapy and evaluation of patients. However, the population studied appeared to be different and the authors may have failed to demonstrate a beneficial effect of vasopressin in a select subgroup of patients. Vasopressin dosing has also been a point of controversy. Hemodynamic data thus far support the use of low-dose infusions. The use of terlipressin (Glypressin), a new analogue of vasopressin, also appears promising.

Topics: Animals; Clinical Trials as Topic; Dogs; Double-Blind Method; Gastric Lavage; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Infusions, Parenteral; Lypressin; Prognosis; Random Allocation; Research Design; Terlipressin; Vasopressins

Topics: Clinical Trials as Topic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Random Allocation; Somatostatin; Vasopressins

In a randomised controlled trial the effect of intermittent bolus injection of triglycyl lysine vasopressin (terlipressin 'Glypressin') (2 mg that 6-hourly), an analogue of vasopressin, was compared with that of a constant peripheral intravenous infusion of vasopressin (0.4 units/Min) in the initial management of bleeding oesophageal varices in nineteen patients. Failure of vasopressin therapy was defined as continued bleeding of sufficient severity to necessitate the passage of a Sengstaken tube. Bleeding was controlled in 70% of patients treated with glypressin but in only 9% of patients given vasopressin. The glypressin group required significantly less blood after randomisation than the vasopressin group. Because of its efficacy, lack of side-effects, and ease of administration, glypressin appears to be valuable in the management of bleeding varices.

Topics: Adult; Aged; Clinical Trials as Topic; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Lypressin; Male; Middle Aged; Random Allocation; Terlipressin; Vasopressins

Topics: Cimetidine; Clinical Trials as Topic; Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatic Techniques; Humans; Peptic Ulcer; Peptic Ulcer Hemorrhage; Stomach Ulcer; Stress, Physiological; Vasopressins

Sixty patients with active upper gastrointestinal bleeding were randomized to received either continuous intravenous infusions of vasopressin (29 patients) or placebo (31 patients) at a rate of 40 U/h. Six hours after beginning the study, 13 patients in the vasopressin group and 11 in the placebo group] had ceased bleeding (p = 0.46). By 24 hours. 17 patients in the vasopressin group and 14 in the placebo group had stopped bleeding (p = 0.30). Restriction of the analysis to patients bleeding from varices showed no advantage with vasopressin treatment after 6 or 24 hours. No consistent trend favoring use of vasopressin to stop hemorrhage was noted during the 30-month study period. There was little difference between the two groups in the number of patients needing surgery (13 on vasopressin, 18 on placebo; p = 0.30) or the number of deaths (eight on vasopressin, 11 on placebo; p = 0.51); the transfusion requirement was the same. In our patients, a continuous intravenous infusion of vasopressin neither controlled bleeding nor altered outcome.

Topics: Clinical Trials as Topic; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Male; Middle Aged; Placebos; Random Allocation; Vasopressins

In a prospective randomized study, 38 patients with massive upper gastrointestinal tract hemorrhage, mostly due to esophageal varices or erosive gastritis, were treated with either standard medical therapy or standard therapy plus selective intra-arterial vasopressin infusion. Cessation of hemorrhage occurred more frequently in the vasopressin-treated group. The study design did not permit meaningful comparisons of mortality of transfusion requirements. We conclude that in patients bleeding from esophageal varices or gastritis, selective intra-arterial vasopressin is more effective in controlling hemorrhage than standard therapy.

Topics: Adult; Aged; Clinical Trials as Topic; Esophageal and Gastric Varices; Female; Gastritis; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Male; Middle Aged; Prospective Studies; Vasopressins

Infusions of intraarterial vasopressin (IAV) into the superior mesenteric artery have been shown to be effective in controlling hemorrhage from esophagogastric varices. Intravenous infusions of vasopressin (IVV), which can be initiated rapidly and require less sophisticated equipment and personnel, have also been reported to control variceal hemorrhage. We undertook a controlled clinical trial to compare these two routes of administration. Twenty-two cirrhotic patients with massive hemorrhage from varices were randomized to receive either IVV or IAV. Intraarterial vasopressin was begun at 0.1 U/min and increased progressively as needed to 0.2, 0.3, 0.4, and 0.5 U/min. Intravenous vasopressin was begun at 0.3 U/min and increased progressively as needed to 0.6, 0.9, 1.2, and 1.5 U/min. Hemorrhage was controlled in 5 of 10 episodes (50%) with IVV and in 6 of 12 episodes (50%) with IAV. Seven of the ten episodes treated with IVV (70%) ended fatally compared with 9 of 12 treated with IAV (75%). Side-effects and complications occurred with similar frequency in the two groups. The two routes of administration are equal in effects, side-effects, and complications. We recommend that IVV, which can be administered more easily, be given a brief therapeutic trial early in the management of hemorrhage from varices.

Topics: Adult; Aged; Blood Transfusion; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Injections, Intravenous; Male; Middle Aged; Random Allocation; Recurrence; Vasopressins

From July 1975 to November 1976 25 patients with bleeding esophagogastric varices documented by endoscopy who failed to respond to conservative medical treatment were transferred to the Surgical Service. These patients, who were mainly Child's Class "C" alcoholic cirrhotic patients, were treated with vasopressin infused continuously using a standardized dose into either a peripheral vein or the superior mesenteric artery (SMA) according to a predetermined randomization. No significant difference in efficacy for control of bleeding (average rate = 56%) related to route of administration was found. Because catheter-related complications in the SMA group were significantly greater, we concluded that the method of choice in vasopressin treatment of esophagogastric variceal bleeding is a continuous infusion by way of a peripheral vein.

Topics: Catheterization; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Mesenteric Arteries; Prospective Studies; Stomach Diseases; Varicose Veins; Vasomotor System; Vasopressins

Intraarterial vasopressin has been reported to be effective in the treatment of massive upper gastrointestinal hemorrhage. A prospective, controlled clinical trial comparing conventional treatment with conventional therapy plus intraarterial vasopressin was undertaken. Sixty episodes of upper gastrointestinal hemorrhage were evaluated during a 40-month period; 32 received conventional and 28 conventional plus vasopressin therapy. The two groups of patients were similar in type and severity of their bleeding lesions and in their underlying diseases. Vasopressin was more effective in controlling hemorrhage from nonvariceal lesions (P less than 0.05) and from varices (P less than 0.01) than conventional therapy. Transfusion requirements were significantly reduced in those patients who received vasopressin. Paradoxically, survival was not affected by vasopressin administration. The failure of cessation of hemorrhage to improve survival is thought to be due to the degree of advancement of the underlying disease, to the torrential nature of the hemorrhage, to the frequency of recurrent hemorrhage, and to the use of intraarterial vasopressin in some patients in the conventional treatment group in whom conventional therapy had failed.

Topics: Adult; Aged; Arrhythmias, Cardiac; Blood Transfusion; Clinical Trials as Topic; Connecticut; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Long-Term Care; Male; Middle Aged; Myocardial Infarction; Peptic Ulcer Hemorrhage; Placebos; Prognosis; Recurrence; Vasopressins

Topics: Clinical Trials as Topic; Ethics, Medical; Gastric Mucosa; Gastrointestinal Hemorrhage; Humans; Oxytocin; Pituitary Hormones, Posterior; Prospective Studies; Stomach Diseases; Vasopressins

Topics: Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Thrombocytopenia; Vasopressins

Vasoactives such as terlipressin, somatostatin, vasopressin, octreotide and nitrates are commonly used to treat variceal bleeding. The present study is a network meta-analysis comparing the efficacy and safety of the above vasoactive agents for treating variceal bleeding.. Electronic databases were searched for appropriate randomized clinical trials evaluating vasoactives in cirrhotic patients with variceal bleeding. Random-effects model was used to generate the pooled estimates. Mortality was the primary outcome and bleeding control, re-bleeding rate, hospital stay, blood transfusion requirements and adverse events were the secondary outcome measures.. Fifty randomized clinical trials were included of which 37 were included for the primary outcome. The overall analysis did not reveal any significant difference in the mortality risk between any of the vaso-active drugs except for terlipressin that had statistically significant benefits from direct pooled estimates. Somatostatin and terlipressin showed significant reduction in the mortality risks at 24 h. Terlipressin significantly reduced re-bleeding rate; somatostatin and vasopressin were associated with better hemostasis; and terlipressin and vasopressin significantly reduced the requirement for blood transfusion. Terlipressin, vasopressin and glyceryltrinitrate/vasopressin were also associated with increased risk of adverse events.. Terlipressin could be the best agent in the vasoconstrictor category for managing variceal bleeding. Somatostatin and vasopressin can serve as alternatives.

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemorrhage; Humans; Network Meta-Analysis; Octreotide; Randomized Controlled Trials as Topic; Somatostatin; Terlipressin; Vasoconstrictor Agents; Vasopressins

To report a novel technique and preliminary clinical outcomes in managing lower gastrointestinal bleeding (LGIB).. Eighteen LGIB patients (11 men and 7 women, mean age: 66.2 years) were treated with artificially induced vasospasm therapy by semi-selective catheterization technique. Epinephrine bolus injection was used to initiate the vascular spasm, and followed by a small dose vasopressin infusion (3-5 units/h) for 3h. The technical success, clinical success, recurrent bleeding and major complications of this study were evaluated and reported.. Sixteen bleeders were in the superior mesenteric artery and 2 in the inferior mesenteric artery. All patients achieved successful immediate hemostasis. Early recurrent bleeding (<30 days) was found in 4 patients with local and new-foci re-bleeding in 2 (11.1%) each. Repeated vasospasm therapy was given to 3 patients, with clinical success in 2. Technical success for the 21 bleeding episodes was 100%. Lesion-based and patient-based primary and overall clinical successes were achieved in 89.4% (17/19) and 77.7% (14/18), and 94.7% (18/19) and 88.8% (16/18), respectively. None of our patients had complications of bowel ischemia or other major procedure-related complications. The one year survival of our patients was 72.2 ± 10.6%.. Pharmaco-induced vasospasm therapy seems to be a safe and effective method to treat LGIB from our small patient-cohort study. Further evaluation with large series study is warranted. Considering the advanced age and complex medical problems of these patients, this treatment may be considered as an alternative approach for interventional radiologists in management of LGIB.

Topics: Acute Disease; Adult; Aged; Aged, 80 and over; Angiography; Catheterization; Contrast Media; Endpoint Determination; Epinephrine; Female; Gastrointestinal Hemorrhage; Hemostatic Techniques; Humans; Male; Middle Aged; Survival Rate; Treatment Outcome; Vasoconstriction; Vasopressins

Technological advances in the last couple of decades have led to a tremendous improvement in the safety and efficacy of embolization making it the therapeutic intervention of choice in angiogram positive lower gastrointestinal bleeding. Vasopressin has thus been forgotten and it is hardly ever used by the current generation of interventionists. However, coil embolization is technically challenging and requires greater expertise. Difficulty in super-selective catheterization and lack of adequate collateralization can also prevent successful delivery of coils. In this article we present the successful use of intra-arterial vasopressin in a patient with Crohn's disease with severe lower gastrointestinal bleeding. Despite not being the first choice, vasopressin can be safely and effectively used in selected patients who are not candidates for embolotherapy. The purpose of this article is to discuss the relative merits and demerits of vasopressin vis-à-vis embolization and to identify the role of vasopressin in the current era of super-selective embolization. Successful control of massive lower gastrointestinal bleeding by intra-arterial vasopressin infusion has previously been reported only once before in Crohn's disease. We suggest that this technique may be used in an attempt to avoid surgery in these patients.

Topics: Catheterization, Peripheral; Colonic Diseases; Crohn Disease; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Male; Mesenteric Arteries; Mesenteric Artery, Superior; Middle Aged; Vasopressins

Topics: Catheterization; Endoscopy; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Octreotide; Somatostatin; Vasopressins

We report a case that was successfully treated for massive lower gastrointestinal (LGI) bleeding due to a recurrent urinary bladder carcinoma. Treatment consisted of combination therapy including embolization of an inferior gluteal artery (IGA) pseudoaneurysm and low-dose arterial vasopressin infusion via a sigmoid artery (SA). A 57-year-old man presented with life-threatening sudden, massive LGI bleeding due to an obturator lymph node (LN) metastasis from a urinary bladder carcinoma. Computed tomography showed that the LN recurrence had invaded all the way to the sigmoid colon, and there was a pseudoaneurysm with extravasation inside the recurrence. An angiogram revealed a left IGA pseudoaneurysm. We therefore excluded the pseudoaneurysm by embolization with microcoils. Following this treatment the bleeding decreased, but intermittent LGI bleeding continued. Endoscopic examination showed the tumor with a huge ulcer inside the colonic lumen, and continuous oozing was confirmed. A second angiogram showed no recurrence of the IGA pseudoaneurysm and no apparent findings of bleeding. Then a 3F microcatheter was placed in the SA selectively using a coaxial catheter system, and vasopressin was infused at a rate 0.05 U/min for 12 h. Bleeding completely ceased 2 days later. There were no signs of ischemic gastrointestinal complications. Massive LGI bleeding has not recurred in 5 months.

Topics: Aneurysm, False; Combined Modality Therapy; Embolization, Therapeutic; Gastrointestinal Hemorrhage; Hemostatics; Humans; Infusions, Intravenous; Male; Middle Aged; Neoplasm Recurrence, Local; Recurrence; Treatment Outcome; Urinary Bladder Neoplasms; Vasopressins

Topics: Enbucrilate; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostasis; Hemostatics; Humans; Injections; Oleic Acids; Sclerosing Solutions; Sclerotherapy; Tissue Adhesives; Vasopressins

Many studies have suggested that endoscopic obliteration using cyanoacrylate for bleeding gastric fundal varices is effective. However, serious complications by injection of cyanoacrylate into varices have also been reported.. Thirty patients with bleeding gastric fundal varices underwent endoscopic injection sclerotherapy using 5% ethanolamine oleate under fluoroscopic guidance plus infusion of vasopressin and a transdermal nitroglycerin patch. The injection of 5% ethanolamine oleate was continued until it filled the varices and their feeder veins under fluoroscopic guidance. The injection needle was removed while thrombin glue was sprayed at the puncture site through the side hole of the injector needle to prevent bleeding from the puncture site.. Complete hemostasis was achieved in 28/30 patients (93.3%). The cumulative rebleeding rate after 1, 3 and 5 years was 13%, 19% and 19%, respectively. The 1-, 3-, and 5-year cumulative mortality rates were 31%, 54% and 59%, respectively. There was no complication related to infusion of vasopressin and sclerotherapy procedure.. The sclerotherapy method carried out using 5% ethanolamine oleate combined with infusion of vasopressin under fluoroscopic guidance might be a feasible method for obliteration of gastric fundal varices as an alternative to cyanoacrylate.

Topics: Adult; Aged; Cyanoacrylates; Esophageal and Gastric Varices; Feasibility Studies; Female; Gastric Fundus; Gastrointestinal Hemorrhage; Hemostasis, Endoscopic; Hemostatics; Humans; Male; Middle Aged; Nitroglycerin; Oleic Acids; Recurrence; Sclerosing Solutions; Sclerotherapy; Survival Analysis; Treatment Outcome; Vasopressins

Topics: Esophageal and Gastric Varices; Evidence-Based Medicine; Gastrointestinal Hemorrhage; Hemostasis, Endoscopic; Hemostatics; Humans; Hypertension, Portal; Liver Cirrhosis; Meta-Analysis as Topic; Sclerotherapy; Somatostatin; Vasopressins

Topics: Aneurysm, Ruptured; Angiography; Angiography, Digital Subtraction; Balloon Occlusion; Chemoembolization, Therapeutic; Embolization, Therapeutic; Gastrointestinal Hemorrhage; Gelatin Sponge, Absorbable; Hemostatic Techniques; Hemostatics; Humans; Microspheres; Polyvinyl Alcohol; Tissue Adhesives; Vasopressins

F-180 is a new, long-acting analog of vasopressin with a selective agonist effect on the vascular V1a receptors, with the advantage of having no effect on renal V2 receptors. F-180 is approximately 20 times more powerful than terlipressin in reducing portal pressure and has less marked systemic effects. The present study investigated the effects of F-180 on the outcome of portal hypertension-related bleeding in hypovolemic rats. Partial portal vein-ligated rats were subjected to portal hypertension-related bleeding by sectioning a first-order branch of the ileocolic vein. After hemodynamic stabilization, a second sectioning of the first-order branch of the ileocolic vein section was performed in the already hypovolemic animals, and either F-180 or placebo was administered. Blood transfusion was adjusted to maintain mean arterial pressure (MAP) gamma > 80 mm Hg. The first section of a first-order branch of the ileocolic vein induced a hemorrhage of similar severity in both groups of rats. After a 2nd sectioning of a first-order branch of the ileocolic vein section, F-180 was more effective than placebo in recovering shock (MAP, 21% +/- 23% vs. 0% +/- 13% in placebo; P <.05), preventing portal pressure (PP) increase during blood transfusion (PP: -1% +/- 19% vs. 47% +/- 65% in placebo; P =.07), reducing transfusion requirements (2.9 +/- 3.3 mL vs. 11.2 +/- 6.0 mL in placebo; P <.01), diminishing the magnitude of collected blood losses (5.1 +/- 2.2 g vs. 12.7 +/-7.7 g in placebo; P <.05), and decreasing the mortality from the portal hypertension-related bleeding (10% vs. 60% in placebo; P <.05). In conclusion, in hypovolemic portal-hypertensive rats during a portal hypertension-related bleeding, F-180 rapidly recovers arterial pressure and decreases transfusion requirements, blood losses, and mortality.

Topics: Animals; Blood Pressure; Blood Transfusion; Gastrointestinal Hemorrhage; Hypertension, Portal; Male; Portal Pressure; Rats; Rats, Sprague-Dawley; Vasoconstrictor Agents; Vasopressins

Topics: Anticoagulants; Embolization, Therapeutic; Gastrointestinal Hemorrhage; Heparin; Humans; Infusions, Intra-Arterial; Tissue Plasminogen Activator; Tolazoline; Vasopressins

Topics: Gastrointestinal Hemorrhage; Hemostatics; Home Infusion Therapy; Hospice Care; Humans; Leiomyosarcoma; Male; Middle Aged; Vasopressins

Case reports about vasopressin-induced cutaneous necrosis are not frequent. Here we report a further case, of which skin manifestations included not only mottling, cyanosis, ecchymosis, bullae and gangrene, but also amber-like change in focal areas. Besides, intermittent paling of the skin with or without deep pain sensation of the limbs over non-injection sites was observed that might be a warning sign of impending skin necrosis. Based on the literature about vasopressin-induced skin necrosis we discuss the possible role of coagulation enhancement of this molecule.

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatics; Humans; Male; Middle Aged; Necrosis; Pigmentation Disorders; Skin Diseases; Vasopressins

A 35-year-old male sustained a full-skin thickness chemical burn involving 60 per cent of TBSA when hydrochloric acid was applied to his face, trunk and extremities by his girlfriend. Debridements and skin graftings were performed smoothly and he was doing well until day 23 after injury, when massive GI tract bleeding caused a drop in blood pressure. Vasopressin was given intravenously to control the bleeding, which stopped, and the blood pressure returned to normal after transfusion. After the vasopressin infusion was tapered off acute pulmonary oedema developed abruptly, which required treatment by intubation and PEEP using a respirator. The lung condition had returned to normal by the following day. A second episode of massive GI tract bleeding recurred 10 days later, again vasopressin was given through a catheter into the inferior mesenteric artery. Again pulmonary oedema developed 38 h after the vasopressin use, the oedema disappeared within 2 days when the vasopressin infusion tapered off. It should be kept in mind that acute pulmonary oedema may develop when high doses of vasopressin are used in the treatment of Curling's ulcer or other GI tract bleeding.

Topics: Acute Disease; Adult; Burns, Chemical; Debridement; Gastrointestinal Hemorrhage; Hemostatics; Humans; Infusions, Intravenous; Male; Pulmonary Edema; Radiography, Thoracic; Skin; Skin Transplantation; Vasopressins

Vasopressin (Pitressin, 8-arginine vasopressin) is a potent vasoconstrictor of splanchnic arterioles. When administered by continuous intravenous infusion, it reduces portal blood flow and pressure and is used in the management of bleeding esophageal varices. We describe a purpuric and necrotic cutaneous reaction to vasopressin that occurred at locations distant from intravenous catheter sites, and we review previous reports of similar reactions.

Topics: Dose-Response Relationship, Drug; Drug Eruptions; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Infusions, Intravenous; Male; Middle Aged; Purpura; Skin; Vasopressins

After positive mesenteric angiography for massive lower gastrointestinal hemorrhage, one is faced with a localized bleeding site and the therapeutic options of embolization, vasopressin infusion, observation, or operation. This review was designed to determine long term outcomes of angiographically controlled bleeding. All cases of mesenteric angiography for hemorrhage performed over a twelve year period were reviewed, with focus on those treated non-operatively. A total of 37 patients had angiographically localized bleeding distal to the ligament of Treitz. Twenty-one patients were controlled with vasopressin, embolization, or spontaneous cessation. Only three patients had recurrent bleeding, at one month, one year, and eight years. No patients died from recurrent bleeding. Five patients died without any further bleeding; mean time to death was 2 years. Twelve patients had no further bleeding at a mean follow-up of 2.6 years. Bleeding controlled by any angiographic measure, was followed by recurrent bleeding in 14% without the need for operative intervention.

Topics: Angiography; Embolization, Therapeutic; Gastrointestinal Hemorrhage; Humans; Mesenteric Arteries; Mesentery; Recurrence; Retrospective Studies; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hormone Antagonists; Humans; Liver Cirrhosis; Liver Transplantation; Portasystemic Shunt, Surgical; Sclerotherapy; Somatostatin; Vasopressins

Bleeding from oesophageal varices is an uncommon but potentially fatal condition that often leads to expensive hospitalizations in intensive care or high-dependency units.. To assess the clinical and economic impact of this condition, we have devised a management plan illustrating current clinical practice in the UK.. Approximately 6.1 million pounds of NHS resources are devoted to the treatment of 3000 acute hospital admissions for variceal bleeding every year. Vasoconstrictors like vasopressin may save approximately 36 lives per annum for an additional 145 thousand pounds. However, current clinical practice requires vasopressin to be concurrently administered with intravenous glyceryl trinitrate, increasing overall costs by 582 thousand pounds to a total of 6.7 million pounds. The additional cost for each extra life saved is estimated at 16,180 pounds.. The efficacy of current vasoconstrictors requires further confirmation. In particular, new agents like octreotide (Sandostatin) should be carefully assessed to determine their potential clinical and economic benefits.

