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Non-pulmonary Critical Care - part 5

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Mặc dù gastropathy cổng thông tin thường thấy trong các thiết lập của dãn tĩnh mạch dạ dày, mức độ nghiêm trọng của nó không tương quan với áp lực cổng thông tin. Tuy nhiên, chảy máu thường được cải tạo bằng cách giảm áp lực cổng thông tin. | INTENSIVE MANAGEMENTOF HEPATIC FAILURE RINELLA SANYAL 251 risks of rebleeding although the data to support such an approach are weak at best. In those with well-preserved liver function a surgical shunt can also provide longterm relief from bleeding.146 Portal Hypertensive Gastropathy Portal hypertensive gastropathy PHG is a manifestation of portal hypertension. Endoscopically it is characterized by a mosaic mucosal pattern with varying degrees of submucosal hemorrhage. It is often asymptomatic but may lead to chronic transfusion-requiring blood loss or acute bleeding rarely . Although portal gastropathy is more often seen in the setting of gastroesophageal varices its severity does not correlate with portal pressure. Nevertheless bleeding is often ameliorated by reduction of portal pressure. Both octreotide and nonselective p-blockade can be helpful in decreasing acute bleeding and the degree of rebleeding from PHG via reduction of portal blood flow.147-149 In refractory cases TIPS can be effective at reducing transfusion requirements.150 THERAPIES TO ACHIEVE HEMOSTASIS Drug Therapy Drug therapy is an integral component of the management of acute portal hypertensive hemorrhage and should be started on presentation. To optimize the effectiveness of drug or endoscopic therapy clotting abnormalities must be corrected. Target INR and platelet count should be 1.5 and 75 respectively. In the setting of renal failure platelets may be dysfunctional and DDAVP Desamino-D-Arginine Vasopressin should be considered. FFP alone or in combination with rFVIIa can be given to rapidly correct coagulopathy. A recent randomized clinical trial showed that when given in addition to standard therapy 100 mg kg of rFVIIa may improve control of bleeding in patients with advanced cirrhosis.1 Somatostatin or octreotide its synthetic analogue stops acute bleeding from varices in 80 of cases.152 It does so through a reduction of portal pressure via effects on vasoactive peptides or through the