ENDOSCOPIC MANAGEMENT OF THE LIVER TRANSPLANT PATIENT

Patients diagnosed with end-stage liver disease face potential complications before undergoing liver transplantation. The development of gastrointestinal blood loss associated with portal hypertension may be caused by esophageal varices, gastric varices, hemorrhoids, or portal hypertensive enteropathy. When evaluating a patient for liver transplantation, the endoscopist is asked to provide information regarding the patient's status and relative risks over the next few years. 35 Confirmation of varices or portal hypertensive gastropathy may aid in the decision making process of whether the patient should be referred for liver transplantation or followed expectantly. Approximately one third of patients with cirrhosis and portal hypertension bleed from ruptured esophageal varices, and untreated patients have a 60% risk of rebleeding. 8 Moreover, a recent prospective analysis confirmed the finding that patients with small varices have a low bleeding risk (Fig. 1). 35 The recent development of endoscopic ultrasound seems to provide an even more sensitive prediction of the likelihood of portal hypertensive bleeding compared with standard endoscopy. 11 Furthermore, an increase in Child-Pugh score is associated with an increase in bleeding risk; therefore, these patients warrant closer endoscopic surveillance. Accordingly, a study from the North Italian Endoscopic Club (NIEC) of 321 patients with varices but without a prior history of variceal bleeding demonstrated that patients with low-risk scores had a 6% risk of bleeding over the next 2 years, whereas those with high-risk scores (Child's class C, large varices, and red spots) had a 76% chance of bleeding over the ensuing 2 years. Although endoscopic treatment lowers the rate of rebleeding, it remains as high as 30% to 50%, depending on the series. 2,6 Endoscopic injection sclerotherapy achieves hemostasis by inducing thrombosis of the bleeding vessel and/or compression of the by tissue edema, but carries significant risk of complications (e.g., mucosal ulcerations, strictures, mediastinitis). Band ligation was first reported a decade ago for the treatment of esophageal varices. Hemostasis is achieved by physical constriction of the varix, thus interrupting blood flow. The majority of data do not show a significant difference between sclerotherapy and band ligation in the control of acute bleeding. 8 Because the field of vision is reduced by the banding device, it may be more appropriate to use sclerotherapy to control acute active hemorrhage at the index endoscopy and to use band ligation when bleeding has ceased. 8 In contrast, ligation has been unequivocally demonstrated advantageous compared with sclerotherapy for the prevention of recurrent variceal rebleeding 17,26 (Fig. 2). Moreover, the number of treatment sessions, the time required to achieve variceal eradication, and the clinically significant complication rate is lower in patients treated with banding. 22 Endoscopic treatment is just one approach to the management of portal hypertensive bleeding. Nonselective beta-blockers have been found useful in the primary prophylaxis of esophageal variceal hemorrhage, and the consensus at present is that all patients who are at high risk should receive beta-blockers. 34 A recent study of patients with large varices randomly assigned to receive propanolol or variceal ligation, however, showed that the latter was more effective for the primary prevention of variceal bleeding. 33 Nitrates and newer agents likely will play an adjuvant role in the management of portal hypertensive bleeding. Recent evidence-based analyses summarize the role of pharmacological treatment (Table 1). 7,32