Medication Summary
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Beta-adrenergic blocking agents
Class Summary
Inhibit chronotropic, inotropic, and vasodilatory responses to beta-adrenergic stimulation. Doses to treat variceal bleeding vary. Long-term administration of oral propranolol has been used in doses of 20-360 mg/d. Randomized trials have used 20-120 mg/d. Gradually increase doses, with a goal of reducing the resting heart rate by 25%. Treatment efficacy may also be measured by reducing the hepatoportal venous gradient (HPVG) to less than 12.
Propranolol (Inderal)
Nonselective beta-blocker that reduces the risk of primary and recurrent variceal bleeding by decreasing the portal pressure. Indicated for primary and secondary prophylaxis of variceal bleeding.
Somatostatin analogs
Class Summary
Have various effects on GI secretion, glandular secretion (eg, growth hormone, insulin, glucagon), and smooth muscle contraction. Inhibit splanchnic blood flow.
Octreotide (Sandostatin, Sandostatin LAR Depot)
Reduces portal flow, thereby reducing portal hypertension. Mechanism of action in this setting is not fully understood. Used in acute variceal bleeding and for recurrent bleeding after endoscopic therapy.
Anticoagulants
Class Summary
Used in the treatment and prophylaxis of thromboembolic disorders. Include direct anticoagulants (eg, heparins, low molecular weight heparins, heparinoids) and indirect anticoagulants (eg, warfarin).
Enoxaparin
A low molecular weight heparin. Inhibits factor Xa by increasing inhibition rate of clotting proteases that are activated by antithrombin III.
Warfarin (Coumadin)
Alters the synthesis of blood coagulation factors II, VII, IX, and X by interfering with the action of vitamin K.
Rivaroxaban
A direct acting oral anticoagulant (DOAC). Inhibits factor Xa, resulting in inhibition of intrinsic and extrinsic pathways of the coagulation cascade.
Thrombolytic agents
Class Summary
Fibrinolysis is the mechanism of clot dissolution. It is mediated by plasminogen, which circulates in the plasma in an inactive form; conversion to its active form, plasmin, occurs when plasminogen binds to fibrin in the presence of a plasminogen activator.
Alteplase (Activase)
Recombinant thrombolytic agent also known as tPA. Plasminogen activation results in the formation of plasmin, which is the enzyme responsible for clot dissolution.
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The etiology of portal vein obstruction.
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Coagulation disorders in portal vein thrombosis.
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Portal vein thrombosis with cavernous transformation. The long arrow indicates the splenic vein at the junction with the superior mesenteric vein just below the site of the thrombosis. The short arrow points to a serpiginous mass consistent with periportal collaterals, the so-called cavernous transformation of the portal vein.
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Hepatocellular carcinoma with portal vein thrombosis. The short arrow indicates the tumor thrombus with an abrupt cut off of the portal vein. The long arrow points to a compensatory, prominent left hepatic arterial branch.
