Wang Varizen

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Wang Varizen

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Wang Varizen Entfernung von Krampfadern an den Beinen Volgograd

N Engl J Med ; Patients with cirrhosis in Child—Pugh class C or those in class B who have persistent bleeding at endoscopy are at high risk for treatment failure and a poor prognosis, even if they have Wang Varizen rescue treatment with a transjugular intrahepatic portosystemic shunt TIPS. This study evaluated the earlier use of TIPS in such patients.

Full Text of Background We randomly assigned, within 24 hours after admission, a total of 63 patients with cirrhosis and acute variceal bleeding who had been treated with vasoactive drugs plus endoscopic therapy to treatment with a polytetrafluoroethylene-covered Varizen bei VVC within 72 hours after randomization early-TIPS group, 32 patients or continuation of vasoactive-drug therapy, Wang Varizen, followed after 3 to 5 days by treatment with propranolol or nadolol and long-term endoscopic band ligation EBLwith insertion of a TIPS if needed as rescue therapy pharmacotherapy—EBL group, 31 patients.

Full Text of Methods The number of days in the intensive care unit and the percentage of time in the hospital during follow-up were significantly higher in the pharmacotherapy—EBL group than in the early-TIPS group.

No significant differences were observed between the two treatment groups with respect to serious adverse events, Wang Varizen. Full Text of Results In these patients with cirrhosis who were hospitalized Wang Varizen acute variceal bleeding and at high risk for treatment failure, the early use of TIPS was associated with significant reductions in treatment failure and in mortality. Full Text of Discussion Variceal bleeding is a severe complication of portal hypertension and a major cause of death in patients with cirrhosis.

Advanced liver failure, failure to control variceal bleeding, early rebleeding, and marked elevations in portal pressure are associated with increased mortality, Wang Varizen. In a study involving patients at high risk for treatment failure, as indicated by a hepatic venous pressure gradient of 20 mm Hg or more, 11 early treatment with TIPS improved the prognosis in comparison with medical treatment Wang Varizen a study by Monescillo et al.

We conducted a study to determine whether early treatment with TIPS, with the use of a stent covered with extended polytetrafluoroethylene e-PTFEcan improve outcomes in patients with cirrhosis and variceal bleeding who are at high risk for treatment failure and death, Wang Varizen. Eligible patients had cirrhosis with acute esophageal variceal bleeding that was being treated with a combination of vasoactive drugs, endoscopic treatment, and Wang Varizen antibiotics.

Patients had Child—Pugh class C disease a score of 10 to 13 or they had class B disease a score of 7 to 9 but with active bleeding at diagnostic endoscopy.

Patients with scores higher than 13 were excluded from the study. In the Child—Pugh classification of liver disease, class A [a score of 5 or 6] indicates the least severe disease, Wang Varizen, class B [7 to 9] moderately severe disease, and class C [10 to 15] the most severe disease, Wang Varizen.

Active variceal bleeding at endoscopy was defined on the basis of the Baveno criteria. Exclusion criteria were an age of more than 75 years, pregnancy, hepatocellular carcinoma that did not meet the Milano criteria for transplantation i. All patients provided written informed consent. The study protocol was approved by the ethics committees of all participating hospitals and followed the Guidelines for Good Clinical Practice in clinical trials.

Randomization was performed within 24 hours after admission. The randomization sequence was generated by computer with the use of a concealed block size of four, Wang Varizen. The coded treatment assignments were kept Risiko für Krampfadern the coordinating center in sealed, Wang Varizen, consecutively numbered, opaque envelopes.

Randomized assignments to the study groups were made by contacting the coordinating center available 24 hours a day by telephone or fax.

Treatment with vasoactive drugs was continued until patients were free of bleeding for at least 24 hours and preferably up to 5 days, at Wang Varizen point treatment with a nonselective beta-blocker either propranolol or nadolol was started. The dose was increased in a stepwise fashion every 2 to Wang Varizen days to the maximum tolerated dose or to wie die Wunden von Krampfadern zu behandeln maximum of mg twice daily for propranolol and mg per day for nadolol.

After these doses were achieved, 10 mg of isosorbidemononitrate was initiated at bedtime, with a stepwise increase in the dose to a maximum of 20 mg twice a day or the maximum tolerated dose.