Topics: Acute Disease; Costs and Cost Analysis; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hospitalization; Humans; Nitroglycerin; Patient Care Planning; United Kingdom; Vasoconstrictor Agents; Vasopressins

Torsade de pointes is an unusual life-threatening ventricular arrhythmia that has been associated with vasopressin, neuroleptic drugs, and electrolyte imbalances, including hypokalemia and hypomagnesemia. Over a 9-month period, we observed torsade de pointes in three patients with cirrhosis and bleeding esophageal varices who did not have prior cardiac disease. All had received endoscopic sclerotherapy and continuous infusions of vasopressin and nitroglycerin. For sedation, two patients received haloperidol and one droperidol. In addition, two patients had either hypokalemia or hypomagnesemia. In all three patients, there was prolongation of the electrocardiographic QT interval and a "long-short" initiating sequence followed by ventricular tachycardia with torsade de pointes morphology. All were successfully cardioverted; there was one late death due to aspiration and septicemia. We conclude that cirrhotics with variceal hemorrhage may be at increased risk of developing this arrhythmia in the setting of treatment with vasopressin, sedation with neuroleptic drugs, and electrolyte abnormalities. We urge close monitoring of these patients for cardiac arrhythmia and recommend that neuroleptics be used cautiously, if at all.

Topics: Adult; Antipsychotic Agents; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis; Male; Middle Aged; Torsades de Pointes; Vasopressins; Water-Electrolyte Imbalance

Topics: Adult; Bradycardia; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Hyponatremia; Pregnancy; Pregnancy Complications, Cardiovascular; Vasopressins

Topics: Catheterization; Embolization, Therapeutic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatics; Humans; Liver Cirrhosis; Sclerotherapy; Somatostatin; Vasopressins

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatics; Humans; Lypressin; Somatostatin; Terlipressin; Vasopressins

A problem in pharmacotherapy for bleeding varices in portal hypertension is non-responders. The aim of this study was to elucidate the features of hemodynamic response to vasopressin in the gastroesophageal collateral vein in patients with esophageal varices.. Flow velocity in the portal and the collateral left gastric vein was measured with an echo-Doppler flowmeter before and during infusion of vasopressin, 0.2 U/min, in 41 patients with cirrhosis and esophageal varices.. The decrease in flow velocity in the left gastric vein with vasopressin (-29 +/- 25%) was significantly smaller than that in the portal vein (-56 +/- 20%). There was no or only minimal change in flow velocity in the left gastric vein in 39% of the patients, especially in those with large-size varices. In 28 patients examined by portal catheterization, changes in flow velocity in the left gastric vein were correlated with portal pressure, and portal pressure in non-responders was significantly higher than that in responders (non-responders: 363 +/- 49, responders: 312 +/- 41 mmH2O, p < 0.05).. It was concluded that hepatofugal blood flow in the gastroesophageal collateral is not readily reduced by vasopressin. However, as the study was performed in a stable condition without variceal bleeding, whether these hemodynamic features will apply during acute variceal bleeding in patients who are known to have a poor hemodynamic response to vasopressin remains to be elucidated.

Topics: Aged; Blood Flow Velocity; Collateral Circulation; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Hemodynamics; Hemostatics; Humans; Hypertension, Portal; Liver Cirrhosis; Male; Middle Aged; Retrospective Studies; Stomach; Ultrasonography, Doppler, Duplex; Ultrasonography, Doppler, Pulsed; Vasopressins; Veins

In 40 patients with esophageal varices, esophageal variceal pressure was assessed endoscopically using a pneumatic pressure sensor. The effects of vasopressin or nitroglycerin on variceal pressure and endoscopic findings were also assessed in two groups of seven patients. The results were as follows: (1) Variceal pressure was increased above 250 mmH2O in all patients who had bled, and the mean variceal pressure was significantly higher in patients who had bled than in those who had not (301 +/- 47 vs. 230 +/- 58 mmH2O respectively, p < 0.001). (2) Variceal pressure correlated with endoscopic findings, determined using the criteria of the Japanese Research Society for Portal Hypertension. It was significantly higher when varices with a feature of F2-F3 or RC(+2)-RC(+3) were compared to those with a feature of F1 or RC(-)-RC(+), respectively. (3) Both groups given vasopressin or nitroglycerin had significant reductions in variceal pressure; however, there was little improvement in endoscopic findings in those given nitroglycerin, compared to the improvement in those given vasopressin. Thus, use of a pneumatic pressure sensor proved to be a pertinent tool for assessing esophageal varices, along with endoscopic signs.

Topics: Aged; Blood Pressure; Blood Pressure Determination; Esophageal and Gastric Varices; Esophagoscopy; Esophagus; Female; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Male; Middle Aged; Nitroglycerin; Vasopressins

Topics: Acute Disease; Esophageal and Gastric Varices; Esophagoscopy; Gastrointestinal Hemorrhage; Humans; Octreotide; Sclerotherapy; Somatostatin; Vasopressins

Several options are available for therapy and prophylaxis of variceal hemorrhage: endoscopic sclerotherapy or endoscopic ligation, shunt surgery, intrahepatic stents (TIPS), transsection or drugs. For acute hemostasis, endoscopic procedures are still the method of choice. Application of vasopressin or somatostatin adjuvant or prior to endoscopy may be considered. Prophylaxis of first bleeding or of rebleeding should be tailored individually.

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatics; Humans; Propranolol; Sclerotherapy; Somatostatin; Vasopressins

The effect of intravenous vasopressin infusion in 5 patients with upper GI bleeding was studied by measuring portal blood flow velocity with pulsed Doppler ultrasound technique. In 4 of 5 patients portal blood flow velocity decreased at 1 hr after vasopressin infusion. In all patients the velocity decreased at 24 or 48 hrs. We think doppler is safe and useful method in the evaluation of vasopressin infusion therapy.

Topics: Adult; Aged; Blood Flow Velocity; Evaluation Studies as Topic; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Intravenous; Male; Middle Aged; Portal Vein; Ultrasonography; Vasopressins

Severe upper gastrointestinal bleeding is unusual in newborns, and is usually seen in sick premature infants. We report on three healthy full-term neonates who, after uneventful deliveries, presented with profuse bleeding in the first 48 h of life. Two infants had duodenal ulcers and one had diffuse hemorrhagic gastritis. All three patients responded to conservative medical therapy and have shown no recurrence of symptoms during a follow-up period of 1-4 yr.

Topics: Duodenal Ulcer; Female; Follow-Up Studies; Gastritis; Gastrointestinal Hemorrhage; Humans; Infant, Newborn; Male; Peptic Ulcer Hemorrhage; Ranitidine; Time Factors; Vasopressins

Continuous infusion of IV vasopressin have been widely used to lower portal pressure and reduce bleeding from esophageal varices. Recently, the combination of vasopressin and nitroglycerin has been noted to be superior to vasopressin alone. This is due to the ability of nitroglycerin to reduce the detrimental effects of vasopressin while preserving its beneficial effects. In September 1989 the authors initiated a protocol in the medical intensive care unit of a large university teaching center that directed caregivers in the simultaneous use of vasopressin and nitroglycerin for use in variceal bleeding.. To determine whether the protocol was being used correctly and whether the addition of nitroglycerin produced the desired cardiovascular effects.. Nineteen patients (25 separate episodes) assigned to the vasopressin/nitroglycerin protocol were monitored retrospectively over a 20-month period for a total of 1068 hours of vasopressin/nitroglycerin infusion. Twenty-four patients received nitroglycerin at 10 to 50 micrograms per minute, 13 at 50 to 100 micrograms per minute and 6 at 100 to 400 micrograms per minute.. Nitroglycerin dosage was not advanced appropriately in 78% of episodes despite evidence of bradycardia, hypertension and peripheral vasoconstriction.. Revision of the protocol, giving additional guidance to clinicians on assessment and nitroglycerin advancement, was necessary and was accomplished.

Topics: Bradycardia; Clinical Protocols; Constriction, Pathologic; Drug Monitoring; Drug Therapy, Combination; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Heart Rate; Hemodynamics; Humans; Hypertension; Infusions, Intravenous; Nitroglycerin; Nursing Assessment; Nursing Evaluation Research; Nursing Records; Patient Care Planning; Practice Patterns, Physicians'; Retrospective Studies; Vasopressins

Topics: Arteriovenous Fistula; Blood Component Transfusion; Blood Transfusion; Carcinoma, Hepatocellular; Child; Endoscopy, Gastrointestinal; Epistaxis; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Hematemesis; Hepatic Artery; Humans; Hypertension, Portal; Liver Neoplasms; Portal Vein; Sclerotherapy; Tomography, X-Ray Computed; Ultrasonography; Vasopressins

A patient with acute esophageal variceal bleeding developed fatal rhabdomyolysis during treatment with a continuous intravenous infusion of vasopressin. Signs of ischemia, including mottling of skin and painful extremities, preceded the development of the characteristic electrolyte abnormalities and cardiac arrhythmias. No other recognized causes of rhabdomyolysis were identified on retrospective review of the hospital course. There are several factors which might promote a peripheral ischemic response to vasopressin in the bleeding cirrhotic patient, including altered resting hemodynamics, increased resting sympathetic tone, impaired vasodilation as a compensatory response to vasopressin, and reduced hepatic drug clearance. Idiosyncratic factors involving vasopressin receptor affinity and distribution, vasopressin-associated vasodilation in some vascular beds, and the effect of vasopressin on the renin-angiotensin system may further contribute to impaired tissue perfusion. These multiple overlapping factors probably lead to rhabdomyolysis in a minority of patients receiving vasopressin infusion.

Topics: Aged; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Infusions, Intravenous; Male; Rhabdomyolysis; Risk Factors; Vasopressins

Topics: Aged; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Infusions, Intravenous; Male; Myocardial Ischemia; Nitroglycerin; Torsades de Pointes; Vasopressins

A series of 23 patients with intractible gastrointestinal (GI) bleeding were managed by the transcatheter method. The series included 5 with hemobilia, 8 with upper GI (UGI) bleeding, 5 with lower GI (LGI) bleeding and 5 with variceal bleeding. The etiology of the hemobilia was surgery, or percutaneous transhepatic cholangiography and drainage (PTCD) complicated by various degrees of biliary tract infection. The causes of UGI bleeding included erosive gastritis, gastric and duodenal ulcers, and traumatic duodenal laceration. All 5 LGI bleedings were due to ischemic colitis and all 5 variceal bleedings were due to hyperdynamic portal hypertension from arterio-portal (A-P) shunting for hepatocellular carcinomas (HCC). Intra-arterial vasopressin infusion was performed on 17 (4, hemobilia; 8, UGI; and 5 LGI bleeding) of these 23 cases as initial management. The success rate for vasopressin in hemobilia, UGI and LGI bleeding was 75% (3/4), 38% (3/8), and 60% (3/5), respectively. The overall initial success rate of vasopressin was 52% (9/17). The relatively poor success rate of vasopressin infusion for UGI bleeding was due to ulcers and laceration. The incidence of rebleeding for vasopressin infusion was 22% (2/9) including one case each of UGI and LGI bleeding. Three patients (1 hemobilia and 2 UGI bleeding) among these 17 cases underwent transarterial embolization (TAE) after failure of intra-arterial vasopressin infusion. One of these 23 cases with hemobilia underwent TAE for initial transcatheter control of the GI bleeding. Five cases of active esophageal variceal bleeding, caused by A-P shunting in HCC, were all successfully controlled by TAE.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Adult; Aged; Angiography; Catheterization; Embolization, Therapeutic; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Hemobilia; Humans; Infusions, Intra-Arterial; Male; Middle Aged; Vasopressins

Topics: Angiography; Embolization, Therapeutic; Extravasation of Diagnostic and Therapeutic Materials; Gastrointestinal Hemorrhage; Humans; Vasopressins

In case of intestinal bleeding, selective angiography is very informative to detect the cause of bleeding and the site of bleeding. Major diseases examined were ischemic lesions of intestine diverticulosis, myogenic tumors, and severe cases of ulcerative colitis. Operations were carried out when indicated. To the rest of the cases interventional angiography was carried out. Interventional angiography for intestinal bleeding was performed to 52 cases inclusive of 9 cases of bleeding from the tumor, 2 cases of diverticulosis, 3 cases of intestinal Behcet and 28 cases of severe ulcerative colitis. Administered drugs were continuous perfusion of vasopressin to the ruptured vessels and water-soluble bolus intraarterial injection of prednisolone to the inflammatory process of ulcerative colitis. All the vasopressin cases were responded to this therapy. Efficacy of intraarterial injection of prednisolone was evaluated in 56 cases including the cases of cooperative study group. Efficacy was compared to the 5 days intensive intravenous therapy, revealing the similar response rate. It was also reported that seven cases to which the 5 days intensive therapy was ineffective responded to intraarterial injection therapy. Mechanism of intraarterial injection therapy was studied by analyzing the pre and post angiographical findings and by measuring mucosal blood flow and oxygen saturation. Administered high dose of prednisolone may improve the microcirculation. Further studies were indicated.

Topics: Adolescent; Adult; Angiography; Behcet Syndrome; Colitis, Ulcerative; Diverticulum; Female; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Intestinal Neoplasms; Male; Middle Aged; Prednisolone; Radiography, Interventional; Vasopressins

It has been suggested that vasopressin given during hemorrhage may be less effective than when given during a stable state in a portal-hypertensive rat model. This study was designed to evaluate the hemodynamic response to vasopressin infusion in 25 HBsAg-positive cirrhotic patients. Nine patients had active variceal hemorrhage before vasopressin infusion, and the other 16 patients were in a stable condition at the time of infusion. The two groups of patients were similar in baseline values except that a higher heart rate was found in patients with hemorrhage (96 +/- 20 vs. 73 +/- 10 beats/min, mean +/- S.D., p less than 0.01). Thirty minutes after vasopressin infusion (0.66 units/min), hepatic venous pressure gradient significantly decreased in both bleeding and stable patients (from 21 +/- 9 to 18 +/- 9 mm Hg, p less than 0.05; and from 18 +/- 4 to 8 +/- 3 mm Hg, p less than 0.0001, respectively). However, the decrease of hepatic venous pressure gradient was less obvious in bleeding patients as compared with stable patients (4 +/- 3 vs. 9 +/- 2 mm Hg, p less than 0.0001). A significant reduction of hepatic venous pressure gradient after vasopressin infusion was found in five bleeding patients without shock (from a median of 16 mm Hg [range = 12 to 26] to 11 mm Hg [range = 6 to 18], p less than 0.05), but not in four bleeding patients with shock (from 28 [range = 15 to 36] to 25 [range = 18 to 33] mm Hg, p greater than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Aged; Blood Pressure; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Heart Rate; Hepatitis B; Humans; Liver Circulation; Liver Cirrhosis; Male; Middle Aged; Vasopressins; Venous Pressure

We report a 33-year-old man who developed cutaneous necrosis of the lower extremities with extensive bulla formation after i.v. administration of vasopressin for the treatment of bleeding esophageal varices. Due to its potent nonselective vasoconstrictive action, vasopressin not only may induce cardiac and gastrointestinal ischemia, but cutaneous ischemia as well. As in our patient, this may lead to extensive necrotic skin lesions at sites distant from the infusion.

Topics: Adult; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Leg Ulcer; Male; Skin Diseases, Vesiculobullous; Vasopressins

Vasopressin is often used to treat variceal hemorrhage. However, its efficacy is uncertain, and its portal hemodynamic effects in this setting are unknown. Eleven patients with alcoholic liver disease and bleeding varices were given vasopressin (0.2 U/min for the first hour, then 0.4 U/min for 24 hours). Portal pressure was monitored using an indwelling hepatic vein balloon catheter. Seventeen patients with variceal bleeding who remained stable over 26 hours of initial treatment with crystalloid and blood products served as a comparison group. Vasopressin infusion (0.2 U/min) produced a significant decrease in wedged hepatic venous pressure, hepatic venous pressure gradient (wedged minus free hepatic venous pressure), and heart rate. Increases in the rate of infusion did not produce further decreases in the parameters measured, but the changes were sustained over the course of the infusion. Hemodynamics remained stable in the control group. Portal pressure did not increase when vasopressin was abruptly discontinued in the 3 patients in whom postinfusion measurements were made. Vasopressin retains its portal hypotensive effects in the setting of variceal hemorrhage. Tachyphylaxis does not develop over 26 hours, and a "rebound" increase in portal pressure probably does not occur when the infusion is discontinued.

Topics: Adult; Blood Pressure; Catheterization; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Hepatic Veins; Humans; Liver Cirrhosis, Alcoholic; Male; Middle Aged; Vasopressins; Venous Pressure

VP has long been used in patients with acute variceal bleeding. While NTG has generally only been added to offset the serious side effects of VP, it potentiates the hemodynamic effects of VP in the portal bed. It is imperative that the critical care nurse understand the combination use of VP and NTG so that intelligent assessment, care planning, and evaluation can occur.

Topics: Clinical Protocols; Critical Care; Drug Therapy, Combination; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Middle Aged; Nitroglycerin; Patient Care Planning; Vasopressins

To assess vasopressin control of esophageal variceal bleeding, we investigated the effect of vasopressin on the left gastric venous flow, portal venous flow, superior mesenteric venous flow, and splenic venous flow in seven cirrhotic patients with esophageal varices, using a duplex system consisting of a real-time ultrasonograph and an echo-Doppler flowmeter. Infusion of vasopressin (0.3 U/min) significantly decreased the blood flow in the left gastric vein (-56%), portal trunk (-54%), superior mesenteric vein (-54%), and splenic vein (-56%) as a result of decrease of blood velocity in these vessels. Thus, vasopressin seems to control esophageal variceal bleeding, in part, by reducing blood velocity and blood flow in the left gastric vein following reduction of blood velocity and blood flow in the superior mesenteric vein and splenic vein.

Topics: Adult; Blood Flow Velocity; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis; Male; Mesenteric Veins; Middle Aged; Portal Vein; Regional Blood Flow; Splenic Vein; Stomach; Ultrasonography; Vasopressins

The purpose of this retrospective study was to determine the diagnostic and therapeutic usefulness of gut angiography in patients with massive upper gastrointestinal bleeding from a nonvariceal source. All patients (n = 64) in this category who underwent a gut angiogram between 1980 and 1986 were studied. Pre-angiogram endoscopy was attempted in all patients and was nondiagnostic in 14 (22%). Contrast extravasation at angiography was seen in 25 of 64 patients (39%), and in over half of these patients endoscopy was nondiagnostic (n = 11) or wrong (n = 3). Attempts to control bleeding in this group by selective arterial embolization (n = 14) or intra-arterial vasopressin (n = 11) successfully averted operation in 13 of 25 patients (52%) and was associated with a 50% reduction in mortality (83% versus 38%). Selective embolization of vessels thought to be bleeding on clinical grounds without evidence of contrast extravasation (i.e., "blind" embolization) was not helpful in controlling hemorrhage. Urgent gut angiography in patients with massive upper gastrointestinal bleeding of arteriocapillary source is a useful diagnostic and therapeutic maneuver and warrants continued application in this group of poor-risk patients.

Topics: Aged; Aged, 80 and over; Angiography; Embolization, Therapeutic; Female; Gastrointestinal Hemorrhage; Humans; Male; Middle Aged; Retrospective Studies; Risk Factors; Vasopressins

Advances in endoscopic therapy have dramatically altered the approach to acute upper gastrointestinal tract hemorrhage. It can no longer be assumed that early endoscopic evaluation of this condition does not affect outcome. In the management of selected patients with nonvariceal hemorrhage, endoscopic therapy affects rates of rebleeding, need for surgery and transfusions, and length of hospitalization. For patients with variceal hemorrhage, the impact of endoscopic treatment is less clear. The endoscopic advances of the past decade have been exciting and have presented new challenges. Future investigators need to better define subgroups of patients who will benefit from this technology and determine which of the many techniques available will be safest and most efficacious.

Topics: Acute Disease; Endoscopy; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Laser Therapy; Peptic Ulcer Hemorrhage; Recurrence; Sclerotherapy; Vasopressins

A 35 year old man presented with massive lower gastrointestinal hemorrhage due to typhoid enteritis. After confirming the site of bleeding on a selective superior mesenteric angiogram, a vasopressin infusion was given at the rate of 0.2-0.4 units/min initially, followed by tapering doses over 36 hours. Cessation of bleeding was achieved immediately. The patients did not have any complications due to the procedure. Continuous vasopressin infusion is an effective method for the treatment of uncontrolled bleeding from typhoid enteritis.

Topics: Adult; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Male; Typhoid Fever; Vasopressins

In the present study, 52 patients with cirrhosis, portal hypertension, and variceal hemorrhage underwent either an elective or an emergency side-to-side portacaval shunt operation. Vasopressin was infused intravenously at 60 units/hour from just prior to abdominal incision until completion of the anastomosis. Eight of 35 patients who received vasopressin alone (23 percent) tolerated increased doses of 75 to 90 units/hour to obtain hemostasis. Four of 52 patients required simultaneous infusion of sodium nitroprusside to correct systemic hypertension. An additional 15 percent reduction in portal venous pressure occurred in these patients. Eleven of 13 patients with vasopressin-induced myocardial ischemia responded to simultaneous infusion of nitroglycerin. Further prospective studies are indicated to adequately delineate the dose and duration of therapy with either nitroprusside or nitroglycerin for simultaneous administration with intravenous vasopressin.

