MEDICAL-TREATMENT OF PORTAL-HYPERTENSION

The medical treatment of portal hypertension has experienced marked pr ogress in the past decade due to the production of effective portal hy pertension therapy. This has been possible because of the better under standing of the pathophysiological mechanisms leading to portal hypert ension. A major step forward was the introduction of beta-blockers for the prevention of bleeding and rebleeding from gastroesophageal varic es. Effective therapy requires the reduction of the hepatic venous pre ssure gradient (HVPG) to 12 mm Hg or below, or at least by 20% of base line values. Unfortunately, this is only achieved in 1/3-1/2 Of patien ts. The combination therapy associated with isosorbide-5-mononitrate a nd propranolol or nadolol administration enhances the fall in portal p ressure and increases the number of patients in whom HVPG decreases mo re than 20% and below 12 mm Hg. Randomized trials (RCTs) support the f act that combination therapy is more effective than propranolol or nad olol alone and better than sclerotherapy. In the treatment of acute va riceal bleeding, pharmalogical therapy offers the unique advantage of permitting the provision of specific therapy immediately after arrival to hospital, or even during transferral to hospital by ambulance, sin ce it does not require sophisticated personnel. Terlipressin has prove d to be effective and to decrease mortality from bleeding. RCTs have s hown that this drug is as effective and safer than emergency sclerothe rapy. Therapy should be maintained for five days to prevent early rebl eeding. Somatostatin is probably as effective as terlipressin.