In addition, within 7 to 14 days after the initial endoscopic treatment, the Wang Varizen, elective session Wang Varizen EBL was performed. EBL sessions were then scheduled every 10 to 14 days until variceal eradication was achieved i. Patients received proton-pump inhibitors until variceal eradication was accomplished. After eradication, Wang Varizen, endoscopic monitoring was performed at 1-month, 6-month, Wang Varizen, and month intervals and then annually.

If varices reappeared, further EBL sessions were initiated. Treatment failure was defined as one severe rebleeding episode i. TIPS was performed within 72 hours after diagnostic endoscopy or, when possible, within the first 24 hoursand vasoactive drugs were administered until then.

If the portal-pressure gradient the difference between portal-vein pressure and inferior vena Wang Varizen pressure did not decrease to below 12 mm Hg, the stent was dilated to 10 mm. Follow-up visits were scheduled at 1 month, at 3 months, and every 3 months thereafter.

Doppler ultrasonography was performed at the first visit, at 6 months, and every 6 months thereafter. Patients were followed until death or liver transplantation up to a maximum of 2 years of follow-up or until the end of the Wang Varizen September The primary end point of the study was a composite outcome of failure to control acute bleeding or failure to prevent clinically significant variceal rebleeding within 1 year after enrollment.

Secondary end points were Wang Varizen at 6 weeks and at 1 year, failure to control acute bleeding, early rebleeding rate of rebleeding at 5 days and at 6 weeksrate of rebleeding between 6 weeks and Krampfadern Behandlung Chelyabinsk year, the development of other complications related to portal hypertension Chinese Rauch Bewertungen für Krampfadern follow-up, the number of days in the intensive care unit, the percentage of follow-up days spent in the hospital, and the use of alternative treatments, Wang Varizen.

In a study by Villanueva et al, Wang Varizen. Because the only rationale for early use of TIPS would be evidence that this approach is better Thrombophlebitis der unteren Extremitäten Klassifizierung the current standard Wang Varizen, the sample size was calculated with the use of a one-sided test.

All data analyses were performed on an intention-to-treat basis according to a preestablished analysis plan. Dichotomous variables were compared by means of Fisher's exact test, and continuous variables were compared by means of the nonparametric Mann—Whitney rank-sum test. The probabilities of reaching the primary end point and of survival were estimated by the Kaplan—Meier method and were compared by means of the log-rank test.

A P value of less than 0. The statistical software packages used for the analysis Wang Varizen SPSS version We screened patients with acute variceal bleeding who were admitted to the participating hospitals for study eligibility.

There were Wang Varizen significant differences in baseline characteristics between the two groups at the time of entry into the study Table 1 Table 1 Baseline Characteristics of the Patients.

A total of 7 patients 3 in the pharmacotherapy—EBL group and 4 in the early-TIPS group were lost to follow-up after a median of 8 Wang Varizen range, 0. A total of 6 patients 2 in the pharmacotherapy—EBL group and 4 in the early-TIPS group underwent liver transplantation during follow-up.

In the pharmacotherapy—EBL group, 22 patients received propranolol median dose, 55 mg [range, 10 Wang Varizen ]Wang Varizen, and only 3 received nadolol. In the remaining 6 patients, nonselective beta-blocker therapy was not initiated because of failure to control bleeding, early rebleeding, or death, Wang Varizen.

In 12 patients, isosorbidemononitrate was added to the nonselective beta-blocker median dose, 25 mg [range, 10 to 40]Wang Varizen, but it was not added in 13 patients because of arterial hypotension, the treating physician's preference, or early death. Variceal eradication was achieved in 12 patients after a median of 2 EBL sessions range, 1 to 7 without rebleeding; in 4 patients, eradication was achieved after treatment of a rebleeding episode with additional EBL sessions.

In the remaining 15 patients, eradication was not achieved in 12 because the primary end point was reached [resulting in rescue TIPS in 7 and death in 5], in 2 who were lost to follow-up, Wang Varizen, and in 1 despite eight EBL sessions.

In the early-TIPS group, all but 1 patient, who withdrew consent, underwent early shunt placement. There were no technical failures or Wang Varizen complications of the TIPS procedure, Wang Varizen. Paroxysmal supraventricular tachycardia occurred in 1 patient and was controlled medically. A total of 27 patients required one stent, and 4 required two stents.

The mean portal-pressure gradient dropped from Despite dilation to 10 mm, the portal-pressure gradient after TIPS remained above 12 mm Hg in 2 patients. Collateral embolization was performed in 2 patients one of whom had a portal-pressure gradient above 12 mm Hg after TIPS.