Topics: Adult; Aged; Coronary Disease; Drug Therapy, Combination; Esophageal and Gastric Varices; Female; Ferricyanides; Gastrointestinal Hemorrhage; Humans; Intraoperative Period; Male; Middle Aged; Nitroglycerin; Nitroprusside; Portacaval Shunt, Surgical; Retrospective Studies; Vasopressins

Topics: Aged; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Infusions, Intravenous; Ischemia; Male; Scrotum; Vasopressins

Sixty-eight patients with massive lower gastrointestinal (G.I.) hemorrhage underwent emergency arteriography. Patients were transfused an average of six units of packed red blood cells within 24 hours of admission. The bleeding source was localized arteriographically in 27 (40%), with a sensitivity of 65% among patients requiring emergency resection. However, twelve of the 41 patients with a negative arteriogram still required emergency intestinal resection for continued hemorrhage. Radionuclide bleeding scans had a sensitivity of 86%. The right colon was the most common site of bleeding (35%). Diverticulosis and arteriovenous malformation were the most common etiologies. Selective intra-arterial infusion of vasopressin and embolization were successful in 36% of cases in which they were employed and contributed to fatality in two patients. Twenty-three patients underwent segmental resection, whereas seven patients required subtotal colectomy for multiple bleeding sites or negative studies in the face continued hemorrhage. Intraoperative infusion of methylene blue via angiographic catheters allowed successful localization and resection of bleeding small bowel segments in three patients. Overall mortality was 21%. The mortality for patients without a malignancy, with a positive preoperative arteriogram, and emergency segmental resection was 13%.

Topics: Aged; Blood Transfusion; Cause of Death; Colectomy; Combined Modality Therapy; Embolization, Therapeutic; Emergencies; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Male; Mesenteric Arteries; Middle Aged; Radiography; Retrospective Studies; Vasopressins

In a series of 602 consecutive sclerotherapies, two cirrhotic patients who had received successful sclerotherapy for control of variceal bleeding while on vasopressin infusions developed mesenteric thrombosis. We found no other cases (in our institution or in literature review) where sclerotherapy or vasopressin infusion alone precipitated mesenteric thrombosis. During vasopressin infusion, there is portal stasis and an increased caudad flow of sclerosant. We suggest that mesenteric thrombosis is a consequence of the combination of these two effects. Direct injection of gastric varices is difficult because of increased postsclerotherapy bleeding, but sclerosis of esophageal varices often leads to their obliteration by the caudad flow of sclerosant. We propose, therefore, that vasopressin infusion during esophageal sclerotherapy may be beneficial in the obliteration of gastric varices. We conclude that (a) in patients without gastric varices, vasopressin infusion increases the incidence of mesenteric thrombosis, and (b) vasopressin infusion during sclerotherapy may enhance the sclerosis of gastric varices.

Topics: Adult; Aged; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis; Male; Mesenteric Vascular Occlusion; Mesenteric Veins; Portal System; Sclerosing Solutions; Thrombosis; Vasopressins

Intravenous (IV) vasopressin has been used to control human upper gastrointestinal (GI) hemorrhage for over 30 years. Although the use of vasopressin has been studied extensively in adults, no study has evaluated its use in children. Vasopressin was used therapeutically in 15 episodes of esophageal variceal hemorrhage and two episodes of bleeding peptic ulcer. Nine of 17 episodes were controlled with vasopressin alone (53%). Balloon tamponade and variceal sclerosis were required for control in the remainder. Blood requirements averaged 53 mL/kg prior to control of hemorrhage. Metabolic complications occurred in 65% of the episodes. There were two groups of patients identified: those receiving greater or those receiving less than .01 units/kg/min of IV vasopressin. All of the complications identified occurred when greater than .01 U/kg/min of vasopressin were used (P less than .05). Control of bleeding was not improved with higher doses of vasopressin. These data suggest that the use of IV vasopressin at doses greater than .01 U/kg/min to control GI bleeding will increase the incidence of complications without improving control of hemorrhage.

Topics: Child; Drug Administration Schedule; Drug Therapy, Combination; Gastrointestinal Hemorrhage; Humans; Infusions, Intravenous; Nitroglycerin; Random Allocation; Vasopressins

A patient experienced hypertension, bradycardia, QT prolongation, and multiple episodes of torsade de pointes while receiving an iv vasopressin infusion. The dysrhythmias were attributed to vasopressin, but may have been potentiated by hypomagnesemia. Upon vasopressin discontinuation, ECG findings returned to normal before magnesium supplementation. Vasopressin may contribute to the development of torsade de pointes.

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Male; Middle Aged; Tachycardia; Vasopressins

Based on laboratory and clinical data from our institution, 113 patients with cirrhosis, portal hypertension, and acute hemorrhage from esophageal varices were treated with high-dose vasopressin arginine (1 to 1.5 U/min) to control the acute bleeding and reduce blood loss during portosystemic shunt operations. Compared with patients receiving a lower dose of vasopressin infusion, these patients had a reduction in both postoperative mortality (21% vs 6%) and the proportion of patients requiring emergency operation (40% vs 18%). A decrease in operative blood loss (1340 vs 793 mL) was also seen. Adverse effects of vasopressin were increased by high-dose infusion, but no significant morbidity occurred. These results suggest that high-dose vasopressin infusion can reduce the mortality of acute variceal hemorrhage and porto-systemic shunting primarily by allowing patients to improve hepatic function prior to an elective operation and by decreasing intraoperative blood loss.

Topics: Acute Disease; Adult; Aged; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Intravenous; Male; Middle Aged; Portasystemic Shunt, Surgical; Vasopressins

Occult bleeding in the small bowel was localized with mesenteric angiography in 64 patients. Two groups of patients were identified. In the first group comprising 38 patients, bleeding sites were localized by the demonstration of contrast extravasation. In the second group of 26 patients, there was no extravasation. However, other angiographic findings suggested the source of bleeding. No active bleeding was necessary for a positive study in the second group. We conclude that in patients with suspected occult small bowel hemorrhage, mesenteric angiography helps localize the bleeding site. Clinically active bleeding is not always necessary, as angiographic findings other than extravasation may localize the source of hemorrhage.

Topics: Adult; Aged; Aged, 80 and over; Angiography; Embolization, Therapeutic; Extravasation of Diagnostic and Therapeutic Materials; Female; Gastrointestinal Hemorrhage; Humans; Intestine, Small; Male; Middle Aged; Vasopressins

Topics: Adult; Gastrointestinal Hemorrhage; Hemostasis, Surgical; Humans; Infusions, Intra-Arterial; Jejunal Neoplasms; Leiomyosarcoma; Male; Mesenteric Arteries; Radiography; Vasopressins

Topics: Adult; Aged; Embolization, Therapeutic; Female; Gastrointestinal Hemorrhage; Humans; Male; Middle Aged; Somatostatin; Stomach Diseases; Vasopressins

Topics: Embolization, Therapeutic; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Vasopressins

Topics: Aged; Gastrointestinal Hemorrhage; Humans; Infusions, Intravenous; Male; Myocardial Infarction; Vasopressins

The cause and treatment of early variceal bleeding in 15 patients who had undergone distal splenorenal shunt were reviewed. Eight of these patients were taken from a group of 91 who underwent selective shunts from July 1983 through June 1985 and had extensive preoperative and postoperative evaluation of shunt patency and pressure gradient. Seven patients operated upon before July 1983 were reviewed because they illustrate the cause, diagnosis, successful and unsuccessful management of bleeding after selective shunt. Urgent selective arteriography combined with shunt catheterization is the key diagnostic and therapeutic maneuver. Thrombosis of the shunt can be successfully managed by revising the anastomosis. Stenosis of the shunt can be successfully treated with balloon dilation or operative revision of the anastomosis. When renal vein hypertension (RVH) occurs, there might be inadequate decompression of the varices. A gradient of 10 millimeters of mercury or greater from left renal vein to vena cava is diagnostic. Measurements of 30 patients who had no bleeding and one patient with documented RVH show the gradient decreases over time. Treatment should be supportive until this adaptation occurs. Hemorrhage can also occur in patients with a patient shunt but without a significant pressure gradient. Inadequate decompression of the varices through the short gastric veins leading to the spleen has been proposed as one cause. Termed short gastric hypertension, this syndrome could be expected to parallel RVH because the venous collaterals will enlarge and eventually decompress the varices. Treatment should be aimed toward supporting the patient until this adaptation occurs. A small number of patients continue to bleed despite these therapeutic interventions but can sometimes be salvaged with a total shunt.

Topics: Catheterization; Dilatation; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Portasystemic Shunt, Surgical; Postoperative Complications; Reoperation; Risk; Splenorenal Shunt, Surgical; Time Factors; Vasopressins

Topics: Esophageal and Gastric Varices; Esophagoscopes; Gastrointestinal Hemorrhage; Humans; Laser Therapy; Recurrence; Sclerosing Solutions; Shock; Vasopressins

Topics: Aged; Colonic Polyps; Female; Gastrointestinal Hemorrhage; Humans; Postoperative Complications; Vasopressins

We report the occurrence of acute portal vein thrombosis in three patients undergoing endoscopic variceal sclerosis (EVS) for bleeding esophageal varices. All patients received intravenous vasopressin in close proximity to or at the time of EVS. By increasing flow of sclerosant caudally into gastric veins during EVS, vasopressin may predispose to retrograde propagation of thrombus into the portal venous system. Combined use of vasopressin and EVS for treatment of bleeding esophageal varices should be undertaken with caution.

Topics: Acute Disease; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Male; Mesenteric Vascular Occlusion; Mesenteric Veins; Middle Aged; Portal Vein; Sclerosing Solutions; Thrombosis; Vasopressins

Topics: Aged; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Infusions, Intravenous; Portacaval Shunt, Surgical; Splenorenal Shunt, Surgical; Vasopressins

Topics: Blood Transfusion; Brain Diseases; Critical Care; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatic Techniques; Humans; Lypressin; Sepsis; Somatostatin; Terlipressin; Vasopressins

Topics: Antacids; Blood Transfusion; Diagnosis, Differential; Emergencies; Gastric Lavage; Gastrointestinal Hemorrhage; Gravity Suits; Humans; Monitoring, Physiologic; Physical Examination; Resuscitation; Shock, Hemorrhagic; Somatostatin; Vasopressins

Topics: Adrenergic beta-Antagonists; Emergencies; Esophageal and Gastric Varices; Esophagoscopes; Gastrointestinal Hemorrhage; Gastroscopes; Hemodynamics; Humans; Hypertension, Portal; Portasystemic Shunt, Surgical; Recurrence; Risk; Sclerosing Solutions; Somatostatin; Vasopressins

Topics: Embolization, Therapeutic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Somatostatin; Tampons, Surgical; Vasopressins

Fifty patients with massive lower gastrointestinal bleeding were initially managed with emergency angiography. The average age was 67.2; mean hematocrit, 23.7; and average transfusion, 7.6 units. Thirty-six patients (72%) had bleeding site located; bleeding sites were distributed throughout the colon. Etiologies of bleeding included diverticular disease (19 patients) and arteriovenous malformations (15 patients). Twenty of 22 (91%) patients receiving selective intra-arterial vasopressin stopped bleeding; however, 50% rebled on cessation of vasopressin. Thirty-five of 50 (70%) patients underwent surgery, with 57% operated on electively after vasopressin therapy. Seventeen patients had segmental colectomy, with no rebleeding. Nine of the 17 patients had diverticular disease in the remaining colon. Operative morbidity in these 35 patients was significantly improved when compared to previously reported patients undergoing emergency subtotal colectomy without angiography (8.6% vs. 37%) (p less than 0.02). Emergency angiography successfully locates the bleeding site, allowing for segmental colectomy. Vasopressin infusion transiently halts bleeding, permitting elective surgery in many instances.

Topics: Adult; Aged; Angiography; Arteriovenous Malformations; Barium Sulfate; Colectomy; Colon; Diverticulum; Diverticulum, Colon; Emergencies; Female; Gastrointestinal Hemorrhage; Humans; Male; Mesenteric Arteries; Middle Aged; Vasopressins

Since 1963, a prospective evaluation of the emergency portacaval shunt procedure has been conducted in 264 unselected patients with cirrhosis and bleeding varices who underwent operation within 8 hours of admission to the emergency department. Of 153 patients who underwent operation 10 or more years ago, 45 (29 percent) have survived from 10 to 22 years and their current status is known. On admission, 40 percent of the long-term survivors had jaundice, 44 percent had ascites, 13 percent had encephalopathy (with an additional 9 percent with a history of encephalopathy), 29 percent had severe muscle wasting, and 82 percent had a hyperdynamic state. There were 9 Child's class A patients, 33 Child's class B patients, and 3 Child's class C patients. At operation, all patients had portal hypertension which was reduced by the shunt to a mean corrected free portal pressure of 18 mm saline solution. The emergency portacaval shunt procedure permanently controlled variceal bleeding. None of the patients bled again from varices, and the shunt remained patent throughout life in every patient. Encephalopathy did not affect 91 percent of the patients, but was a recurrent problem in 9 percent, usually related to the use of alcohol. Lifelong abstinence from alcohol occurred in 58 percent of the long-term survivors, but 11 percent resumed regular drinking and 31 percent consumed alcohol occasionally. Liver function declined compared with preoperative function in only 18 percent of the patients, almost always because of alcohol use. Ten years after operation, 73 percent of the patients were in excellent or good condition, and 68 percent were gainfully employed or engaged in full-time housework. Comparison of the 10 to 22 year survivors with our early group of 180 patients reported previously and our recent group of 84 patients showed no significant differences in preoperative or operative data. The single factor that appeared to influence long-term survival was resumption of regular use of alcohol. We conclude that the emergency portacaval shunt procedure, by preventing hemorrhage from varices, results in prolonged survival and an acceptable quality of life for a substantial number of patients with advanced alcoholic cirrhosis.

Topics: Adult; Aged; Alcohol Drinking; Coma; Emergencies; Esophageal and Gastric Varices; Follow-Up Studies; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis, Alcoholic; Male; Middle Aged; Portacaval Shunt, Surgical; Postoperative Complications; Prospective Studies; Quality of Life; Time Factors; Vasopressins

The results of selective intraarterial vasopressin-infusion therapy and embolization therapy were compared in two groups of patients with major gastrointestinal hemorrhage. The site of bleeding, clinical course, complications, and transfusion requirements were evaluated in each group. Intraarterial vasopressin infusion therapy resulted in successful control of hemorrhage in 16 (70%) of 23 patients. Four patients, however, rebled and an operation was necessary, reducing the overall success rate to 52% (12 of 23). In the group treated with embolization therapy, primary success was achieved in 17 (71%) of 24 patients. Four patients in whom initial embolization failed to control bleeding underwent repeat embolization and in all four permanent control of hemorrhage was obtained, producing an overall success rate of 21 (88%) of 24. Analysis of our results according to site of hemorrhage suggests that at certain sites embolization is a preferred method of treatment; embolization allows earlier control of gastrointestinal hemorrhage and a reduction in transfusion requirements.

Topics: Adult; Aged; Angiography; Blood Transfusion; Embolization, Therapeutic; Female; Gastrointestinal Hemorrhage; Humans; Male; Middle Aged; Vasopressins

Topics: Catheterization; Embolization, Therapeutic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Sclerosing Solutions; Vasopressins

Intraarterial vasopressin infusion of the inferior mesenteric artery was used in the treatment of 2 patients with massive hemorrhage following colonoscopic polypectomy. Both patients had multiple medical problems and were considered to be very-high-risk candidates for emergency surgery. Arteriography readily demonstrated the site of bleeding, and vasopressin infusion effectively controlled the hemorrhage in both patients without complication. Angiographic management allowed elective colonic resection 1 month later in 1 patient and prevented surgery in the other who has not bled again in the 6 months following the procedure. The role of arteriography in the management of postpolypectomy hemorrhage is discussed.

Topics: Aged; Catheterization; Colonic Diseases; Colonic Polyps; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Male; Mesenteric Arteries; Postoperative Complications; Radiography; Vasopressins

Patients with variceal or other gastrointestinal hemorrhage require aggressive resuscitative measures and early diagnosis for optimal therapy. A number of nonsurgical endoscopic modalities, such as laser therapy, sclerotherapy, heater probe and electrocoagulation (monopolar or bipolar), are available to arrest and sometimes to prevent hemorrhage. The family physician should be aware of these options so that access to them can be offered to patients if needed.

Topics: Electrocoagulation; Endoscopy; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hot Temperature; Humans; Laser Therapy; Sclerosing Solutions; Vasopressins

Thallium 201 (201Tl) myocardial scans were obtained in 16 patients just prior to the discontinuation of a vasopressin infusion (.1 to .2 units/min) administered for the treatment of upper gastrointestinal bleeding. Repeat scintigraphy was performed two to three hours after the vasopressin was stopped. Eleven of the 16 patients (69 percent) demonstrated areas of decreased myocardial 201Tl uptake that resolved after the infusion was stopped. Heart rate-blood pressure product was significantly lower at the time of the second scan. Autopsies were secured in three of 11 scan-positive patients: one had severe coronary artery obstruction, one nonsignificant disease, and another had normal coronary arteries. Vasopressin, even at low doses, can induce abnormalities in myocardial perfusion that are probably mediated by a direct effect on the coronary circulation. They are usually not detectable by routine monitoring techniques and conceivably form the basis for the cardiovascular morbidity associated with the use of this agent.

Topics: Adult; Aged; Electrocardiography; Female; Gastrointestinal Hemorrhage; Heart; Hemodynamics; Humans; Male; Middle Aged; Radioisotopes; Radionuclide Imaging; Thallium; Vasopressins

Lower intestinal bleeding related to enterocolic angiodysplasia is now accepted as a common clinical situation in the elderly. A planned approach is mandatory to allow early localization and appropriate therapy. Colonoscopy, scintigraphy and angiography used judiciously have almost entirely replaced exploratory laparotomy as a diagnostic tool. Nonoperative treatment comprising arteriographic selective vasopressin infusion and endoscopic coagulation has been followed in some cases by hemorrhage control. Such techniques, if easily obtainable, have their place; however, surgery remains the ultimate method for definitive treatment. A previous knowledge of the nature of ileal involvement is essential if surgical hemostasis is to be achieved. The recent successful management of three patients exemplifies the problems found in dealing with iliocecal bleeding angiodysplasia.

Topics: Aged; Arteriovenous Malformations; Blood Transfusion; Cecum; Colonoscopy; Female; Gastrointestinal Hemorrhage; Humans; Ileum; Male; Middle Aged; Vasopressins

Topics: Esophageal and Gastric Varices; Gastrointestinal Diseases; Gastrointestinal Hemorrhage; Gastroscopy; Hemostasis; Hemostatic Techniques; History, 20th Century; Humans; Laser Therapy; Lasers; Vasopressins

A 79-year-old woman with primary biliary cirrhosis was admitted with esophageal variceal hemorrhage. She was initially managed with sclerosing of esophageal varices with no relief from the bleeding. Intravenous Vasopressin was started, but had to be discontinued because of cutaneous changes. A portocaval shunt was performed to control the variceal bleeding. Postoperatively she did poorly from sepsis and hepatic encephalopathy and died 46 days after admission to the hospital.

Topics: Abdomen; Aged; Drug Eruptions; Ecchymosis; Esophageal and Gastric Varices; Female; Foot; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Leg; Portacaval Shunt, Surgical; Skin; Temperature; Vasopressins

Topics: Colonic Diseases; Combined Modality Therapy; Embolization, Therapeutic; Gastrointestinal Hemorrhage; Humans; Rectum; Vasopressins

Two patients with severe liver disease developed scrotal necrosis after intravenous vasopressin infusion for bleeding esophageal varices. One of these patients also developed anterior abdominal wall skin necrosis. Although ischemic complications secondary to vasopressin are probably not totally avoidable, attention to hypovolemia, concomitantly administered pressor drugs, patient position, and points of local pressure may decrease the likelihood of these previously unreported complications.

Topics: Abdominal Muscles; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Male; Middle Aged; Necrosis; Scrotum; Skin Diseases; Vasopressins

A 5-year-old girl with biliary atresia is described who developed lower gastrointestinal bleeding from colonic varices. Vasopressin infusions temporarily controlled the bleeding. Following a right hemicolectomy the bleeding has not recurred.

Topics: Child, Preschool; Colon; Colonic Diseases; Female; Gastrointestinal Hemorrhage; Humans; Radiography; Vasopressins

Topics: Adolescent; Adult; Age Factors; Aged; Child; Colectomy; Colitis, Ulcerative; Colonic Diseases; Colonoscopy; Electrocoagulation; Embolization, Therapeutic; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Injections, Intravenous; Intestine, Small; Laser Therapy; Mesenteric Arteries; Middle Aged; Radiography; Vasopressins

The purpose of the present study was to determine whether the gastric cytoprotective effect of a prostaglandin such as 16,16-dimethyl prostaglandin (dmPGE2) is mediated by an increase in mucosal blood flow. Gastric mucosal blood flow was measured in urethane-anesthetized rats by the hydrogen gas clearance technique. In control rats given no ethanol, intragastric administration of dmPGE2 (10 micrograms/kg body wt) produced a significant reduction (15.3%) in gastric mucosal blood flow 30 min after treatment. This dose of dmPGE2 significantly reduced the formation of the gross gastric lesions produced by absolute ethanol in anesthetized rats. In vehicle-pretreated animals, blood flow was invariably absent in the ethanol-induced mucosal lesion areas. In the nonlesion areas, gastric mucosal blood flow was the same in prostaglandin-pretreated and vehicle-pretreated animals as in control (no ethanol) rats. Thus, although dmPGE2 pretreatment protected against ethanol-induced gastric mucosal injury and prevented the accompanying blood flow stasis, it did not do this by an increase in gastric mucosal blood flow. The protection also is not due to a decrease in flow because, in separate groups of anesthetized rats, a 15% reduction in gastric mucosal blood flow induced by either hemorrhage or intravenous vasopressin did not protect the gastric mucosa against absolute ethanol-induced injury. Whether the maintenance of gastric mucosal blood flow is a primary or secondary effect of prostaglandin cytoprotection remains to be determined.

Topics: 16,16-Dimethylprostaglandin E2; Animals; Ethanol; Gastric Mucosa; Gastrointestinal Hemorrhage; Male; Prostaglandins E, Synthetic; Rats; Rats, Inbred Strains; Regional Blood Flow; Stomach Diseases; Vasopressins

Topics: Adolescent; Adult; Endoscopy; Esophageal and Gastric Varices; Esophagus; Female; Gastrointestinal Hemorrhage; Humans; Intubation; Male; Middle Aged; Polidocanol; Polyethylene Glycols; Sclerosing Solutions; Vasopressins

Topics: Angiography; Antacids; Barium Sulfate; Cimetidine; Combined Modality Therapy; Embolization, Therapeutic; Endoscopy; Gastric Lavage; Gastrointestinal Hemorrhage; Humans; Laser Therapy; Peptic Ulcer Hemorrhage; Prognosis; Tranexamic Acid; Vasopressins

Topics: Ascites; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Portal System; Propranolol; Sclerosing Solutions; Vasopressins

Results obtained in the control of oesophageal varix rupture haemorrhage by intravenous vasopressin perfusion or selective intraarterial administration are reported. This comparative study shows intravenous administration to be the best method since it produces the same therapeutic effects with fewer undesirable side-effects than when administered arterially. In view of the high level of complications caused by selective arterial catheters, this administration method would only appear justified in cases where selective arterial catheterisation is to be carried out in any case.

