Portal Hypertension: Drug Therapy

Therapeutic Targets

• Avoidance of complications and sequelae such as esophageal variceal or fundus variceal hemorrhage.
• In variceal bleeding: hemostasis.
• Avoidance of sepsis (blood poisoning).
• Avoidance of recurrent bleeding (bleeding again).

Therapy recommendations

• Reduction of portal pressure via reduction of portal-venous inflow → improved prognosis: fewer complications of portal hypertension and consequently reduced mortality (morbidity). Suitable for long-term therapy – also in terms of primary and secondary prophylaxis of variceal bleeding:
  • Propranolol (nonselective beta-blocker) – first-line agent; reduction of heart rate and cardiac output (HRV) and reduction of splanchnic blood flow (visceral blood flow).
  • Long-term therapy with non-selective beta-blockers (NSBBs) can reduce portal pressure by ≥ 20% of the original value or to ≤ 12 mmHg in 30-40% of affected individuals.
• Primary prophylaxis of variceal bleeding:
  • Goal: avoid first esophageal variceal or fundal variceal bleeding.
  • The risk of first variceal bleeding is approximately 30%.
  • Indications for primary prophylaxis: increased risk of bleeding = large varices, (“red color signs” or stage III).
  • Permanent use of non-selective beta-blockers, e.g. propranolol; bleeding risk can thus be reduced by about 50%.
• In acute esophageal variceal or fundus variceal bleeding:
  • Vasoactive substances such as terlipressin, somatostatin(-derivatives) – vasopressin is used less and less because of significant side effects!
  • Bleeding can often be stopped at least in the short term by medication.
• In the therapy of acute esophageal variceal bleeding should always also antibiosis / antibiotic therapy (eg, with ciprofloxacin) to prevent sepsis (blood poisoning); therapy duration 5-7 days; in addition, the risk of early bleeding recurrence (recurrence of bleeding) is reduced
• Secondary prophylaxis, as recurrent bleeding is common!
  • In early bleeding recurrences: renewed administration of vasoactive substances as well as antibiotic infection prophylaxis for esophageal variceal bleeding.
  • The risk of subsequent recurrent hemorrhage can be minimized by, among other things, permanent use of nonselective beta-blockers.
• After variceal hemorrhage: prophylaxis of coma hepaticum (hepatic coma)!
  • Suction of the bloody stomach contents to reduce the protein load on the liver.
  • Intestinal cleansing
  • Administration of lactulose (orally and as an enema).
  • Taking rifaximin (non-absorbable antibiotic).
• If necessary, therapy of ascites (abdominal dropsy): diuretics.