The treatment of portal hypertension: A meta-analytic review

Abstract

BOSCH'Portal hypertension is a major complication of chronic liver disease.Its main clinical consequence, bleeding from ruptured esophagogastric varices, represents a dramatic medical emergency, with mortality rate ranging from 30% to 50%, and is one of the leading causes of death in patients with cirrhosis.'-'Many efforts have been made over the past 3 decades in the treatment and prevention of variceal bleeding.Endoscopic variceal sclerotherapy, esophageal transection, and selective shunts have been introduced.During the last decade, marked progress in the knowledge of the pathophysiology of portal hypertension has opened the scene to pharmacological treatments, resulting in a dramatic change in the therapeutic approach to portal hypertension.The spectrum of therapeutic options has been further expanded by the introduction of endoscopic band ligation of esophageal varices, small diameter synthetic H-graft porta-caval shunt, and the transjugular intrahepatic portosystemic shunt (TIPS).Finally, liver transplantation is increasingly used in patients with portal hypertension in endstage liver disease.This has resulted in an increasing number of randomized clinical trials and publications dealing with the treatment of portal hypertension (Tables 1 to 6; Figs. 1 to 5).Unfortunately, therapeutic decision is not easy.Physicians choosing therapy for portal hypertension are faced with many treatments, most of them recently introduced and incompletely or poorly evaluated.In addition, we lack criteria for the selection of Abbreviations: TIPS, transjugular intrahepatic portosystemic shunt; HVPG, hepatic venous pressure gradient; RCT, randomized controlled trial; POR, pooled odds ratio; CI, confidence interval; EST, emergency sclerotherapy; PSE, chronic or recurrent portal systemic encephalopathy; DSRS, distal splenorenal shunt; PCS, portacaval shunt;