Topics: Adult; Aged; Arrhythmias, Cardiac; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Hypertension; Injections, Intra-Arterial; Injections, Intravenous; Male; Middle Aged; Vasopressins

Blood flow in the azygos vein, an index of blood flow through gastro-oesophageal collaterals, was measured by continuous thermal dilution in 100 patients with cirrhosis. Azygos blood flow was directly related to portal pressure (r = 0.54, P less than 0.001). Patients with portal hypertension had very high azygos blood flow (692 +/- 32 ml/min) in comparison with controls (n = 11, 174 +/- 29 ml/min). Patients with previous oesophageal bleeding had similar azygos blood flow as those without, but azygos blood flow was significantly greater in patients with massive or recurrent bleeding than in those with less severe haemorrhage, suggesting that the magnitude of collateral flow may influence the course of variceal bleeding. Patients with grade III varices had higher azygos blood flow than those with grades II or I. In addition, both oesophageal tamponade and vasopressin infusion, procedures of known value in variceal bleeding, markedly reduced azygos blood flow (-40% and -25%, respectively). Measurement of azygos blood flow allows evaluation of haemodynamic changes in the oesophageal collaterals of patients with portal hypertension, and provides useful information on the effect of therapeutic procedures aimed at arresting or preventing variceal haemorrhage.

Topics: Azygos Vein; Blood Flow Velocity; Blood Pressure; Esophageal and Gastric Varices; Esophagoscopy; Female; Gastrointestinal Hemorrhage; Hemodynamics; Humans; Hypertension, Portal; Liver Circulation; Liver Cirrhosis; Liver Cirrhosis, Alcoholic; Male; Middle Aged; Portacaval Shunt, Surgical; Splenorenal Shunt, Surgical; Vasopressins

Topics: Catheterization; Celiac Artery; Diatrizoate; Diatrizoate Meglumine; Drug Combinations; Extravasation of Diagnostic and Therapeutic Materials; Female; Gastrointestinal Hemorrhage; Humans; Infant, Newborn; Infusions, Intra-Arterial; Radiography; Umbilical Arteries; Vasopressins

Since bleeding from acute lesions of the gastric mucosa can cease spontaneously and the mortality rate of emergency surgery is high, conservative treatment is always preferable. Satisfactory results were obtained with continuous infusions of vasopressin in low doses (0.2 U/kg/hr for 8 hours) so that this treatment appears a valid alternative to more recent techniques (somatostatin).

Topics: Acute Disease; Adult; Aged; Female; Gastritis; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Male; Middle Aged; Peptic Ulcer Hemorrhage; Radiography; Stomach Ulcer; Vasopressins

A patient bleeding from oesophageal varices in whom injection sclerotherapy failed to control bleeding required peripheral vein vasopressin infusion for a total of five days. Three days after stopping the infusion she collapsed and died. Post mortem examination showed the cause of death to be intestinal infarction resulting from superior mesenteric and portal vein thrombosis. This complication has not previously been described in association with vasopressin infusion into peripheral veins. The duration of each infusion should be minimised and blood volume should be carefully monitored throughout. The condition should be suspected in patients who develop unexplained abdominal pain or collapse following vasopressin treatment.

Topics: Aged; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Infarction; Infusions, Parenteral; Intestines; Mesenteric Vascular Occlusion; Mesenteric Veins; Portal Vein; Thrombosis; Vasopressins

Topics: Embolization, Therapeutic; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Male; Rupture, Spontaneous; Vasopressins

A number of recently introduced drugs have been applied to the treatment of acutely bleeding oesophageal varices. Another well established drug, propranolol, may have found a further useful therapeutic role in preventing bleeding from these vessels. However, before widespread use of these drugs can be endorsed further evidence of their efficacy and safety must be produced.

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Propranolol; Somatostatin; Vasopressins

Topics: Anti-Ulcer Agents; Gastric Mucosa; Gastritis; Gastrointestinal Hemorrhage; Humans; Peptic Ulcer Hemorrhage; Prostaglandins; Somatostatin; Stomach Ulcer; Stress, Physiological; Vasopressins

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Rupture, Spontaneous; Somatostatin; Vasopressins

Topics: Cimetidine; Gastrointestinal Hemorrhage; Humans; Propranolol; Somatostatin; Vasopressins

Topics: Acute Disease; Adult; Aged; Embolization, Therapeutic; Emergencies; Female; Gastrointestinal Hemorrhage; Gastroscopy; Humans; Male; Middle Aged; Radiography; Stomach; Vasopressins

The current state of endoscopic polypectomy of the large intestine is analysed. The indications for this treatment and the main complications arising (haemorrhages, perforations, colonic rupture) are evaluated with details of possible treatment and/or prevention. The connections with histology and surgery are also discussed. Finally, the treatment and follow-up of cancerised rectocolonic polyps are discussed in detail.

Topics: Arginine Vasopressin; Electrocoagulation; Epinephrine; Follow-Up Studies; Gastrointestinal Hemorrhage; Humans; Intestinal Perforation; Intestinal Polyps; Intestine, Large; Laser Therapy; Postoperative Complications; Rupture; Vasopressins

The Mallory-Weiss syndrome is characterized by repeated bouts of retching and/or vomiting followed by the sudden onset of hematemesis or melena. Bleeding arises from linear, nonperforating mucosal lacerations at the cardia, cardioesophageal junction, distal esophagus, or a combination of these sites. Hiatal hernia is often a coexisting finding. Severity of hemorrhage can vary from mild to severe (100 to 2,000 ml). The clinical course is usually benign. The diagnosis can be suspected from the history and confirmed by upper gastrointestinal endoscopy. In the majority of patients, medical management controls the bleeding. About 10% to 20% of unselected patients require surgical intervention. With the proper, prompt use of fiberoptic endoscopy in the diagnosis of upper gastrointestinal hemorrhage has come an increase in the number of cases of Mallory-Weiss syndrome being identified. This is true even in community hospitals. The result has been a decrease in surgical intervention and overall mortality.

Topics: Adult; Aged; Blood Transfusion; Diagnosis, Differential; Endoscopy; Female; Gastrointestinal Hemorrhage; Humans; Male; Mallory-Weiss Syndrome; Middle Aged; Prognosis; Therapeutic Irrigation; Vasopressins; Vomiting

After a review of recent literature on angiodysplasias of the digestive system, a diagnostic procedure based on personal experience is proposed for haemorrhagic patients. Criteria for the selection of treatment protocols are then proposed for cases where angiodysplasia is recognised as the cause of the bleeding.

Topics: Angiography; Arginine Vasopressin; Blood Vessels; Colonoscopy; Duodenoscopy; Embolization, Therapeutic; Female; Gastrointestinal Hemorrhage; Hemangioma; Humans; Male; Mesenteric Arteries; Middle Aged; Telangiectasis; Vasopressins

Topics: Embolization, Therapeutic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Portasystemic Shunt, Surgical; Propranolol; Recurrence; Sclerosing Solutions; Vasopressins

Topics: Angiography; Cimetidine; Gastric Lavage; Gastrointestinal Hemorrhage; Humans; Iron; Vasopressins

Bilateral nipple necrosis developed in two patients after intravenous vasopressin therapy for bleeding esophageal varices. When vasopressin therapy was promptly tapered and discontinued, recovery of skin changes occurred gradually. The role and some of the reported complications of vasopressin therapy in bleeding esophageal varices are discussed herein.

Topics: Adult; Breast Diseases; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Injections, Intravenous; Male; Middle Aged; Necrosis; Nipples; Vasopressins

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Liver Cirrhosis; Vasopressins

Portal cineangiography after umbilicoportal cannulation was used to evaluate esophageal vein perfusion and diameter in 13 cirrhotic patients with severe portal hypertension, prior to and during intravenous vasopressin infusion (0.35 IU per min). Between the 15th and the 20th minute of infusion no change had occurred in the diameters of left gastric veins, esophageal varices, portal veins, or splenic veins. Considerable reduction in the left gastric vein perfusion was indirectly documented by prolongation of washout time (greater than + 145%) and increase in vascular density. These modifications were disproportionate in relation to the simultaneous changes in portal pressure (-16%). These results demonstrate that during vasopressin infusion: (a) there is no constriction of the varices at the level of the lower esophageal sphincter; (b) there is a marked decrease in the perfusion of left gastric vein and esophageal varices; and (c) there is a moderate portal pressure decrease which, by itself, may not be a reliable index of the splanchnic hemodynamic response to vasopressin in cirrhotic patients.

Topics: Adult; Blood Pressure; Cineangiography; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis; Male; Middle Aged; Portal Vein; Stomach; Time Factors; Vasopressins; Veins

Continuous vasopressin infusion has been shown to control bleeding from oesophageal varices in patients with cirrhosis of the liver. The mortality, however, has not been changed. To investigate whether reduction of portal blood flow over a period of hours deteriorates the liver function, we measured the splanchnic blood flow and galactose and oxygen consumption in five cirrhotic patients during liver vein catheterization. Vasopressin was given as a continuous infusion of 0.2 units per min for three h. The splanchnic blood flow was reduced to 70% of control values and remained so throughout the infusion. After three h no impairment of the liver function was found. The wedged hepatic pressure (portal pressure) rose slightly, probably due to the increase of the central venous pressure reflecting impaired cardiac function. The reported beneficial effect of vasopressin on varix bleeding probably depends on the reduced portal flow per se.

Topics: Adult; Blood Pressure; Central Venous Pressure; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Liver; Liver Circulation; Liver Cirrhosis, Alcoholic; Male; Middle Aged; Splanchnic Circulation; Vasopressins

Topics: Adult; Aged; Catheterization; Embolization, Therapeutic; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Male; Middle Aged; Neoplasms; Postoperative Complications; Vasopressins

Myoglobinuria and acute renal failure were observed in two patients with vasopressin-treated gastrointestinal hemorrhage. Because there were no other obvious causes of renal failure in either patient, we propose that skeletal muscle ischemia developed during vasopressin infusion, followed by release of myoglobin and renal damage. This association should be considered in the period after vasopressin-treated gastrointestinal hemorrhage.

Topics: Acute Kidney Injury; Aged; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Ischemia; Male; Middle Aged; Muscles; Myoglobinuria; Rhabdomyolysis; Vasopressins

Angiographic therapy to control gastric bleeding was attempted in 200 patients. One hundred ninety-four patients were treated with intraarterial vasopressin and 17 of them were also treated with transcatheter embolization. Six patients underwent primary embolization, and an additional six received intravenous vasopressin. The initial rate of bleeding control in all patients angiographically treated was 73%. When embolization was used in some of the patients who did not respond to vasopressin, the overall control rate increased to 79%. Recurrent bleeding occurred in 18%. When angiographic therapy was attempted again in the patients with recurrent hemorrhage, the bleeding was stopped in 36%. Major complications occurred in 6.5% and minor in 17.5%. Of the patients with bleeding that was angiographically controlled, 73% survived and 27% died of associated clinical conditions. Among the failures of angiographic therapy, 48% died during the same hospital admission. Intraarterial infusions of vasopressin or transcatheter embolization are useful for the control of gastric bleeding.

Topics: Adolescent; Adult; Aged; Arteries; Catheterization; Celiac Artery; Embolization, Therapeutic; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Male; Middle Aged; Radiography; Recurrence; Stomach; Stomach Diseases; Time Factors; Vasopressins

Ten patients with portal hypertension and esophageal varices had percutaneous transheptic portography with selective catheterization of the short gastric or left gastric vein. The effect was studied on variceal blood flow after injection of various drugs (vasopressin IV, pentagastrin IV, somatostatin IV, domperidone IV, and methylcholine SC). Vasopressin had no effect on variceal flow; pentagastrin gave a total occlusion of flow in five of nine patients; somatostatin interrupted the flow in one of four patients; domperidone obstructed flow completely in one patient, while another receiving the same dose was unaffected; methylcholine did not affect the flow in three patients examined.

Topics: Adult; Choline; Domperidone; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Male; Middle Aged; Pentagastrin; Pressure; Somatostatin; Vasopressins

As medical treatment of haemorrhage from esophageal varices vasopressin is discussed. The analogue triglycyl-vasopressin has less side-effects and a longer plasma half-life. According to the first randomized study with only a small number of patients bleeding from varices triglycyl-vasopressin was superior to vasopressin. The efficacy of somatostatin to reduce splanchnic blood flow in patients with liver cirrhosis is controversial. In a placebo-controlled trial propranolol prevented rebleeding from varices in patients with cirrhosis. However, beta-blockers should not be given to patients with advanced cirrhosis. Several controlled studies prove cimetidine not to be effective in ulcer bleeding. Somatostatin and secretin could be candidates for pharmacotherapy of haemorrhage from ulcers and erosions. In an own randomized and multicenter trial on 100 patients with stopped ulcer bleeding it was proven that the combination of the synergistically acting receptor antagonists cimetidine and pirenzepine prevent rebleeding significantly better than a prophylactic treatment of either cimetidine or pirenzepine alone. An improvement of mortality rates of upper gastrointestinal bleeding seems also to be possible by using such a combined prophylaxis. As prophylaxis of stress-ulcer bleeding cimetidine - recently ranitidine, too - and antacids are applied. Instead of a widely used enhancement of the doses of H2-blockers a combined application of H2-receptor antagonists and pirenzepine is also recommended in this indication which offers theoretical and practical advantages.

Topics: Acute Disease; Anti-Ulcer Agents; Cimetidine; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Peptic Ulcer Hemorrhage; Recurrence; Somatostatin; Vasopressins

The management of lower gastrointestinal bleeding has evolved from a number of technological advances allowing precise diagnosis and localization of the bleeding site. This study of 40 angiographically demonstrated lower gastrointestinal bleeding lesions reinforces much of the data indicating the diagnostic and therapeutic trends. Twenty-four patients had bleeding diverticula with angiographic demonstration in 11 patients. Seven cases of vascular ectasia were identified, and nine patients had a variety of significant bleeding sites other than the two main sites that were listed. Pitressin was useful for control of bleeding in six of seven diverticular patients but was less useful in the vascular ectasia group in which only one patient was actively bleeding. Total abdominal colectomy and segmental resection were successful in control of hematochezia in 24 of 25 operative cases. Sixteen patients did not require surgical treatment.

Topics: Aged; Angiography; Arginine Vasopressin; Colectomy; Diverticulum, Colon; Diverticulum, Stomach; Female; Gastrointestinal Hemorrhage; Humans; Hypertension; Male; Middle Aged; Vasopressins

Five patients given vasopressin by infusion to reduce portal hypertension developed signs of cutaneous gangrene 18-24 hours after the start of the infusion. Four patients were treated by application of local dressings; in three cases the lesions healed, but the fourth patient died from variceal haemorrhage. The remaining patient required split skin grafting but died 48 hours after operation. The mechanism of this effect of vasopressin is not clear, but if local blanching of the skin is noted during infusion the catheter should be flushed immediately with a vasodilator in an effort to counteract the drug's vasoconstrictor effect.

Topics: Adult; Aged; Constriction, Pathologic; Esophageal and Gastric Varices; Female; Gangrene; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Infusions, Parenteral; Male; Skin; Vasopressins

The synthetic drug Ornipressin was injected through a 3-French catheter introduced into the superior or inferior mesenteric artery by a coaxial method in nine patients with massive bleeding from the colon. In all patients the bleeding was stopped. In one female patient with a tumour, bleeding recurred, but was stopped by embolisation treatment. There were no complications needing treatment. As a method of treatment for bleeding from diverticula, the following procedure is recommended: an attempt should be made to stop bleeding by injecting vasopressin, or one of its derivatives and the use of a 3-French catheter by a co-axial method is advantageous. If vasopressin is contra-indicated, or is unsuccessful, catheter embolisation is recommended.

Topics: Aged; Catheterization; Colonic Diseases; Embolization, Therapeutic; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Male; Mesenteric Arteries; Middle Aged; Ornipressin; Radiography; Vasopressins

Topics: Angiography; Catheters, Indwelling; Colonic Diseases; Endoscopy; Esophageal Diseases; Gastrointestinal Hemorrhage; Hemobilia; Humans; Hypertension, Portal; Intestinal Diseases; Peptic Ulcer Hemorrhage; Stomach Diseases; Vasoconstrictor Agents; Vasopressins

Topics: Gastrointestinal Hemorrhage; Humans; Vasopressins

A case of solitary cecal ulcer with major hemorrhage followed by perforation after treatment with intra-arterial vasopressin in a patient with end-stage renal failure is presented. Though vasopressin has been used with success in the treatment of colonic hemorrhage, caution should be applied in patients with a bleeding cecal ulcer as the vasoconstriction produced by vasopressin may cause perforation in an area whose blood supply is already compromised.

Topics: Cecal Diseases; Female; Gastrointestinal Hemorrhage; Humans; Intestinal Perforation; Kidney Failure, Chronic; Middle Aged; Radiography; Ulcer; Vasopressins

The basic approach to a patient with upper GI hemorrhage is primarily stabilization of any hemodynamic insufficiency. A patient history that includes alcohol abuse, ulcer disease, or esophageal varices may call for immediate endoscopy. Approximately 20% of all patients fail to respond to any therapy except surgery; however, a majority of patients who receive appropriate support and resuscitation will stop bleeding.

Topics: Cautery; Endoscopy; Esophageal and Gastric Varices; Fluid Therapy; Gastrointestinal Hemorrhage; Humans; Vasopressins

Topics: Adult; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Mesenteric Arteries; Mesenteric Veins; Varicose Veins; Vasopressins

Topics: Adult; Aged; Bucrylate; Embolization, Therapeutic; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Male; Middle Aged; Portography; Vasopressins

Over a 3-year period continuous intravenous infusion of moderate doses of vasopressin in 13 patients bleeding profusely from hemorrhagic gastritis, was associated with rapid control of the bleeding in 11 patients, while in 2 patients prolonged infusion was required to stop the hemorrhage. In 2 patients there was a relapse of the hemorrhage 3 and 7 days after the initial treatment, which was successfully controlled by renewed vasopressin infusion. There was no mortality and no complications of the vasopressin treatment were encountered. The results compared favourably with the experience from the preceding 3-year period where a comparable group of patients undergoing conventional medical and surgical treatment suffered a mortality of 38%. This study therefore suggests that vasopressin infusion performed continuously with moderate doses over extended periods, improves survival of patients with severe hemorrhagic gastritis through control of bleeding.

Topics: Adult; Aged; Female; Gastritis; Gastrointestinal Hemorrhage; Humans; Injections, Intravenous; Male; Middle Aged; Vasopressins

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Propranolol; Somatostatin; Vasopressins

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemodynamics; Humans; Hypertension, Portal; Liver Circulation; Liver Cirrhosis; Propranolol; Somatostatin; Vasopressins

Topics: Angioplasty, Balloon; Diagnosis, Differential; Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Intubation, Gastrointestinal; Liver Cirrhosis; Portacaval Shunt, Surgical; Prognosis; Sclerosing Solutions; Vasopressins

Topics: Adult; Aged; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatic Techniques; Humans; Male; Middle Aged; Portacaval Shunt, Surgical; Puerto Rico; Sclerosing Solutions; Vasopressins

Three patients with bleeding jejunal diverticula that presented as life-threatening massive rectal hemorrhage were examined angiographically, with localization of the bleeding point. Vasopressin infusion did not result in adequate hemostasis in the two patients in whom it was attempted. Jejunal diverticula represent an uncommon, but not rare, source of massive gastrointestinal bleeding, usually presenting as "lower" tract hemorrhage. Without angiographic localization, surgical exploration for bleeding arising from jejunal diverticula has been difficult because of their occult nature and proximal location. A previously normal small intestine series does not preclude their presence.

Topics: Aged; Diverticulum; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Jejunal Diseases; Male; Radiography; Vasopressins

Topics: Colitis; Colon; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Intestinal Mucosa; Ischemia; Male; Middle Aged; Vasopressins

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Vasopressins

The effects of 30-minute intravenous and superior mesenteric artery (SMA) infusions of vasopressin in dosages of 2.75 mU and 14 mU per min per kg were compared in five dogs that had cirrhosis and portal hypertension induced by fractionated intraportal polyvinyl alcohol injections. A reduction in portal pressure of approximately 35% was found with both SMA doses and the larger intravenous vasopressin dose, while the smaller intravenous dose reduced portal pressure only 18%. A significantly larger decrease in portal blood flow was found with SMA than intravenous vasopressin administration. Cardiovascular side effects were dose-dependent but independent of the administration mode. Liver enzymes were not affected. Portal vein thrombosis occurred in one dog after the larger SMA dose.

Topics: Animals; Dogs; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hypertension, Portal; Infusions, Intra-Arterial; Infusions, Parenteral; Liver Cirrhosis; Male; Mesenteric Arteries; Vasopressins

The fate of 359 consecutive alcoholic cirrhotic male patients with bleeding esophageal varices was determined through chart review and personal interview. Three historical periods (1966-70; 1971-75; 1976-80) were defined based on availability of different therapeutic modalities. Management of acutely bleeding varices by conservative, nonsurgical means, including embolization, was preferable to emergency surgery when considering 30-day mortality rates. Percutaneous transhepatic embolization of esophagogastric varices significantly improved the rate of control of hemorrhage and 30-day survival over previously employed nonsurgical methods. The combination of nonsurgical management of acute variceal hemorrhage followed by selective distal splenorenal shunting resulted in maximum salvage of the alcoholic cirrhotic patient.

Topics: Embolization, Therapeutic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis, Alcoholic; Male; Portasystemic Shunt, Surgical; Prognosis; Recurrence; Retrospective Studies; Splenorenal Shunt, Surgical; Vasopressins

Topics: Aged; Arrhythmias, Cardiac; Coronary Disease; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Male; Vasopressins

This patient demonstrates that peripheral vascular ischemia and gangrene may complicate the use of intraarterial vasopressin in the absence of catheter-related phenomena such as microemboli or catheter dislodgement. Discontinuation of vasopressin effectively reverses ischemic changes. Sympathetic blocking agents or direct-acting vasodilators may accelerate the reversal of the vasopressin induced ischemia. In the patient with a history of previous extremity cold injury, vasopressin may precipitate severe ischemia or gangrene by its direct effect at the arteriolar level in an extremity with already increased sympathetic vascular tone. Peripheral circulatory status must be assessed frequently during vasopressin infusion especially in patients with a history of frostbite.