The probability of remaining free from uncontrolled variceal bleeding or variceal Wang Varizen is shown in Panel A, and the probability of survival is Wang Varizen in Panel B. In these patients, the Wang Varizen for End-Stage Liver Disease MELD score which ranges from 6 to 40, with higher scores indicating more severe disease increased from a mean of In 7 of these Wang Varizen, TIPS with an e-PTFE—covered stent was used as rescue therapy; although bleeding was controlled, 4 of these patients died within 36 days range, 1 to In 5 patients, no further treatment was considered because of severe liver failure, and all died.

In the 9 patients Wang Varizen died, the mean MELD score was The remaining 2 patients who reached the primary end point underwent additional EBL sessions and were alive at the end of the follow-up period. An additional 4 patients 3 in the pharmacotherapy—EBL group and 1 in the early-TIPS group had a rebleeding episode Wang Varizen was not clinically significant i, Wang Varizen.

Causes of death are summarized Thrombophlebitis mit Injektionen Table 2, Wang Varizen. In the pharmacotherapy—EBL group, 12 patients had a total of 17 episodes of hepatic encephalopathy, whereas in the early-TIPS group, 8 patients had a total of 10 episodes Table 3 Table 3 Adverse Events, Wang Varizen. Most of these episodes occurred during the index bleeding. Wang Varizen total of 3 patients in the pharmacotherapy—EBL group and 2 in the early-TIPS group had stage III hepatic encephalopathy, and 1 patient in each group had mild, recurrent hepatic encephalopathy.

Aktion Thrombophlebitis bacterial peritonitis developed during the index bleeding in 2 patients in the pharmacotherapy—EBL group, both of whom died.

In addition, the hepatorenal syndrome developed during the index bleeding in 7 patients: As shown in Table 3Wang Varizen, there were no significant between-group differences in the numbers of patients who had adverse effects. In the study by Monescillo et al. Therefore, it is difficult to extrapolate the results of this study for application to clinical practice. Our study was specifically designed to show whether an early decision to use TIPS, with e-PTFE—covered stents and based on clinical criteria, can improve the prognosis for patients Wang Varizen variceal bleeding who are at high risk.

We found that in patients treated early with TIPS, the risks of failure to control bleeding and of variceal rebleeding were reduced. In addition, and even more important, the early use of TIPS was associated with a reduction in mortality. This beneficial Behandlung von Ulcus cruris venosum Pulver on survival was observed even though rescue TIPS was used in patients in whom medical treatment failed.

Wang Varizen was very high among the patients who underwent rescue TIPS after treatment failure, a result that is consistent with the findings in previous studies. Previous studies evaluating the role of TIPS in the prevention of recurrent variceal bleeding clearly showed that TIPS reduces the rebleeding rate but increases hepatic encephalopathy without improving survival.

It should be noted that previous studies of TIPS differed from our study in that they used bare stents or did not limit enrollment to patients at high risk for treatment failure. In the study by Escorsell et al.

Therefore, the study design precluded the possibility of Wang Varizen a benefit of TIPS in these high-risk patients. In high-risk patients, Wang Varizen, the potentially deleterious effects of e-PTFE—covered TIPS appear to be counterbalanced by its high efficacy in controlling bleeding and thus preventing further clinical deterioration. In contrast, TIPS should not be used as the initial treatment in patients with Child—Pugh class A disease, since the rates of medical-treatment failure and mortality are low among such patients.

Although the risks of treatment failure and death were higher in patients with Child—Pugh class C disease than in those with class B disease, our trial was not powered to conduct appropriate subgroup analyses. Therefore, further evaluation will be needed to determine whether the early use of TIPS equally benefits these two subgroups of patients. The early use of TIPS was not associated with an increase in the number or severity of episodes of hepatic encephalopathy.

In conclusion, in patients with Child—Pugh class C Wang Varizen or class B disease with active bleeding who were admitted for acute variceal bleeding, Wang Varizen, the early use of TIPS with an e-PTFE—covered stent Wang Varizen associated with significant reductions in the failure to control bleeding, in rebleeding, and in mortality, with no increase in the risk of hepatic encephalopathy.

Lalemanand an Wang Varizen grant from Gore, Wang Varizen. Caca, Wang Varizen lecture fees and Wang Varizen for travel expenses from Gore; and Dr.

Диагностика и симптомы рака молочной железы. УЗИ, маммография и лечение в Дельта Клиник.

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