Cardiac varice

Aspirin can increase the risk of variceal bleeding in patients with cirrhosis. In fact, according to a case-control study (147), patients with cirrhosis and esophageal or cardiac varices who take NSAIDs are three times more likely to have a first episode of variceal bleeding compared with similar patients who are not taking NSAIDs. 

In 125 patients with cirrhosis who were admitted to hospital with a first episode of bleeding related to esophageal or cardiac varices, compared with 75 patients with cirrhosis, but no previous or current history of variceal bleeding, who were admitted to the same hospitals, a questionnaire showed that more patients with a first episode of bleeding had used aspirin, either alone or in combination with other NSAIDs compared with controls (OR = 4.9). This increased risk of bleeding was seen only in patients with grade 2 or grade 3 varices. 

Only non-selective p-blockers reduce bleeding complications in patients with known varices. Blockade of P, receptors reduces cardiac output and splanchnic blood flow. 02-Adrenergic blockade prevents p2-receptor-mediated splanchnic vasodilation while allowing unopposed a-adrenergic effects this enhances vasoconstriction of both the systemic and splanchnic vascular beds. The combination of P, and P2 effects makes the non-selective p-blockers preferable to car-dioselective agents in treating portal hypertension.1,36,41... 

Dizziness occurred in 7.4% of 68 patients randomized to somatostatin and 8.2% of 73 randomized to octreotide, both by rapid infusion, to control variceal bleeding, in which the effectiveness of somatostatin and its analogues is probably via a transient reduction in heart rate and cardiac output (13). 

Portal pressure is a function of resistance in the portal venous system and ih.e flow of blood through it. In cirrhosis, portal venous resistance is increased, and inflow of blood is increased by splanchnic vasodilatation and elevation of cardiac output. Variceal bleeding is increasingly likely as the pressure gradient between the portal and systemic venous systems rises beyond 12 mmHg. 

The radiographic detection or monitoring of oesophageal varices using contrast medium is only carried out in rare cases (after immobilizing the oesophagus by medication). When this procedure is applied, the areas of the cardiac and fornix fundus should be carefully examined, (s. fig. 14.9)... 

Results The results of paracentesis have generally been good up to now the number of successfully treated patients was higher, inpatient hospitalization was shorter, and complications were less frequent or less severe. The response to diuretic therapy improved considerably discontinued diuretic therapy could be successfully taken up again. (158,159) Plasma values of renin, aldosterone and norepinephrine dropped. There was an improvement in lung volume (141,143) as well as in cardiac function values. (152,153,156) The pressure in the oesophageal varices fell. (150) Paracentesis of 6 litres of ascitic fluid removes 6 X 130 mmol sodium. 

Terlipressin has similar, but less pronounced, systemic hemodynamic effects to vasopressin, including increases in mean arterial pressure and reduced heart rate (6). Of 105 patients who had continuous terlipressin infusions for variceal bleeding in a multicenter study, lower limb ischemia developed in two and cardiac ischemia in one (7). 

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