Topics: Aged; Arm; Gangrene; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Male; Mesenteric Arteries; Vasopressins

Initial management of acute upper gastrointestinal (UGI) bleeding depends on the clinical status of the patient. Symptoms of reduced blood volume or shock are clear indications for blood transfusion; oxygen therapy also may be needed. A brief history and physical examination, gastric aspiration, and gastric lavage help in ascertaining if bleeding is in the UGI tract; endoscopy, barium x-ray studies, and angiography help to identify the exact site. Bleeding from the most common causes of UGI tract hemorrhage--duodenal and gastric ulcers, esophagitis, and Mallory-Weiss tears--stops spontaneously or with gastric lavage in about 85% of patients. Patients with variceal hemorrhage have a worse prognosis and require intensive care. Vasopressin (Pitressin) infusion, either intravenous or intraarterial, is the first treatment to try. If it is not effective, balloon tamponade, sclerotherapy if available, or surgery may be necessary. Advances in medical, endoscopic, and surgical therapy may reduce morbidity and mortality in the future.

Topics: Blood Transfusion; Drainage; Endoscopy; Esophageal and Gastric Varices; Fluid Therapy; Gastric Lavage; Gastrointestinal Hemorrhage; Humans; Sclerosing Solutions; Vasopressins

The use of vasopressin infusion or arterial embolization in the treatment of 87 patients with gastrointestinal hemorrhage is reviewed. A bleeding point was identified angiographically in 46 patients (53%), with a higher success rate in those with upper gastrointestinal hemorrhage (63%) than in those with lower (39%) gastrointestinal hemorrhage. Vasopressin infusion in 33 patients completely stopped hemorrhage in 14 and slowed hemorrhage pending surgery in another 5. Gelfoam embolization was successful as definitive therapy in 12 of 15 patients. Mortality as a result of hemorrhage or its sequelae was 40% in patients with upper gastrointestinal hemorrhage and 21% in those with lower gastrointestinal hemorrhage.

Topics: Acute Disease; Adolescent; Adult; Aged; Angiography; Child; Embolization, Therapeutic; Female; Gastrointestinal Hemorrhage; Gelatin Sponge, Absorbable; Humans; Infusions, Intra-Arterial; Male; Middle Aged; Vasopressins

All those who deal with patients suffering from this discouraging and lethal disease are constantly searching for the ideal method in which to control active hemorrhage from esophageal varices. Continued nonoperative management in those whose hemorrhage does cease on purely conservative measures results in an unacceptably high mortality, the most common cause of which is recurrent bleeding. Those patients who undergo portoazygos disconnection via the transabdominal or transthoracic route are equally prone to recurrent hemorrhage unless an elective portosystemic shunt is performed. Whether such a shunt is done as an elective or as an emergency procedure, the postoperative mortality and morbidity are high. Although protection against recurrent bleeding can be expected in most, the natural history of liver disease progression (and prognosis therefrom) remains unaltered, if not occasionally aggravated. Resurgence of interest in injection sclerotherapy for immediate control of hemorrhage, with subsequent longterm control of varices by repeated injections at intervals of several months, has received enthusiastic support. Preservation of existing hepatocellular function, the simplicity of the technique, especially with the fibreoptic endoscope, and its likely impact on medical care costs in this disease are attractive benefits. It is not perfect, and prospective randomized controlled trials are required to prove its superiority over other forms of treatment, but it currently appears to be the most viable alternative. We are not alone in fervently hoping that portoazygos disconnection will rarely be required and that portosystemic shunting will become a superfluous procedure, comfortably consigned to the history books.

Topics: Acute Disease; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Intubation; Male; Methods; Middle Aged; Sclerosing Solutions; Vasopressins

Over a period of one year, five of 101 patients admitted to our center because of upper gastrointestinal bleeding were found to have a Mallory-Weiss tear. This condition usually responds to conservative management. Torrential bleeding necessitating surgery is uncommon. Three of the patients, reported here, bled torrentially and were considered surgical candidates. Two received systemic vasopressin while being prepared for operation, with rapid, dramatic cessation of bleeding. Although this is a limited experience, we are impressed enough to believe that intravenous vasopressin should be given a trial in all hospitalized patients who continue to bleed from a tear in the region of the esophagogastric junction.

Topics: Adult; Critical Care; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Male; Mallory-Weiss Syndrome; Middle Aged; Vasopressins

A case of massive lower gastrointestinal bleeding from Crohn's disease is reported. This is an uncommon complication of the disease and the literature is reviewed. Successful control of gastrointestinal bleeding by intra-arterial vasopressin infusion has not previously been reported in Crohn's disease. We suggest that this technique may be used in an attempt to avoid surgery.

Topics: Adult; Crohn Disease; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Vasopressins

Vasopressin has been used for 25 years to control bleeding from esophageal varices. Its efficacy is believed to be due to a direct vasoconstrictor activity on splanchnic arterioles and precapillary sphincters, with secondary reduction in portal venous blood flow and pressure. While it has been administered by both the intra-arterial and intravenous routes, the latter has gained favor in the light of laboratory and clinical investigations. The most common complications are cardiovascular, and bradycardia is an early sign of toxicity; adverse effects may be avoided with simultaneous infusion of isoproterenol. Vasopressin has not been shown to prolong survival from esophageal bleeding. It is effective in controlling upper gastrointestinal hemorrhage and is commonly viewed as a means of buying time to prepare the patient for shunt surgery. Vasopressin infusion may reduce both operation time and blood loss during shunt surgery. New analogs of vasopressin presently under investigation may facilitate its administration and reduce morbidity.

Topics: Cardiovascular Diseases; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Infusions, Parenteral; Splanchnic Circulation; Vasopressins

A 59-year-old man with severe variceal bleeding received therapy with intravenously administered vasopressin and cimetidine. Inappropriate bradycardia, sinoatrial and atrioventricular blocks, and terminal bradycardia leading to asystole, occurred during bleeding, with the greatest number of rhythm abnormalities occurring during combined cimetidine and vasopressin therapy. The results of post-mortem examination showed only mild coronary artery disease. The hazards of combined vasopressin and cimetidine therapy are reviewed.

Topics: Arrhythmias, Cardiac; Bradycardia; Cimetidine; Coronary Disease; Drug Therapy, Combination; Electrocardiography; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Guanidines; Heart Block; Humans; Male; Middle Aged; Vasopressins

Continuous intravenous infusion of small doses of vasopressin (0.05 microgram/kg/h) in anaesthetized dogs was effective in reducing gastric mucosal flow, whereas moderate doses (0.2 micrograms/kg/h) induced a substantial flow reduction. Larger doses of vasopressin (2-4 micrograms/kg/h) precipitated massive gastric flow reduction with subsequent hyperaemia, which was not effectively controlled by moderate vasopressin doses. The effect of intraportal infusion of vasopressin on mucosal flow was similar to that of intravenous infusion. Prolonged intravenous infusion of moderate vasopressin doses maintained mucosal flow reduction over extended periods. The implications of the findings are discussed with particular reference to clinical use of vasopressin as a means of controlling bleeding from gastric mucosal lesions in patients.

Topics: Animals; Dogs; Dose-Response Relationship, Drug; Gastric Mucosa; Gastrointestinal Hemorrhage; Hydrogen; Infusions, Parenteral; Regional Blood Flow; Vasopressins

Topics: Catecholamines; Gastric Juice; Gastric Mucosa; Gastrointestinal Hemorrhage; Humans; Somatostatin; Vasoconstrictor Agents; Vasopressins

Sixty-five sites of arterial gastrointestinal hemorrhage in 63 patients were managed with transcatheter therapy. Arterial vasopressin infusion was attempted primarily for all but three sites; embolization was used in these cases and in those for whom vasopressin infusion failed to control bleeding. The results obtained suggest that this regimen, that is, primary vasopressin infusion with embolization reserved for infusion failures or contraindications, is more effective for control of arterial gastrointestinal hemorrhage than the use of either method alone. The role of primary embolization for control of this type of bleeding may need reassessment.

Topics: Angiography; Arteries; Catheterization; Embolization, Therapeutic; Gastric Mucosa; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Intestinal Diseases; Intestine, Small; Intestines; Pylorus; Stomach; Stomach Diseases; Vasopressins

The records of 88 patients bleeding 140 times from oesophageal varices were retrospectively evaluated. The treatment consisted mainly of intravenous vasopressin and balloon tamponade. Percutaneous transhepatic and transoesophageal sclerotherapy were used as additional treatments. Acute operation was avoided as long as possible. With this conservative attitude the hospital mortality was 24%. A high mortality was correlated with low serum albumin, initial unconsciousness, high blood transfusion demand, and alcoholism. The first bleeding episode of the patient had a higher mortality than the following ones. Our experience with a conservative attitude in stopping bleeding from oesophageal varices has made it possible to construct an outline for treatment which can be followed in most of these patients.

Topics: Blood Transfusion; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Kidney Function Tests; Liver Function Tests; Male; Middle Aged; Retrospective Studies; Serum Albumin; Vasopressins

Topics: Angiography; Catheterization; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Intestine, Large; Ischemia; Ischemic Attack, Transient; Thrombosis; Vasodilator Agents; Vasopressins

Topics: Animals; Antacids; Blood Pressure; Cimetidine; Dogs; Gastric Juice; Gastritis; Gastrointestinal Hemorrhage; Humans; Vasopressins

Topics: Angiography; Embolization, Therapeutic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Vasopressins

The management of patients with gastrointestinal (GI) bleeding depends on accurate localization of the site of hemorrhage. Endoscopy and arteriography, although successful in achieving this goal in the majority of patients, are invasive and have other shortcomings. The introduction of the 99mTc-sulfur colloid technique has greatly simplified the evaluation and management of these patients. This test is useful in detecting and localizing the bleeding site in the lower GI tract. Scintigraphy is now used as the initial study of choice in patients with rectal bleeding. Advances made in angiography and nuclear medicine techniques also have resulted in improved management of patients. Conservative approaches succeed in controlling hemorrhage in most patients. Vasopressin is the most widely tested agent and has been adopted by many as the preferred preparation for this purpose. Before the introduction of the 99mTc-sulfur colloid technique, angiography was used to monitor the effectiveness of this drug, whether administered intravenously or intraarterially. With the use of scintigraphy and intravenous administration of vasopressin, these patients now can be managed noninvasively. Only when the intravenous Pitressin infusion fails to stop hemorrhage, is the intraarterial approach considered. Surgery is used as a last resort when these measures fail to stop the bleeding.

Topics: Colon, Sigmoid; Contrast Media; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Injections, Intravenous; Radiography; Radionuclide Imaging; Sigmoid Diseases; Sulfur; Technetium; Technetium Tc 99m Sulfur Colloid; Vasopressins

Topics: Aged; Fluid Therapy; Gastrointestinal Hemorrhage; Humans; Intubation, Gastrointestinal; Male; Middle Aged; Nursing Assessment; Vasopressins

The mortality in patients with upper gastrointestinal bleeding has not changed in the past quarter century in spite of the introduction of new modes of therapy and treatment. In this review we address the possible reasons for a lack of change in mortality and the implications raised for the use of new techniques. We review the factors that affect the mortality of acute upper gastrointestinal hemorrhage and the diagnostic accuracy of upper gastrointestinal endoscopy. Based on this information, we present guidelines for the therapy of the major causes of upper gastrointestinal bleeding. These guidelines should be useful until new therapies have been assessed and become generally available.

Topics: Age Factors; Blood Transfusion; Cimetidine; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Gastroscopy; Humans; Mallory-Weiss Syndrome; Peptic Ulcer; Vasopressins

Topics: Blood Transfusion; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis; Resuscitation; Shock; Vasopressins

Evaluation and initial management of a patient with gastrointestinal (GI) bleeding progresses in stepwise fashion, beginning with assessment of the severity of bleeding. For this, the hematocrit must be considered in conjunction with factors reflecting vascular volume such as blood pressure and heart rate. Resuscitation to maintain tissue oxygenation should than be instituted with intravenous fluids and blood products in amounts appropriate to the severity of hemorrhage. Vital signs are monitored carefully. During resuscitation, attention is directed to determining whether bleeding comes from the upper or lower GI tract. If upper GI bleeding has been proven, gastric lavage is performed through a large-bore orogastric tube using copious quantities of fluid. Empiric therapy for upper GI bleeding, usually aimed at reducing gastric acidity, may be instituted as decisions regarding diagnostic techniques are considered. Endoscopy is a more accurate diagnostic tool than barium x-rays and can be performed in all but massively bleeding patients. There is overwhelming evidence, however, that, at least in patients who cease bleeding during resuscitation, endoscopy does not alter outcome. Since endoscopy is expensive, it should be reserved for selected patients in whom a specific diagnosis will dictate an important change in therapy.

Topics: Antacids; Blood Pressure; Blood Transfusion; Blood Volume; Cimetidine; Endoscopy; Fluid Therapy; Gastric Lavage; Gastrointestinal Hemorrhage; Heart Rate; Hematocrit; Humans; Resuscitation; Vasopressins

Most patients with upper gastrointestinal hemorrhage from Mallory-Weiss tear cease bleeding spontaneously and do not require specific therapy. Patients who either continue to bleed and those who rebleed represent specific therapeutic problems. Angiotherapy, either intraarterial vasopressin infusion (13 cases) or arterial embolization (two cases), was used to treat 15 patients with persistently bleeding Mallory-Weiss tears. Permanent hemostasis was achieved in the majority of patients treated. Results from the current study are compared with those previously reported in the literature. In addition the complications of each treatment method are discussed with emphasis on the cardiac complications of vasopressin.

Topics: Adolescent; Adult; Aged; Embolization, Therapeutic; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Male; Mallory-Weiss Syndrome; Middle Aged; Myocardial Infarction; Postoperative Complications; Retrospective Studies; Vasopressins

The hospital costs and its respective components for 32 patients with acute variceal bleeding were determined. The average total cost for treating the 32 patients was $35,000. The cost for those patients who underwent elective surgery ($53,000) was approximately twofold that of the elective medical group. Nutritional and metabolic rehabilitation that prolonged hospitalization, reutilization of the intensive care unit, and perioperative blood requirements were the significant factors that increased the cost of treating the surgically treated patients. Derivation of the cost/benefit ratio, however, showed that the decreased rehospitalization rate of the surgically treated group and the apparent better "quality of life" almost offset the increased initial hospital costs for this group.

Topics: Adult; Aged; Blood Transfusion; Cost-Benefit Analysis; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Middle Aged; Portasystemic Shunt, Surgical; Vasopressins

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Recurrence; Vasopressins

Topics: Acute Disease; Adult; Aged; Diverticulum, Colon; Duodenal Ulcer; Gastritis; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Mallory-Weiss Syndrome; Middle Aged; Peptic Ulcer Hemorrhage; Radiography; Stomach; Stomach Ulcer; Varicose Veins; Vasopressins

The relevant findings in 11 cases of per catheter control of haemorrhage from different sites in the large and small bowel are presented together with a description of the techniques and some of the possible complications of vasopressin infusion and gelfoam embolisation. In six of these cases vasopressin infusion was sus achieved by embolisation, three following the failure of vasopressin therapy. In one case embolisation of the ileo-colic artery produced a caecal infarct. Important differences in the vascular supply to the large and small bowel and their practical significance in embolisation are discussed.

Topics: Adult; Aged; Embolization, Therapeutic; Female; Gastrointestinal Hemorrhage; Gelatin Sponge, Absorbable; Humans; Infusions, Intra-Arterial; Male; Mesenteric Arteries; Middle Aged; Radiography; Vasopressins

Topics: Esophageal and Gastric Varices; False Negative Reactions; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Injections, Intravenous; Statistics as Topic; Vasopressins

We reviewed the courses of 40 patients with variceal bleeding treated with a standardized protocol, including intravenous (IV) vasopressin (Pitressin) and transhepatic embolization. Twelve of the 32 patients with acute episodes of massive variceal bleeding responded to the administration of IV vasopressin alone. Of the 20 patients who did not respond to vasopressin therapy, emergency transhepatic portography with embolization produced cessation of bleeding in ten (50%). The remaining ten patients who failed to respond to either IV vasopressin therapy or transhepatic embolization died, regardless of whether they were treated with aggressive medical therapy or emergency portosystemic shunt. Transhepatic embolization in both the emergent and elective situation demonstrated a thrombotic complication rate of 20%, which limited or precluded eventual therapy with elective portosystemic shunt. Because of this relatively high incidence of occult portal thromboses after transhepatic embolization, transhepatic portography should be obtained routinely prior to elective portosystemic shunts in those patients who have a history of transhepatic embolization.

Topics: Adult; Aged; Embolization, Therapeutic; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Hemoperitoneum; Humans; Infusions, Parenteral; Male; Middle Aged; Portal System; Radiography; Thrombosis; Vasopressins

Peripheral intravenous Pitressin infusion, use of the Sengstaken-Blakemore tube, or both effectively controlled variceal hemorrhage in 69 percent of patients, allowing an interval of medical management before elective portasystemic shunt surgery. Prolonged preoperative in-hospital management significantly improved hepatic function in initially poor risk patients. This improvement in hepatic function appeared to result in decreased postoperative morbidity and an operative mortality equal to that of good risk patients.

Topics: Adult; Aged; Digestive System; Female; Gastric Lavage; Gastrointestinal Hemorrhage; Humans; Liver Function Tests; Male; Middle Aged; Portacaval Shunt, Surgical; Splenorenal Shunt, Surgical; Stomach; Tampons, Surgical; Varicose Veins; Vasopressins

The transcatheter method appropriate for use in the control of arteriocapillary gastrointestinal bleeding is a point of controversy. Intraarterial vasopressin infusion, which has been performed in more than 500 patients at the Massachusetts General Hospital, has achieved control in 90% of patients actively bleeding from the stomach and colon. In view of the severity of hemorrhage and associated illnesses in these patients, the complication rate associated with this method was low. Intraarterial vasopressin infusions were ineffective in pyloroduodenal and postoperative bleeding sites and hemorrhage from abscesses. While embolization can control bleeding in these areas, complications have been shown despite precise selective catheter placement. Because of catheterization difficulties and the permanency of the vascular occlusion, embolization is reserved for patients in whom surgical intervention would be associated with extreme risks.

Topics: Adult; Aged; Angiography; Catheterization; Embolization, Therapeutic; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Male; Middle Aged; Vasopressins

Topics: Catheterization; Embolization, Therapeutic; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Vasopressins

Percutaneous transhepatic embolization of varices (PTEV) has proved to be effective in the control variceal bleeding, particularly in Child's Class C Category patients whose bleeding was not adequately controlled by pitressin perfusions. PTEV, using Gel-Foam soaked in sodium tetradecyl sulfate, controlled acute variceal bleeding in 71--95% of patients and appears to be more effective as an embolizing agent than bucrylate, which controlled 43--57%. Considering the poor condition of the patients particularly during acute bleeding episodes, PTEV is a relatively safe therapeutic procedure that buys time for the surgeons to perform a decompressive shunt electively as definitive surgery. A one-year recurrent bleeding rate of 30% and a two year recurrence of 37.5% was noted. Thus, for long term control of variceal bleeding, a surgical decompressive shunt is recommended in addition to PTEV.

Topics: Catheterization; Embolization, Therapeutic; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Gelatin Sponge, Absorbable; Humans; Sodium Tetradecyl Sulfate; Vasopressins

Topics: Embolization, Therapeutic; Gastrointestinal Hemorrhage; Humans; Vasopressins

Mesenteric vascular effects of prostaglandins B2 and F2 alpha were studied and compared to those of vasopressin in the dog, cat and baboon. Vasopressin reduced superior mesenteric blood flow (SMBF) 80-100%, and significantly increased hepatic arterial blood flow and systemic arterial pressure. Prostaglandin B2 produced vasodilatation at low doses and biphasic vasodilatation/vasoconstriction at high doses. Prostaglandin F2 alpha elicited only vasoconstriction, reducing SMBF, left gastric, and inferior mesenteric blood flow 80-100%. Systemic arterial pressure was not significantly changed. Thus, vasopressin and prostaglandin F2 alpha are equally effective mesenteric vasoconstrictors. Because of reduced systemic effects, prostaglandin F2 alpha has excellent potential as a mesenteric vasoconstrictor to control gastrointestinal hemorrhage.

Topics: Animals; Blood Pressure; Cats; Dogs; Female; Gastrointestinal Hemorrhage; Haplorhini; Hepatic Artery; Male; Mesenteric Arteries; Papio; Prostaglandins; Prostaglandins B; Prostaglandins F; Stomach; Vasoconstriction; Vasoconstrictor Agents; Vasopressins

Topics: Animals; Cardiac Output; Coronary Circulation; Dogs; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Heart; Heart Ventricles; Injections, Intravenous; Nitroglycerin; Vasopressins

The value of the catheter occlusion therapy is analyzed in 92 cases retrospectively, and the indication, and complication risk of these procedures are considered. In the following vessel areas occlusion with different methods have been performed with decreasing frequency; kidneys, pelvis, legs, gastrointestinal tract, external carotid and internal carotid artery. Serious complications have been observed in therapeutic investigations at the head, especially in occlusions of the external carotid artery. In this group embolisation therapy should be performed with strict indication only.

