Prise en charge des hémorragies digestives liées à l'hypertension portale

Gastrointestinal bleeding is a frequent and severe complication of portal hypertension. The most frequent aetiology of bleeding is variceal rupture. Despite improvement of prognosis after variceal bleeding over the past two decades, six-weeks mortality rate remains high, ranging from 15 to 30%. Poor hepatic function, severe portal hypertension with hepatic venous pressure gradient (HVPG) over 20 mmHg and active bleeding at endoscopy are independently associated with poor prognosis. First-line treatment includes resuscitation, prophylactic antibiotherapy, and combined use of vasoactive drugs started as soon as possible and endoscopic procedure. Ligation is the endoscopic treatment of choice in bleeding œsophageal varices. Uncontrolled bleeding should be an indication for salvage transjugular portosystemic shunt (TIPS). Trials are currently ongoing to precise the indications of early TIPS in selected patients with an HVPG over 20 mmHg, and the usefulness of administration of recombinant activated factor VII (rFVIIa) when there is an active bleeding at endoscopy.