Topics: Adrenal Gland Neoplasms; Cavernous Sinus; Embolization, Therapeutic; Female; Femoral Artery; Gastrointestinal Hemorrhage; Glomus Jugulare Tumor; Humans; Iliac Artery; Kidney Neoplasms; Neoplasm Recurrence, Local; Ovarian Neoplasms; Renal Artery; Vasopressins

Topics: Adult; Cecal Diseases; Cytomegalovirus Infections; Female; Gastrointestinal Hemorrhage; Humans; Kidney Transplantation; Male; Middle Aged; Postoperative Complications; Transplantation, Homologous; Ulcer; Vasopressins

Topics: Adult; Colon; Colonic Diseases; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Male; Mesenteric Arteries; Radiography; Vasopressins

Topics: Angiography; Digestive System; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Infusions, Parenteral; Injections, Intravenous; Vasoconstriction; Vasopressins

A retrospective analysis of results obtained over a three year period in 66 patients receiving selective intra-arterial vasopressin (SIAV) for control of 69 episodes of massive gastrointestinal bleeding was presented. SIAV was used when there was a failure of conventional medical therapy and the patient's pathology and/or complicating medical conditions necessitated an attempt at controlling an emergent condition by nonoperative means. Hemmorrhage was completely controlled in 43% of variceal bleeds, 67% of hemorrhage gastritis, 45% of bleeding ulcers, and in 62% of colonic sources. The incidence of rebleeding following initial control was 16%. The surgical mortality for patients who were initial failures of SIAV was 50%. Patients undergoing elective surgery after complete control by SIAV had an 8% mortality. There were five catheter related complications. Minor complications occurred in 41% of patients, but required no treatment. Major complications occurred in 40% of cirrhotic and 21% of noncirrhotic bleeding episodes; and were a contributing factor in five cirrhotic deaths and three noncirrhotic deaths. In critically ill patients in the setting of an Intensive Care Unit, selective intra-arterial vasopressin appears: 1) to be an effective means of controlling certain types of gastrointestinal hemorrhage; 2) to provide an opportunity for an increase in survival rate.

Topics: Adult; Aged; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Middle Aged; Recurrence; Retrospective Studies; Vasopressins

Use of vasopressin injection (Pitressin) as an adjunct in the treatment of various types of gastrointestinal hemorrhage also produces an antidiuretic hormone effect of free water retention. This produces difficulties in fluid and electrolyte management and in the interpretation of changes in mental and hemodynamic status. This effect and its management are directly related to the total dose of the drug administered.

Topics: Gastrointestinal Hemorrhage; Humans; Inappropriate ADH Syndrome; Male; Middle Aged; Vasopressins

This report describes a case of massive gastric hemorrhage, initially controlled by selective arterial vasopressin infusion. Infusion was followed by extensive necrosis of the gastric wall which necessitated subtotal gastrectomy. Gastric necrosis following arterial infusion is rare and in this case appears to be due to migration of the infusion catheter into a peripheral branch of the left gastric artery in a patient whose gastric circulation had been compromised by prior surgery. The complications related to the use of arterial infusion for the control of gastric hemorrhage are discussed and the literature is reviewed.

Topics: Angiography; Catheters, Indwelling; Constriction, Pathologic; Female; Gastrectomy; Gastric Mucosa; Gastrointestinal Hemorrhage; Humans; Infarction; Infusions, Intra-Arterial; Middle Aged; Necrosis; Stomach; Vasopressins

Topics: Adult; Aged; Arteriovenous Malformations; Colonic Diseases; Diverticulum, Colon; Female; Gastrointestinal Hemorrhage; Humans; Intestine, Small; Intestines; Male; Middle Aged; Rectal Diseases; Vasopressins

Large-bowel bleeding usually arises from either angiodysplasia or colonic diverticula. Diverticular bleeding is more common in the right or the transverse colon, even though diverticula are more common on the left. Arteriography in these patients may identify the bleeding site, and in some cases vasopressin infusion controls the bleeding. Embolization of the large bowel is not recommended because of the danger of necrosis.

Topics: Aged; Angiography; Colon; Diverticulum, Colon; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Male; Mesenteric Arteries; Rectum; Vasopressins

The presence of mesenteric varices was demonstrated angiographically in 7 patients with portal hypertension. In 4 of these cases the mesenteric varices were the source of lower gastrointestinal bleeding which was successfully controlled by intra-arterial infusion of vasopressin. The radiological diagnosis and management of mesenteric varices is discussed and the pertinent literature is briefly reviewed.

Topics: Adult; Angiography; Celiac Artery; Female; Gastrointestinal Hemorrhage; Humans; Male; Mesenteric Arteries; Mesenteric Veins; Middle Aged; Varicose Veins; Vasopressins

For the initial control of haemorrhage from oesophageal varices, two methods of vasopressin administration have been compared--the conventional bolus of 20 units and a low dose infusion of 0.4 units per minute. Twenty patients bleeding from oesophageal varices, confirmed by endoscopy, were allocated into either treatment group (10 in each). Vasopressin infusion stopped bleeding in 86 per cent of the episodes in contrast to 12.5 per cent (P less than 0.01) with bolus doses. Balloon tamponade with a Sengstaken-Blakemore tube was used to control bleeding in only 2 episodes in patients on infusion and in 10 episodes in patients on bolus doses of vasopressin (P less than 0.05). Our study confirms that low dose vasopressin infusion in more effective in controlling bleeding from oesophageal varices than conventional bolus doses.

Topics: Blood Transfusion; Emergencies; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Injections, Intravenous; Male; Middle Aged; Vasopressins

Topics: Aneurysm; Angiography; Embolization, Therapeutic; Gastrointestinal Hemorrhage; Gastrointestinal Neoplasms; Humans; Vasopressins

Topics: Acute Disease; Adult; Female; Gastrointestinal Hemorrhage; Humans; Male; Middle Aged; Radiography; Vasoconstrictor Agents; Vasopressins

The cirrhotic patient with acute bleeding from esophageal varices has less than a 50% chance of leaving the hospital alive; the outlook for survival is so poor that even desperate measures are worthwhile. Some traditional nonsurgical methods for the control of the bleeding are either ineffective at worst or temporary at best. Balloon tamponade is not recommended at all, but intravenously administered vasopressin may be helpful in allowing the necessary diagnostic investigations to be completed. Most important at this stage are the measures necessary to improve the general status of the patient--restoration of blood volume with fresh blood, prevention of ammonia intoxication, support of the liver, correction of metabolic alkalosis and treatment of the hyperdynamic state with digitalis and cardiotonic drugs. Controlling the bleeding is not the greatest problem--the greatest problem is achieving survival of a critically ill patient who undergoes a formidable operation (e.g., variceal ligation stops the bleeding, but is itself an operation of considerable magnitude). In our hands emergency shunting is the best treatment providing a definitive procedure with the highest 10-year survival rate and the lowest complication rate.

Topics: Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostatic Techniques; Humans; Infusions, Intra-Arterial; Infusions, Parenteral; Ligation; Liver Cirrhosis; Mesenteric Arteries; Methods; Portacaval Shunt, Surgical; Vasopressins

Topics: Angiography; Embolization, Therapeutic; Endoscopy; Gastrointestinal Hemorrhage; Humans; Hydrogen-Ion Concentration; Peptic Ulcer Hemorrhage; Postoperative Complications; Stomach Ulcer; Stress, Physiological; Vasopressins

Oesophageal varices are found in the submucosa of the lower oesophageal sphincter (L.E.S.). Portagraphic studies after vasopressin administration showed occlusion of submucosal oesophageal varices and distension of the para-oesophageal veins. Oesophagography and endoscopy after administration of anticholinergics showed considerable dilatation of the submucosal oesophageal varices. Because vasopressin increases, and anticholinergics decrease, L.E.S. pressure it is suggested that L.E.S. pressure is an important factor in the development of submucosal oesophageal varices.

Topics: Blood Pressure; Esophageal and Gastric Varices; Esophagogastric Junction; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis; Portal Vein; Vasopressins; Vena Cava, Inferior

BLOOD FLOWS THROUGH THE CANINE HEPATIC (HBF) AND SUPERIOR MESENTERIC ARTERIES (MBF) WERE MEASURED WITH ELECTROMAGNETIC FLOWMETERS, DURING INFUSIONS OF VASOPRESSIN, BY THREE ROUTES OF ADMINISTRATION: 1) intra-hepatic-arterially (IHA), 2) intra-portal-venously (IPV) and 3) intra-systemic-venously (IV). Mean control HBF was 148 +/- 17 (S.E.) ml min(-1); MBF was 243 +/- 27 ml min(-1); aortic pressure (AP) was 126 +/- 3 mm Hg; portal venous pressure (PVP) was 8.8 +/- 1.0 mm Hg. Infusions of vasopressin, at a rate of 5 x 10(-3) units kg(-1) min(-1), IHA, reduced HBF significantly (p < .001) to 121 +/- 21 ml min(-1), within one minute. Flow returned to control, despite continued drug infusion; and at the end of the fifth minute of infusion, the value (134 +/- 21 ml min(-1)) was not significantly (p > .05) different from control. During the same infusion, MBF fell to 129 +/- 28 ml min(-1) (p < .001), by the sixth minute of the infusion and remained at this level for the duration of the infusion. AP increased to 137 +/- 13 mm Hg, by the sixth minute of the infusion and was sustained at this level for the duration of the infusion. PVP decreased to 7.0 +/- 1.0 mm Hg, by the tenth minute of the infusion. The responses to IPV vasopressin were indistinguishable from those following IHA vasopressin, with the exception that HBF was reduced to only 147 +/- 22 ml min(-1) (from a preinfusion control of 160 +/- 23 ml min(-1)), at one minute. HBF returned to control, despite continuation of the infusion. IV vasopressin, at the same concentration, caused no change in HBF throughout the ten minute infusion. These observations indicate that the canine hepatic arterial circulation responds to vasopressin with vasoconstriction characterized by autoregulatory escape. By any of the three routes of administration, vasopressin causes a significant and sustained reduction in blood flow through the superior mesenteric artery. Autoregulatory escape, from vasopressin-induced mesenteric arterial constriction, is not observed. Based on these observations, significant changes in mesenteric arterial blood flow can be anticipated without associated significant changes in hepatic arterial blood flow, regardless of the route of administration of vasopressin.

Topics: Animals; Dogs; Electromagnetic Phenomena; Female; Gastrointestinal Hemorrhage; Hepatic Artery; Homeostasis; Infusions, Parenteral; Liver Circulation; Male; Mesenteric Arteries; Portal Vein; Regional Blood Flow; Rheology; Vascular Resistance; Vasopressins

Angiography is useful in the diagnosis of active gastrointestinal bleeding if the rate is greater than 0.5 mL/min. For upper gastrointestinal bleeding, endoscopy is the preferred initial investigation and angiography is used for diagnosis only if the site of bleeding is still obscure. Angiography is the preferred method for investigation of massive lower gastrointestinal bleeding if results of sigmoidoscopy are negative. Vasopressin infusion is most useful for control of bleeding from esophageal varices, erosive gastritis and diverticular disease of the colon. Embolization with Gelfoam or clot is possible for massive hemorrhage from a single source in poor-risk patients. This is most successful for gastric or duodenal bleeding since the collateral blood supply prevents infarction. Some of the methods and complications of embolization are discussed and examples are given. Standard surgical principles should still apply in most cases.

Topics: Adult; Aged; Angiography; Embolization, Therapeutic; Endoscopy; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Middle Aged; Peptic Ulcer Hemorrhage; Vasopressins

Two patients developed local gangrene after subcutaneous infiltration of vasopressin (Pitressin, Parke, Davis & Company, Detroit, Mich.) utilized for the control of bleeding from esophageal varices. In the 1st patient, ischemic gangrene resulted in transmetatarsal amputation and also necessitated skin grafts on the forearm. The 2nd patient developed gangrene and clostridial sepsis and expired. The effects of systemically administered Pitressin are reviewed and suggestion to prevent local necrosis are presented.

Topics: Adult; Aged; Arm; Esophageal and Gastric Varices; Female; Foot; Gangrene; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Male; Skin; Vasopressins

Morbidity and mortality data from patients with bleeding esophagogastric varices treated with portosystemic shunts relate to the clinical status of the patient and to control of hemorrhage both in the immediate postoperative period as well as later. To obtain comparable data following selective infusion of pitressin into the superior mesenteric artery (SMA), records of 23 consecutive patients with cirrhosis, diagnosed by endoscopy as bleeding from varices and treated with SMA pitressin infusions, were reviewed. Twenty-four infusions were performed and hemorrhage was controlled in 12. Fourteen of the 23 patients subsequently underwent portosystemic shunts. Pitressin infusion controlled hemorrhage preoperatively in seven of these, and five survived one year or longer. The remaining seven, in whom bleeding was not controlled by pitressin, died postoperatively. One of the nine patients not undergoing a portosystemic shunt survived more than eight weeks after pitressin infusion. Vascular complications occurred in seven of 17 who died. These complications and the delay between institution of pitressin and operative therapy to control variceal hemorrhage appears to be a factor in the high mortality rate. Portosystemic shunt remains the best therapy for uncontrolled hemorrhage and to prevent recurrent bleeding from esophageal varices.

Topics: Esophageal and Gastric Varices; Esophagoscopy; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Liver Cirrhosis; Mesenteric Arteries; Portacaval Shunt, Surgical; Vasopressins

In acute gastrointestinal bleeding visceral angiography has been showing its importance for years. It contributes to diagnosis especially in cases with persistent acute hemorrhage. In chronic gastrointestinal bleeding conventional radiographic procedures such as upper gastrointestinal series and barium enema will be preferred to angiography. The function of the radiologist goes beyond mere diagnosis of gastrointestinal bleeding. Treatment with vasopressin via the angiographic catheter has proven its clinical value. This method will be indicated especially in cases with high risk anesthesia and surgery. It will help to postpone necessary surgery to a more favorable moment following hemostasis. Side effects such as hypertension and antidiuresis are relatively rare and easy to manage. Numerous substances are used for embolization showing that ideal material has not been found yet and further development seems necessary. In contrast to vasopressin treatment, vascular occlusion is often irreversible, complications (unwanted reflux of embolization material, necrosis and plugging of the catheter) are more difficult to manage. Superselective visualization of a bleeding artery is always needed. Embolization is justified in cases when a possibility for anesthesia and surgery cannot be foreseen. The electrical vascular occlusion using direct current is still in the phase of animal experiments; its clinical value has not sufficiently been assessed as yet.

Topics: Aneurysm; Angiography; Duodenal Diseases; Embolization, Therapeutic; Enteritis; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Male; Peptic Ulcer; Peutz-Jeghers Syndrome; Postoperative Complications; Salmonella Infections; Vasopressins

The haemostatic effect of triglycylvasopressin (TGLVP) on the gastric mucosa was evaluated in an experimental model in the rat. TGLVP was found to reduce the bleeding significantly compared with the untreated controls. The haemostatic effect was most prounounced and prolonged when 200 microgram/kg b.w. was given intravenously. The clinical application of this finding is discussed.

Topics: Animals; Gastric Mucosa; Gastrointestinal Hemorrhage; Hemostasis; Injections, Intravenous; Rats; Vasopressins

Earlier published results have shown an increased 5-day survival in burned mice treated with Triglycylvasopressin. In order to analyze the cause of the increased survival, the distribution of cardiac output was studied in 51 mice divided into three groups. The investigation was performed on the 5th day after burn using a soluble indicator technique (86Rb). The first group consisted of unburned animals. In the second and third groups, a standardized burn of 15% of the body surface was undertaken. The animals in the second group were used as controls and received isotonic saline solution for 5 days. The third group were used as controls and received isotonic saline solution and in addition Triglycylvasopressin, a vasopressin with prolonged effect, 100 microgram/kg body weight subcutaneously twice a day in such a way that the total volume of fluid was identical in the different groups. Cardiac output distribution showed an increased fraction to kidney, liver and small bowel and a decreased fraction to carcass in the Triglycylvasopressin-treated animals compared to burned controls.

Topics: Animals; Burns; Cardiac Output; Drug Evaluation, Preclinical; Female; Gastrointestinal Hemorrhage; Lypressin; Male; Mice; Vasopressins

The authors report the experience which the have acquired since 1970 in the use of posterior pituitary extract as part of the treatment of gastrointestinal bleeding in cirrhotics. 100 cases have been collected, in 73 patients. These may be divided into two groups: one of 32 patients, who did not receive posterior pituitary extract, with 31 deaths, and one of 41 patients who did receive the extract, with 6 deaths. These figures should be viewed in parallel with the results obtained by other techniques, and it would seem that comparison with other statistics is feasible. In addition, emphasis must be placed upon the simplicity of the administration and surveillance of treatment. Attention is also drawn to the absence of any inherent complication associated with the use of the drug, despite the administration, in certain cases, of high doses.

Topics: Gastrointestinal Hemorrhage; Humans; Injections; Liver Cirrhosis; Oxytocin; Pituitary Gland, Posterior; Tissue Extracts; Vasopressins

The effect of vasopressin on the lower esophageal sphincter has been investigated in 12 healthy volunteers. Peripheral infusion of 0.2 U/min resulted in a significant (p less than 0.05) decrease in sphincter pressure. Accordingly, vasopressin-induced myogenic compression of bleeding varices has been ruled out as a potential additional hemostatic mechanism of vasopressin.

Topics: Esophageal and Gastric Varices; Esophagogastric Junction; Gastrointestinal Hemorrhage; Hemostatics; Humans; Manometry; Pressure; Vasopressins

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hepatic Encephalopathy; Humans; Hypertension, Portal; Liver Cirrhosis; Splenectomy; Splenomegaly; Vasopressins

Transcatheter therapy for arteriocapillary gastrointestinal bleeding is often an effective form of treatment. The choice of transcatheter therapy (ie, vasoconstrictor or occlusive) often is dependent on the etiology and location of bleeding. Vasopressin is a generally safe form of treatment which is often successful in treating bleeding secondary to gastritis, Mallory-Weiss mucosal tears, and diverticular disease. It is less effective in treating bleeding peptic ulcers, neoplastic bleeding, or bleeding when clotting abnormalities exist. Occlusive therapy is an effective alternate form of therapy in selected circumstances. Ischemic complications from vasoconstrictor and embolic therapy may occur and require appropriate caution and discretion with their use.

Topics: Aged; Catheterization; Embolization, Therapeutic; Female; Gastrointestinal Hemorrhage; Gastrointestinal Neoplasms; Humans; Infusions, Intra-Arterial; Male; Methods; Middle Aged; Peptic Ulcer Hemorrhage; Radiography; Vasoconstriction; Vasopressins

Catheter dislodgement is a major cause of technical failures in intraarterial vasopressin therapy for gastrointestinal bleeding. Ten such cases were observed in the past five years. In seven patients catheter dislodgement led to recurrent bleeding during vasopressin infusion. In one patient aortic infusion of vasopressin caused recurrent bleeding and reversible acrocyanosis of the feet, and in two patients vasopressin infusion into the left renal artery resulted in chest pain and hematuria. Catheter dislodgement should be suspected if bleeding that was initially controlled recurs during vasopressin infusion.

Topics: Adolescent; Angiography; Aorta, Abdominal; Catheterization; Celiac Artery; Female; Gastrointestinal Hemorrhage; Heart Valve Prosthesis; Humans; Infusions, Parenteral; Male; Middle Aged; Peptic Ulcer Hemorrhage; Postoperative Complications; Spinal Injuries; Vascular Diseases; Vasopressins

The effects of various doses of intravenous vasopressin on mesenteric arterial blood flow, intestinal oxygen consumption, and cardiac output in anesthetized dogs were investigated. Optimal dose rate of intravenous vasopressin was found to be 3.0 mU/kg/min. At this dose rate, mesenteric arterial blood flow, intestinal oxygen consumption, and cardiac output decreased by 57%, 57% and 26%, respectively. Increasing the dose rate to 8.0 mU/kg/min did not offer significant gains. Maximum effect was observed 20 min after the beginning of the infusion. The effects disappeared 10-20 min after the infusion was discontinued, with the exception of superior mesenteric blood flow which showed a rebound increase. We conclude that in the anesthetized dog, intravenous infusions of vasopressin at low dose rates (3.0 mU/kg/min) substantially reduce mesenteric blood flow and intestinal oxygen extraction with moderate reduction of cardiac output. Possible clinical applications of low dose intravenous infusions of vasopressin would include reduction of portal hypertension and bowel protection during radiation therapy.

Topics: Animals; Arginine Vasopressin; Blood Pressure; Cardiac Output; Dogs; Gastrointestinal Hemorrhage; Infusions, Parenteral; Intestinal Mucosa; Intestines; Mesenteric Arteries; Oxygen Consumption; Radiation Injuries, Experimental; Regional Blood Flow; Time Factors; Vasopressins

Selective arteriography and infusions of vasopressin have become valuable tools for localization and therapy of acute gastrointestinal hemorrhage. Gastric mucosal hemorrhage can be treated successfully in about 84% of cases. Gastric ulcers can be treated successfully in about 65-70%. Acute colonorectal bleeding is controlled in about 90% of patients.

Topics: Aged; Angiography; Female; Gastrointestinal Hemorrhage; Humans; Male; Peptic Ulcer Hemorrhage; Vasopressins

Seven patients with compensated liver cirrhosis and esophageal varices, all with a base line wedge hepatic vein pressure greater than 20 cm H2O, received 1-mg doses of vasopressin hormonogen (tGLVP) intravenously. There was a significant mean decrease in wedge pressure of 32%, which lasted for at least 20 min (the duration of measurement), with no change in cardiac output measured. The only cardiac response was a 10 to 20% bradycardia at the height of the moderate pressor response-otherwise the ECG was without change. In 5 patients who received the same tGLVP dose during surgery, direct measurements of portal venous pressure showed the same degree of decrease within 10 min of intravenous injection. Fifteen patients with liver cirrhosis and severe bleeding from esophageal varices were treated conservatively with blood transfusion and tGLVP as the only major drug aside from antibiotics. A nonrandomized control group of 13 patients with the same age distribution, stage of disease, number of previous bleeds, etc., was treated conservatively in the same manner, except that they received either no hemodynamically active drugs or short acting neurohypophysial peptide preparations such as Pitressin. In the control group there was a 61.5% total mortality, a 53.8% mortality directly related to uncontrollable bleeding, and a mean duration of the bleeding episode of 11 days. In the tGLVP-treated group total mortality was 20%, mortality directly related to uncontrollable bleeding was 13.3%, and mean duration of the bleeding episode was 2.9 days. These results appear to justify a large scale clinical trial of the vasopressin hormonogen in this disease.

Topics: Adult; Aged; Blood Pressure; Cardiac Output; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Hemodynamics; Humans; Liver Cirrhosis; Lypressin; Male; Middle Aged; Portal Vein; Vasopressins

Over a four-year period, eight patients with documented gastrointestinal bleeding had angiography as a part of their investigation and treatment at the Department of Radiology, Victoria General Hospital, Halifax, Nova Scotia. A review of these eighty cases has been carried out and angiography has been found to be both safe and reliable in the diagnosis of gastrointestinal bleeding. Cautiously administered intra-arterial pitressin infusion therapy will arrest bleeding in about one-third of cases and in most others will reduce blood loss so that a critically ill patient may be made more fit for subsequent surgery. Patients who have recently received intravenous pitressin should not be given intra-arterial pitressin.

Topics: Aged; Angiography; Chronic Disease; Diagnostic Errors; Female; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Male; Middle Aged; Rectum; Vasopressins

Topics: Angiography; Embolization, Therapeutic; Gastrointestinal Hemorrhage; Gelatin; Hemorrhage; Humans; Male; Middle Aged; Vasopressins

Topics: Anesthetics, Local; Anti-Bacterial Agents; Diazepam; Gastrointestinal Hemorrhage; Humans; Posture; Vasopressins

Topics: Acute Disease; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Radiography; Vasopressins

Topics: Diuresis; Gastrointestinal Hemorrhage; Humans; Vasopressins

A four year experience in the management of 585 patients with massive upper gastrointestinal tract bleeding (U. G. I. B.)has been reviewed. The effect of routine fiberoptic gastroscopy, selective angiography, and selective pitressin arterial infusion has been analyzed as it effects the more accurate diagnosis and better non-operative therapy of these dangerously ill patients. Duodenal and gastric ulcer, which comprise one-half of such patients, are best treated by early operation. Mallory-Weiss-syndrome is more frequent than previously appreciated. Pitressin infusion is worthy of trial in diffuse gastritis, varicose- and stress ulcer bleeding. Stress bleeding is usually one manifestation of multiple organ failure due to bacterial sepsis.

Topics: Duodenal Neoplasms; Esophageal and Gastric Varices; Gastrectomy; Gastritis; Gastrointestinal Hemorrhage; Humans; Mallory-Weiss Syndrome; Methods; Peptic Ulcer Hemorrhage; Stomach Neoplasms; Vagotomy; Vasopressins

Topics: Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Liver Circulation; Vasopressins

Topics: Angiography; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Liver Cirrhosis; Peptic Ulcer Hemorrhage; Stomach Ulcer; Vasopressins

Studies were designed to determine whether angiotensin II has a direct stimulatory effect on arginine-vasopressin in man and to determine the role, if any, played by angiotensin II in the control of vasopressin release in physiological and pathological conditions. Acute infusion of angiotensin II in normal volunteers produced small but definite increases in plasma levels of arginine-vasopressin (5-4+/-0-3(S.E.M.) to 6-4+/-0-2 pg/ml) only when plasma angiotensin II levels were supraphysiological. Concurrent measurements of plasma arginine-vasopressin and angiotensin II were made during acute changes in fluid balance and posture in normal volunteers and in clinical conditions characterized by high plasma levels of angiotensin II (Addison's disease and Bartter's syndrome). The results of these studies allow us to conclude that there is little to suggest a direct effect of angiotensin II which is likely to be relevant to the normal physiological control of arginine-vasopressin in man.

Topics: Addison Disease; Angiotensin II; Arginine Vasopressin; Bartter Syndrome; Gastrointestinal Hemorrhage; Humans; Male; Osmolar Concentration; Posture; Vasopressins

Topics: Angiography; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Male; Middle Aged; Thrombosis; Vasopressins

Topics: Embolization, Therapeutic; Gastrointestinal Hemorrhage; Humans; Vasopressins

Continuous low dose peripheral vein pitressin has been shown to be effective in controlling variceal bleeding in seven episodes of bleeding in six patients. No significant side-effects were seen. The expense, delay and hazard associated with superior mesenteric artery catheterization for selective arterial pitressin infusion were avoided. If these results can be reproduced, low dose peripheral vein pitressin infusion may prove to be a valuable addition to the treatment of bleeding esophageal varices.

Topics: Adult; Aged; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Male; Middle Aged; Vasopressins

Topics: Angiography; Barium Sulfate; Counseling; Esophageal and Gastric Varices; Esophagoscopy; Gastrointestinal Hemorrhage; Hemostatic Techniques; Hepatic Encephalopathy; Humans; Hypertension, Portal; Medical History Taking; Physical Examination; Vasopressins; Water-Electrolyte Imbalance

Topics: Adult; Aged; Female; Gastrointestinal Hemorrhage; Hemostatic Techniques; Humans; Infusions, Intra-Arterial; Male; Middle Aged; Vasopressins

Liver function and clotting tests were evaluated in 39 patients with variceal bleeding prior to superior mesenteric artery vasopressin infusion. In six patients with mild hepatic dysfunction (Child's class A), permanent control of hemorrhage was achieved in all six and all survived the hospitalization. In 21 patients with moderate dysfunction (Child's class B), permanent control of hemorrhage was achieved in 13 (62%) and temporary control for 24 hr or longer in the remaining eight (38%). Survival in class B was 67% (14 of 21). In only four of 12 patients with severe hepatic dysfunction (Child's class C) was control of hemorrhage achieved (33 percent). None of these patients survived. Therapeutic failure also was associated with clotting derangements and the initial bleeding rate. It is concluded that the effectiveness of vasopressin in variceal hemorrhage is a function of the underlying liver disease and derangements in clotting function.

Topics: Adult; Aged; Blood Coagulation; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Liver Cirrhosis; Male; Mesenteric Arteries; Middle Aged; Vasopressins

Recent laboratory data have suggested equivalent therapeutic value of selective intraarterial or peripheral intravenous infusions of vasopressin in the control of gastrointestinal bleeding. However, recent experience in two clinical cases continues to support a therapeutic advantage of the selective intraarterial route and casts doubt on the applicability of the laboratory results to man. Until further data is accumulated, it is premature to discard the presumed therapeutic advantage of the selective intraarterial infusion of vasopressin.

Topics: Adult; Arteries; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Injections, Intra-Arterial; Male; Radiography; Vasopressins

Topics: Animals; Blood Flow Velocity; Cardiac Output; Dogs; Female; Gastrointestinal Hemorrhage; Haplorhini; Hepatic Artery; Injections, Intra-Arterial; Injections, Intravenous; Macaca mulatta; Male; Mesenteric Arteries; Regional Blood Flow; Vasomotor System; Vasopressins

Topics: Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Injections, Intra-Arterial; Vasopressins

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Vasopressins

Topics: Adult; Angiography; Catheterization; Embolization, Therapeutic; Gastrointestinal Hemorrhage; Humans; Injections, Intravenous; Vasopressins

Topics: Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Ileum; Infusions, Parenteral; Intestinal Diseases; Ischemia; Jejunum; Mesenteric Arteries; Mesenteric Vascular Occlusion; Middle Aged; Thrombosis; Vasopressins

Topics: Animals; Dogs; Female; Gastrointestinal Hemorrhage; Hemostasis, Surgical; Intestinal Mucosa; Ischemia; Jejunum; Male; Mesenteric Arteries; Radioisotope Dilution Technique; Regional Blood Flow; Vasopressins; Xenon Radioisotopes

Two patients developed spontaneous bacterial peritonitis after infusions of vasopressin into the superior mesenteric or gastroduodenal arteries for upper gastrointestinal hemorrhage. The peritonitis in these patients differed from the typical picture in which a single aerobic organism is responsible, by the presence of multiple organisms, some of which were anaerobic. These findings suggest that the arterial vasoconstriction decreased the integrity of the intestinal mucosal barrier and permitted the transmural migration of enteric organisms from the lumen of the bowel into the ascites-filled peritoneal cavity.

Topics: Anaerobiosis; Arteries; Ascitic Fluid; Bacterial Infections; Duodenum; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Intestines; Male; Mesenteric Arteries; Middle Aged; Peritonitis; Stomach; Stomach Ulcer; Vasopressins

Topics: Angiography; Antacids; Esophagoscopy; Gastrointestinal Hemorrhage; Gastroscopy; Humans; Vasopressins

Upper gastrointestinal bleeding in patients with hepatic cirrhosis carries considerable mortality. Difficulties are encountered both in determining the source of bleeding and in controlling blood loss. The techniques of selective visceral angiography not only supply diagnostic information, but can be used to administer selective intra-arterial vasoconstrictor therapy to control blood loss. We report our experience with 28 patients in whom angiography was performed with particular reference to six patients treated with selective vasoconstrictor therapy. Although the precise role of the technique is not yet established, early experience is most promising. We believe it will play an important role in a difficult group of patients in the future and may well supplant present methods of controlling bleeding.

Topics: Adult; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Male; Mesenteric Arteries; Middle Aged; Radiography; Vasopressins

Vasopressin infusion initially controlled 80 per cent of patients bleeding from portal hypertension, and 53 per cent did not rebleed after removal of the catheter. This figure is significantly greater than the 28 per cent of patients totally controlled by esophageal tamponade (p less than 0.075). Similar rates of success were achieved by vasopressin infusion for gastric, duodenal, and colonic bleeding sites. These results suggest that visceral arterial infusion of vasopressin is the method of choice for the short-term therapeutic management of massive gastrointestinal bleeding from portal hypertension. Vasopressin infusion also appears to be a valuable means of treating patients with massive gastrointestinal bleeding secondary to shallow gastric ulcers, gastritis, Mallory-Weiss tears, colonic bleeding and "poor risk" patients with deep gastric, marginal, or duodenal ulcers when conventional medical therapy has failed. The presence of a coagulation abnormality in patients with portal hypertension significantly reduced the complete control of bleeding to only 27 per cent ( p less than 0.010) and survival rate to 14 per cent (p less than 0.050). Visceral arterial perfusion proved to be an effective means of arresting hemorrhage, but the overall improvement in hospital mortality in this group of poor risk patients remains unproved.

Topics: Abdomen; Angiography; Celiac Artery; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Infusions, Parenteral; Mesenteric Arteries; Peptic Ulcer Hemorrhage; Vasopressins

Topics: Blood Transfusion; Esophageal Diseases; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Liver Cirrhosis; Peptic Ulcer Hemorrhage; Recurrence; Stomach Ulcer; Varicose Veins; Vasopressins

Alterations in gastric physiology caused by selective embolization and vasopressin infusion of the left gastric artery were evaluated in 29 dogs. Gastric acidity was not significantly altered following Gelfoam embolization but decreased sharply with vasopressin infusion. These results suggest that the segmental occlusion caused by Gelfoam embolization permits significant collateral blood flow to the gastric mucosa, while the arteriolar and capillary constriction caused by vasopressin effectively decreases mucosal blood flow. These findings are consistent with the clincal observation that embolization is more effective in controlling bleeding ulcers, while vasopressin infusion is more effective for controlling hemorrhagic gastritis.

Topics: Angiography; Animals; Dogs; Embolization, Therapeutic; Gastric Juice; Gastric Mucosa; Gastrins; Gastritis; Gastrointestinal Hemorrhage; Histamine; Models, Biological; Peptic Ulcer Hemorrhage; Stomach; Vasopressins

Topics: Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Middle Aged; Vasopressins

Emergency fiberoptic panendoscopy and visceral angiography both had comparable diagnostic accuracy in our series of 55 patients with actively bleeding upper gastrointestinal lesions. The diagnostic accuracy of the barium meal was found inferior to both fiberoptic panendoscopy and visceral angiography. Panendoscopy proved capable of quickly and safely diagnosing site and source of the active bleeding lesion. Visceral angiography requiring additional time, expense and personnel commitment proved an effective back-up procedure when panendoscopy was unsuccessful or contradictions existed. Emergency angiography was well tolerated by gravely ill patients. The therapeutic advantage of angiography with infusion of vasopressin upon completion of the diagnostic study remains to be shown as an advantage over panendoscopy.

Topics: Acute Disease; Adult; Angiography; Celiac Artery; Diagnostic Errors; Esophageal and Gastric Varices; Female; Fiber Optic Technology; Gastrointestinal Hemorrhage; Gastroscopy; Humans; Male; Mesenteric Arteries; Middle Aged; Vasopressins

Topics: Acute Disease; Angiography; Gastrointestinal Hemorrhage; Humans; Vasopressins

Vasopressin and its analogs are used inthe treatment of bleeding esophageal varices. Since gastrointestinal reflux may have a deleterious effect on variceal hemorrhage, the effect of 2,3-phenylalanine-8-lysine-vasopressin upon the lower esophageal sphincter (LES) was studies by rapid pull-through manometry in 24 persons. PLV infusion up to a dosis of 2.7 mU/kg/h raised LES pressure from 15.1 +/- 1.3 (SEM) to 17.9 +/- 2.0 mm Hg. Higher doses lowered LES pressure progressively to 12.1 +/- 0.7 mmHg at 54 mU/kg/h. The serum gastrin level did neither correlate with basal LES pressure not with LES pressure changes during PLV infusion. Therefore, PLV does not appear to act indirectly through serum gastrin. Because of the danger of systemic side effects and of the undesirable in LES pressure with the usual high doses of vasoactive substances, a continuous infusion of lower doses of vasopressin analogs appears to be advantageous.

Topics: Adult; Esophageal and Gastric Varices; Esophagogastric Junction; Female; Gastrins; Gastrointestinal Hemorrhage; Humans; Lypressin; Male; Methods; Vasopressins

A case of a massive colonic hemorrhage in nontoxic, quiescent ulcerative colitis is described. The source of active colonic bleeding was primarily defined with selective superior mesenteric arteriography and was completely controlled with transcatheter vasopressin infusion. A suubsequent elective segmental distal transverse and descending colectomy revealed chronic ulcerative colitis; localized marked inflammatory giant pseudopolyp formation near the splenic flexure was responsible for the bleeding.

Topics: Aged; Chronic Disease; Colitis, Ulcerative; Colonic Diseases; Female; Gastrointestinal Hemorrhage; Humans; Radiography; Vasopressins

Topics: Aspirin; Blood Transfusion; Child; Child, Preschool; Esophageal and Gastric Varices; Esophagitis, Peptic; Esophagoplasty; Gastritis; Gastrointestinal Hemorrhage; Humans; Infant; Infant, Newborn; Parasympatholytics; Peptic Ulcer; Stress, Psychological; Vasopressins; Vitamin K Deficiency Bleeding

Principles of management of bleeding esophageal varices are 1. fluid therapy of bleeding shock, 2. prevention of hepatic coma, 3. emergency endoscopy, 4. balloon tubes (Senkstaken-Blakemore, Linton-Nachlas), and 5. with some restriction, selective infusion of vasopressin into the a. mesenterica superior. If these procedures fail, sclerosing of esophageal varices stops bleeding in more than 90% of the cases. Bleeding from varices of the gastric fundus may be stopped by gastro-esophageal disconnection (Pettinari-Hassab). Both procedures have with 15% and 25% respectively, the lowest mortality. Patients for surgical shunt are carefully selected within the interval after bleeding. Shunts are the distal splenal-renal and the mesenteric-caval anastomosis with dacron prothesis (H-shunt). The shunt is the favorable therapy for prehepatic block in patients older than 14 to 16 years. The endoscopic sclerosing of esophageal varices and the gastro-esophageal disconnection are chosen in younger patients or when shunt procedures are not possible. The posthepatic block is treated successfully by conservative means. In most cases, surgical therapy is contraindicated because of poor prognosis. When conservative measures fail, in few cases emergency endoscopic sclerosing of esophageal varices or latero-lateral porto-caval anastomosis can be tried.

Topics: Acute Disease; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Plasma Substitutes; Sclerosing Solutions; Time Factors; Vasopressins

Topics: Angiography; Catheterization; Esophageal and Gastric Varices; Gastric Mucosa; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Portal System; Stomach Diseases; Vasopressins

Topics: Acute Disease; Angiography; Chronic Disease; Contrast Media; Gastrointestinal Hemorrhage; Humans; Male; Middle Aged; Vasopressins

Topics: Adult; Esophageal and Gastric Varices; Esophagogastric Junction; Female; Gastrointestinal Hemorrhage; Humans; Lypressin; Male; Phenylalanine; Vasopressins

Selective intraarterial infusion of vasopressin was performed in 32 patients for 35 episodes of gastrointestinal bleeding. Active bleeding was from esophageal varices in 11 cases and from an arterial site in 22 (stomach 11, duodenum 1, jejunum 2, colon 7, liver 1), including a jejunal diverticulum and a colonic ulcer in Behcet's disease. Two patients, not actively bleeding, were infused for portal decompression before an elective mesocaval shunt. Active bleeding was controlled in 64% of patients with variceal hemorrhage and in 59% of those with arterial sources. Infusion periods ranged from 15 minutes to 70 hours. There were no significant complications directly attributable to this therapy.

Topics: Adolescent; Adult; Aged; Angiography; Female; Gastrointestinal Hemorrhage; Humans; Infusions, Intra-Arterial; Intestines; Male; Middle Aged; Stomach; Vasopressins

Topics: Animals; Bile; Bile Acids and Salts; Disease Models, Animal; Dogs; Gastric Juice; Gastric Mucosa; Gastritis; Gastrointestinal Hemorrhage; Humans; Hydrogen-Ion Concentration; Ischemia; Peptic Ulcer Hemorrhage; Secretory Rate; Stomach Ulcer; Vasopressins

Topics: Adult; Gastrointestinal Hemorrhage; Humans; Ileitis; Infusions, Parenteral; Male; Typhoid Fever; Vasopressins

Topics: Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Vasopressins

Vasopressin administered as a peripheral infusion (40 U/hr) significantly reduced portal vein pressure in ten awake patients with cirrhosis and portal hypertension. A vasopressin-induced reduction in cardiac output occurred in five of the ten patients (50 per cent). Vasopressin-induced changes in systemic arterial pressure, heart rate, and portal venous pressure were independent of alterations in cardiac output. When the five patients with vasopressin-induced reductions in cardiac output were given a combination of vasopressin and isoproterenol, cardiac output was maintained and the reduction in portal vein pressure was equal to that observed with unopposed vasopressin therapy. Thus, the addition of isoproterenol prevented a vasopressin-induced reduction in cardiac output while permitting vasopressin to reduce portal vein pressure.

Topics: Blood Pressure; Cardiac Output; Drug Evaluation; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Heart Rate; Humans; Infusions, Parenteral; Isoproterenol; Liver Cirrhosis; Male; Portal System; Vasopressins

Twenty-four patients with massive rectal hemorrhage and known or subsequently proved colonic diverticular disease had the bleeding site localized by mesenteric angiography and received intra-arterial infusion of vasopressin to arrest the bleeding. In twenty-two patients the bleeding was controlled with the vasopressin infusion whereas in the remaining two, hemorrhage did not stop and surgery was performed. Of the twenty-two patients in whom bleeding was arrested by vasopressin infusion, twelve received no further surgical therapy, five had elective prophylactic surgical resection after a period of hemostasis, and the remaining five underwent segmental resection for bleeding that recurred after cessation of the infusion. Of the twelve patients who were not operated on, three had rebleeding two, four, and twelve months after vasopressin infusion and two of these three patients required surgery. The remaining nine have had no recurrent bleeding for periods ranging from seven to thirty-four months. Of ten patients who had segmental resection after precise localization of the bleeding site and initial control with vasopressin, no one has had recurrent hemorrhage for periods ranging from two to eighteen months.

Topics: Aged; Diverticulum, Colon; Evaluation Studies as Topic; Female; Follow-Up Studies; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Male; Mesenteric Arteries; Radiography; Recurrence; Vasopressins

Seventeen patients with upper and lower gastrointestinal hemorrhage were treated with selective intra-arterial continuous vasopressin infusion. 62.5 per cent of variceal and 60 per cent of nonvariceal episodes of hemorrhages were permanently controlled by vasopressin. The initial total success rate was 76.5 per cent. No major complications occurred. Early success with this technique has encouraged its continued use under a controlled setting for indications for its use to be evaluated.

Topics: Adult; Aged; Celiac Artery; Drug Evaluation; Esophageal and Gastric Varices; Esophagoscopy; Female; Gastrointestinal Hemorrhage; Gastroscopy; Humans; Injections, Intra-Arterial; Male; Mesenteric Arteries; Middle Aged; Muscle, Smooth; Preoperative Care; Vasopressins

Over a four-year period, 585 patients were hospitalized for massive upper gastrointestinal bleeding. Endoscopy diagnosed the cause of bleeding in 80% of 200 patients so studied. Selective angiography localized the bleeding site in 12 of 20 patients, and infusion of vasopressor stopped hemorrhage in six. Barium studies was 90% accurate in diagnosing ulcer disease but failed to detect gastritis. One hundred thirty (22%) patients were operated upon for medically uncontrolled bleeding. The proportion of patients requiring surgery fell from 33% in year one to 13% in year four. Benign ulcer disease caused bleeding in 51% of surgical patients, while gastritis was found in 20%, esophageal varices in 15% and stress ulcer in 8%. Overall operative mortality was 29%. Among 38 duodenal ulcer patients, mortality was 18%. Vagotomy and pyloroplasty were more effective than resection in this group. Resection for distal gastric ulcers in 22 patients resulted in a mortality of 14% and no rebleeding. While V&P controlled bleeding in 12 alcoholics with gastritis, five (42%) died postoperatively. Mortality among 20 patients with esophageal varices was 35%, although all five survived who had porto-caval shunts. Eight of 10 patients operated upon for stress ulcer bleeding died. Postoperative rebleeding occurred in 14 patients, eight of whom were again operated upon. In all but one a new lesion was found to be responsible for hemorrhage. Increasing use of gastroscopy and selective angiography can be expected to improve diagnostic capabilities in patients with upper gastrointestinal bleeding. Infusing vasopressor into selected arteries should reduce the need for surgical control of gastritis, variceal and stress ulcer bleeding, conditions poorly managed by current operative techniques.

Topics: Alcoholism; Angiography; Barium Sulfate; Esophageal and Gastric Varices; Gastritis; Gastrointestinal Hemorrhage; Gastroscopy; Humans; Injections, Intra-Arterial; Peptic Ulcer Hemorrhage; Recurrence; Retrospective Studies; Risk; Vasopressins

A bleeding gastric ulcer was surgically created in 18 dogs, and the left gastric artery was successfully catheterized by percutaneous techniques in 15. Nine of these dogs were treated with vasopressin infusion which did not arrest the hemorrhage. A total of 11 dogs (five of them following unsuccessful vasopressin therapy) underwent embolization with strips of Gelfoam, and hemorrhage stopped in ten. This technique of embolization is concluded to be of value in the management of gastric hemorrhage.

Topics: Angiography; Animals; Arteries; Catheterization; Celiac Artery; Contrast Media; Dogs; Embolism; Gastrointestinal Hemorrhage; Gelatin Sponge, Absorbable; Stomach; Stomach Ulcer; Vasopressins

Topics: Endoscopy; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Vasopressins

Nalpha-glycyl-glycyl-glycyl-(8-lysine)-vasopressin, a hormone analogue with prolonged pharmacological action due to slow release of active nonapeptide by enzyme action in vivo, has been administered to 5 control subjects and to 14 patients actively bleeding from upper gastrointestinal sites. The control subjects showed a prolonged pressor response to 100mug/kg body weight associated with a rise in cardiac output, with no ECG signs of myocardial toxicity. 13 of the 14 bleeding patients showed not only pressor responses and haemodynamic and clinical improvement when administering doses of 20-100 mug/kg, but clear signs of standstill of upper gastrointestinal bleeding.

Topics: Adolescent; Adult; Aged; Animals; Colic; Defecation; Dogs; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Glycine; Heart; Hemodynamics; Humans; Lypressin; Male; Middle Aged; Nausea; Peptic Ulcer Hemorrhage; Sweating; Urination; Vasopressins

Diagnosis and the treatment of gastrointestinal bleeding by selective and superselective technique and the perfusion of vasopressors have been noted to have significant success. Transluminal embolization of a bleeding site represents an alternative method in patients who represent a poor operative risk and in those in whom vasopressor therapy has failed. The potential risks include intestinal ischemia and vary with the anatomic site.

Topics: Adult; Aged; Angiography; Catheterization; Embolization, Therapeutic; Gastrointestinal Hemorrhage; Gelatin Sponge, Absorbable; Humans; Male; Vasopressins

Topics: Adult; Aged; Angiography; Colonic Diseases; Diverticulum, Colon; Gastrointestinal Hemorrhage; Humans; Male; Mesenteric Arteries; Mesenteric Veins; Middle Aged; Perfusion; Vasopressins

Topics: Aged; Drug Evaluation; Female; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Vasopressins

Topics: Colonic Neoplasms; Female; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Intestinal Polyps; Mesenteric Arteries; Middle Aged; Postoperative Complications; Radiography; Vasopressins

Angiography has added a new dimension to the management of hemorrhage from the large bowel. In patients with diverticular hemorrhage, mesenteric angiography not only localizes the bleeding site but, in addition, the bleeding can be acutely controlled with intraarterial infusion of vasopressin, making an emergency colectomy unnecessary. Similarly in patients bleeding from inflammatory bowel disease or in patients with post-operative hemorrhage, angiography provides information about the nature of the lesion and selective arterial infusions of vasopressin can control the bleeding. At times intestinal varices have angiographically been demonstrated as a potential source of rectal hemorrhage while in patients with unexplained lower gastrointestinal bleeding and repeatedly negative barium and endoscopic examinations, angiography has been valuable for the diagnosis of angiodysplasia of the colon.

Topics: Acute Disease; Aged; Angiography; Blood Vessels; Colitis, Ulcerative; Colon; Colonic Neoplasms; Diverticulum, Colon; Endoscopy; Gastrointestinal Hemorrhage; Humans; Intestinal Polyps; Intestine, Large; Male; Mesenteric Arteries; Middle Aged; Varicose Veins; Vasopressins

Dissatisfaction with the high morbidity and mortality of traditional methods of handling massive gastrointestinal hemorrhage has led to the exploration of means other than surgical to attain hemostasis. Some, such as selective arterial infusion of surgical Pituitrin, have quickly won general acceptance in hospitals where facilities and interested personnel are available. Others, such as alkalinization, have become popular because of their inherent simplicity. Systemic hypothermia, requiring intensive patient care, has not been without considerable risk of significant complications. Iced saline lavage has never been subjected to critical evaluation. It is possible that the emptying of the stomach through mechanical destruction of the intragastric clot by repeated irrigations, reducing the antral stimulation by relief of distension, may be as important as the temperature of the solution in the stomach. Gastric irrigations with norepinephrine solutions have awaited the results of physiologic studies showing that the cardiovascular and renal effects of injected levarterenol are avoided, and that permanent damage to the gastrointestinal mucosa does not result. Trials have been confined largely to very poor-risk patients, and the hemostasis that has resulted has not been explainable, in all cases, on the basis of the physiologic activity of the agent (e.g., control of bleeding from tumor vessels). Evacuation of gastric content prior to introduction of the norepinephrine solution seems important. Lower gastrointestinal bleeding from benign disease has also responded to advances in applied pharmacology, with intra-arterial infusion of surgical Pituitrin again coming into progressively wider use. Intraperitoneal instillation of norepinephrine has also proved useful, even in patients who have adhesions from prior surgery or inflammatory disease, but closer monitoring of blood pressure and urine output are necessary because some of this solution is absorbed by the parietal peritoneum and not deactivated by the liver before entering the systemic circulation. Taken together, selective arterial infusion of vasopressin and topical application of norepinephrine can be considered complementary rather than competitive therapies. Because of the more extensive experience with selective angiographic infusion, it should be the first choice in institutions where it is readily available. For patients in whom arterial puncture is inadvisable, and where angiography is not readily

Topics: Antacids; Gastrectomy; Gastric Lavage; Gastritis; Gastrointestinal Hemorrhage; Humans; Hypothermia, Induced; Injections, Intra-Arterial; Norepinephrine; Peptic Ulcer Hemorrhage; Postoperative Care; Stomach; Stress, Psychological; Vagotomy; Vasopressins

Endoscopy, barium studies and angiography are all valuable diagnostic procedures in gastrointestinal bleeding. They are not mutually exclusive procedures but the correct sequence of investigation varies. Correct localization can be achieved in 84% of cases of massive gastrointestinal bleeding by their combined use. Vasoconstrictive therapy is also possible in severely ill patients and other poor surgical risk candidates.

Topics: Adult; Angiography; Barium Sulfate; Endoscopy; Epinephrine; Gastrointestinal Hemorrhage; Humans; Male; Varicose Veins; Vasopressins

Topics: Blood Transfusion; Blood Vessel Prosthesis; Catheterization; Collateral Circulation; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Injections, Intravenous; Mesenteric Arteries; Mesenteric Veins; Portacaval Shunt, Surgical; Radiography; Renal Veins; Splenic Vein; Vasopressins; Vena Cava, Inferior

Topics: Acute Disease; Adult; Aged; Angiography; Arteries; Celiac Artery; Duodenum; Endoscopy; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Injections, Intra-Arterial; Male; Mesenteric Arteries; Middle Aged; Perfusion; Stomach; Vasopressins

Topics: Angiography; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Injections, Intra-Arterial; Methods; Vasopressins

Topics: Angiography; Contrast Media; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hepatic Artery; Humans; Hypertension, Portal; Injections, Intra-Arterial; Liver Cirrhosis; Mesenteric Arteries; Portacaval Shunt, Surgical; Splenic Artery; Vasopressins

Topics: Adult; Aged; Female; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Male; Middle Aged; Radiography; Splenic Artery; Vasopressins

Topics: Adult; Aged; Angiography; Animals; Celiac Artery; Dogs; Epinephrine; Female; Gastritis; Gastrointestinal Hemorrhage; Humans; Infusions, Parenteral; Injections, Intra-Arterial; Male; Middle Aged; Vasopressins

Topics: Catheterization; Esophageal and Gastric Varices; Gangrene; Gastrointestinal Hemorrhage; Hepatic Encephalopathy; Humans; Intestinal Diseases; Male; Mesenteric Arteries; Mesenteric Vascular Occlusion; Middle Aged; Portal Vein; Sepsis; Thrombophlebitis; Thrombosis; Vasopressins

Two cases of complicating hemorrhage resulting from typhoid fever which were demonstrated by selective superior mesenteric arteriography are presented. The site of bleeding was at the caecum which is an uncommon site in typhoid hemorrhage. In both cases there was failure to stop the bleeding by using a vasopressin infusion. However, arteriography proved very helpful in locating the site of bleeding and vasopressin infusion can still be recommended to decrease intraluminal hemorrhage and improve the general condition of the patient before undergoing operation.

Topics: Angiography; Cecum; Colectomy; Erythrocytes; Female; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Lymphocytes; Macrophages; Male; Mesenteric Arteries; Plasma Cells; Rectum; Typhus, Epidemic Louse-Borne; Ulcer; Vasopressins

Topics: Blood Transfusion; Endoscopy; Gastrointestinal Hemorrhage; Humans; Radiography; Radionuclide Imaging; Vasopressins

Topics: Adult; Angiography; Arteries; Blood Transfusion; Catheterization; Esophageal and Gastric Varices; Gastritis; Gastrointestinal Hemorrhage; Gelatin Sponge, Absorbable; Hemostasis; Humans; Ileum; Jejunum; Male; Peptic Ulcer Hemorrhage; Postoperative Complications; Stomach; Vasopressins

Topics: Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Male; Mesenteric Arteries; Middle Aged; Peptic Ulcer Hemorrhage; Time Factors; Vasopressins

Topics: Acute Disease; Duodenal Ulcer; Epinephrine; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Portography; Stomach Ulcer; Vasopressins

Topics: Angiography; Celiac Artery; Epinephrine; Gastrointestinal Hemorrhage; Humans; Mesenteric Arteries; Vasopressins

Topics: Animals; Blood Pressure; Cardiac Output; Disease Models, Animal; Dogs; Gastrointestinal Hemorrhage; Hemodynamics; Oxygen; Pancreas; Pancreatitis; Portal System; Regional Blood Flow; Vascular Resistance; Vasopressins; Venous Pressure

Seventeen patients bleeding from oesophageal varices were treated by continuous infusion of vasopressin through a catheter inserted percutaneously and positioned in the superior mesenteric artery and in two other patients catheterization proved technically impossible. Bleeding was completely controlled on only four out of 18 occasions in the 17 patients treated. In seven patients, bleeding was controlled for two or more days but then recurred although the infusion was continued with an increased dose of vasopressin. There was a high incidence of complications, including bleeding from the site of catheter insertion in the groin and septicaemias. Sengstaken balloon tamponade and oesophageal transection had to be used to control bleeding in some patients but only six out of 17 survived to leave hospital.

Topics: Adult; Catheterization; Endocarditis, Bacterial; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Heart Arrest; Humans; Injections, Intra-Arterial; Liver Diseases; Male; Meningitis, Pneumococcal; Mesenteric Arteries; Middle Aged; Radiography; Thromboembolism; Vasopressins

Topics: Adult; Angiography; Celiac Artery; Female; Gastritis; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Male; Mesenteric Arteries; Middle Aged; Peptic Ulcer; Stress, Physiological; Vasopressins

Topics: Gastrointestinal Hemorrhage; Humans; Propranolol; Radiography; Vasopressins

Topics: Aged; Angiography; Colectomy; Diverticulum, Colon; Female; Gastrointestinal Hemorrhage; Humans; Mesenteric Arteries; Vasopressins

Topics: Adult; Aged; Arteriovenous Shunt, Surgical; Catheterization; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Articular; Liver Cirrhosis; Male; Mesenteric Arteries; Middle Aged; Perfusion; Vasopressins

Topics: 1-Propanol; Aged; Angiography; Blood Transfusion; Catheterization; Celiac Artery; Epinephrine; Female; Gastrointestinal Hemorrhage; Heparin; Humans; Injections, Intra-Arterial; Male; Mesenteric Arteries; Methods; Middle Aged; Vasoconstrictor Agents; Vasopressins

Topics: Age Factors; Blood Transfusion; Endoscopy; Esophageal and Gastric Varices; Fiber Optic Technology; Gastrointestinal Hemorrhage; Humans; Intubation, Gastrointestinal; Liver Cirrhosis; Melena; Neurologic Manifestations; Postoperative Complications; Radiography; Retrospective Studies; Vasopressins

Topics: Angiography; Arteries; Blood Flow Velocity; Gastrointestinal Hemorrhage; Hepatic Artery; Humans; Injections, Intra-Arterial; Mesenteric Arteries; Splenic Artery; Stomach; Vasopressins

Topics: Adult; Angiography; Contrast Media; Foot; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Intestine, Small; Ischemia; Male; Mesenteric Arteries; Vasopressins; Wounds and Injuries

Topics: Adolescent; Adult; Aged; Blood Transfusion; Child; Coronary Vessels; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Iliac Vein; Male; Mesenteric Veins; Middle Aged; Portacaval Shunt, Surgical; Splenectomy; Vasopressins; Venae Cavae

Topics: Adult; Blood Vessels; Fundus Oculi; Gastrointestinal Hemorrhage; Humans; Male; Pseudoxanthoma Elasticum; Recurrence; Skin; Stomach; Vasopressins

Topics: Anemia; Angiography; Celiac Artery; Colonic Diseases; Contrast Media; Gastrointestinal Hemorrhage; Humans; Intestinal Neoplasms; Melena; Mesenteric Arteries; Time Factors; Vasopressins

Topics: Adult; Aged; Emergencies; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Hemostasis; Heparin; Humans; Male; Mesenteric Arteries; Middle Aged; Vasopressins

Topics: Alcoholism; Angiography; Autopsy; Esophageal and Gastric Varices; Fatty Liver; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Infarction; Injections, Intra-Arterial; Intestine, Small; Liver Cirrhosis; Male; Mesenteric Arteries; Mesenteric Vascular Occlusion; Mesenteric Veins; Thrombosis; Vasopressins

Topics: Angiography; Animals; Blood Pressure; Dogs; Epinephrine; Female; Gastric Mucosa; Gastrointestinal Hemorrhage; Injections, Intra-Arterial; Male; Microcirculation; Stomach Diseases; Vasopressins

Topics: Adult; Angiography; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Male; Mesenteric Arteries; Middle Aged; Stomach; Vasopressins

Topics: Animals; Aorta, Abdominal; Blood Pressure; Disease Models, Animal; Dogs; Gastrointestinal Hemorrhage; Pancreas; Pancreatitis; Regional Blood Flow; Vascular Resistance; Vasopressins

Topics: Aged; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Male; Vasopressins; Water Intoxication

Topics: Aged; Angiography; Epinephrine; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Male; Middle Aged; Peptic Ulcer Hemorrhage; Propranolol; Stomach Ulcer; Vasopressins

Topics: Adolescent; Adult; Aged; Angiography; Child; Child, Preschool; Epinephrine; Esophageal and Gastric Varices; Female; Gastritis; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Injections, Intra-Arterial; Male; Middle Aged; Peptic Ulcer Hemorrhage; Ulcer; Vasopressins

Topics: Angiography; Celiac Artery; Duodenal Ulcer; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Injections, Intra-Arterial; Liver Cirrhosis; Mesenteric Arteries; Peptic Ulcer Hemorrhage; Stomach Ulcer; Vasopressins

Topics: Acute Disease; Blood Transfusion; Emergencies; Esophageal and Gastric Varices; Esophagoscopy; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Liver Cirrhosis; Methods; Middle Aged; Vasopressins

Topics: Adult; Aged; Arteries; Capillaries; Celiac Artery; Colonic Diseases; Diverticulum, Colon; Duodenal Ulcer; Epinephrine; Gastritis; Gastrointestinal Hemorrhage; Hernia, Diaphragmatic; Humans; Infusions, Parenteral; Male; Mallory-Weiss Syndrome; Mesenteric Arteries; Middle Aged; Peptic Ulcer Hemorrhage; Radiography; Stomach Ulcer; Vasopressins

Topics: Adult; Aged; Angiography; Female; Gastrointestinal Hemorrhage; Humans; Male; Methods; Middle Aged; Vasopressins

Topics: Animals; Cardiac Output; Dogs; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Isoproterenol; Vasopressins

Topics: Angiotensin II; Animals; Blood Circulation; Blood Pressure; Clonidine; Cold Temperature; Drug Synergism; Gastric Juice; Gastric Mucosa; Gastrointestinal Hemorrhage; Immobilization; Male; Norepinephrine; Rats; Secretory Rate; Stomach Ulcer; Stress, Physiological; Vasoconstrictor Agents; Vasodilator Agents; Vasopressins

Topics: Adult; Child; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Laparotomy; Middle Aged; Vasopressins

Topics: Acute Disease; Adolescent; Adult; Aged; Angiography; Arteriosclerosis; Celiac Artery; Crohn Disease; Duodenal Ulcer; Epinephrine; Esophageal and Gastric Varices; Female; Follow-Up Studies; Gastrointestinal Hemorrhage; Hernia, Diaphragmatic; Humans; Injections, Intra-Arterial; Male; Mallory-Weiss Syndrome; Mesenteric Arteries; Middle Aged; Peptic Ulcer Hemorrhage; Propranolol; Vasoconstrictor Agents; Vasopressins

Topics: Adult; Aged; Alcoholism; Blood Transfusion; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis; Male; Middle Aged; Portacaval Shunt, Surgical; Postoperative Complications; Tampons, Surgical; Therapeutic Irrigation; Time Factors; Vasopressins

Topics: Animals; Blood Pressure; Cats; Dogs; Epinephrine; Gastrointestinal Hemorrhage; Humans; Intestines; Propranolol; Vasopressins; Venous Pressure

Topics: Acute Disease; Adolescent; Adult; Angiography; Animals; Blood Vessels; Catheterization; Celiac Artery; Child, Preschool; Dogs; Epinephrine; Gastrointestinal Hemorrhage; Hepatic Artery; Humans; Injections, Intra-Arterial; Mesenteric Arteries; Methods; Propranolol; Time Factors; Vasoconstrictor Agents; Vasopressins

Topics: Aminocaproates; Blood Coagulation Disorders; Blood Transfusion; Duodenal Ulcer; Esophageal and Gastric Varices; Esophagitis; Fibrinogen; Fibrinolysis; Gastritis; Gastrointestinal Hemorrhage; Heparin; Humans; Liver Diseases; Phosphorus Isotopes; Portacaval Shunt, Surgical; Stomach Ulcer; Therapeutic Irrigation; Vasopressins; Vitamin K

Topics: Adult; Arrhythmias, Cardiac; Cardiac Output; Coronary Circulation; Coronary Disease; Electrocardiography; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Muscle, Smooth; Vasopressins

Topics: Angiography; Gastrointestinal Hemorrhage; Humans; Vasopressins

Topics: Acute Disease; Adult; Aged; Alcoholism; Animals; Colitis; Colitis, Ulcerative; Diverticulum, Colon; Dogs; Epinephrine; Female; Gastrointestinal Hemorrhage; Humans; Ileitis; Injections, Intra-Arterial; Male; Mesenteric Arteries; Middle Aged; Peptic Ulcer Hemorrhage; Propranolol; Regional Blood Flow; Stomach Ulcer; Vasoconstrictor Agents; Vasopressins

Topics: Blood Transfusion; Cardia; Esophageal and Gastric Varices; Gastrectomy; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Methods; Postoperative Complications; Stomach; Vasopressins

Topics: Aged; Angiography; Catheterization; Female; Gastrointestinal Hemorrhage; Hematuria; Humans; Iliac Artery; Vasopressins

Topics: Cryosurgery; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Portacaval Shunt, Surgical; Tampons, Surgical; Vasopressins

Topics: Animals; Dogs; Gastrointestinal Hemorrhage; Hepatectomy; Hypotension, Controlled; Liver Function Tests; Liver Neoplasms; Trimethaphan; Vasopressins

Topics: Adolescent; Adult; Aged; Alcoholism; Child; Emergencies; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Liver Cirrhosis; Liver Function Tests; Male; Middle Aged; Portacaval Shunt, Surgical; Postoperative Complications; Vasopressins

Topics: Acute Disease; Animals; Gastric Mucosa; Gastritis; Gastrointestinal Hemorrhage; Rats; Vasopressins

Topics: Adult; Angiography; Animals; Blood Flow Velocity; Cardiac Output; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Infusions, Parenteral; Liver Function Tests; Male; Mesenteric Arteries; Pituitary Hormones, Posterior; Vasopressins

Topics: Blood Pressure; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Manometry; Portal Vein; Pressure; Vasopressins

Topics: Aged; Blood Volume Determination; Cardiovascular Diseases; Cerebrovascular Disorders; Chromium Isotopes; Gastrointestinal Diseases; Gastrointestinal Hemorrhage; Hematocrit; Hemoglobinometry; Humans; Hydrocortisone; Iodine Isotopes; Metaraminol; Methylphenidate; Phenoxybenzamine; Respiratory Tract Diseases; Shock, Hemorrhagic; Urologic Diseases; Vasopressins

Topics: Animals; Blood Flow Velocity; Blood Pressure; Chlorpromazine; Dogs; Gastrointestinal Hemorrhage; Hypertonic Solutions; Infusions, Parenteral; Intestine, Small; Intestines; Isoproterenol; Mesentery; Norepinephrine; Phenoxybenzamine; Phentolamine; Portal System; Rats; Regional Blood Flow; Shock, Hemorrhagic; Splanchnic Nerves; Vasopressins

Topics: Animals; Blood Circulation; Blood Flow Velocity; Blood Pressure; Dogs; Gastric Mucosa; Gastrointestinal Hemorrhage; Vasopressins

Topics: Blood Transfusion; Drug Therapy; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hepatic Encephalopathy; Humans; Vasopressins

Topics: Blood Transfusion; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemorrhage; Humans; Hypertension; Hypertension, Portal; Liver Cirrhosis; Mortality; Omentum; Splenectomy; Surgical Procedures, Operative; Vasopressins

Topics: Arginine Vasopressin; Esophageal and Gastric Varices; Felypressin; Gastrointestinal Hemorrhage; Hemorrhage; Humans; Vasopressins

Topics: Adolescent; Biomedical Research; Blood Pressure; Cardiac Catheterization; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Geriatrics; Humans; Hypertension; Hypertension, Portal; Infusions, Parenteral; Liver Circulation; Liver Cirrhosis; Lysine; Pharmacology; Phenylalanine; Portal Pressure; Portal Vein; Toxicology; Vasopressins

Topics: Angiotensins; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension; Hypertension, Portal; Liver Cirrhosis; Pharmacology; Toxicology; Vasopressins

Topics: Clinical Laboratory Techniques; Diagnosis; Drug Therapy; Endoscopy; Esophageal and Gastric Varices; Gastrectomy; Gastric Hypothermia; Gastrointestinal Hemorrhage; Humans; Hypothermia, Induced; Peptic Ulcer Hemorrhage; Radiography; Syncope; Vasopressins

Topics: Emergencies; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Hemostasis; Hepatitis; Humans; Liver Cirrhosis; Portacaval Shunt, Surgical; Vasopressins