The Management and Prevention of Complications

The standard medication protocol for the treatment of portal hypertension and its conditions seems to point to the wide range use of non selective beta blockers called nadolol or propranolol.  Non selective beta blockers are used to bring down the pressure in the varices to prevent the first variceal hemorrhage, or lessen the risk of re-bleeding.    Unfortunately, most causes of portal hypertension cannot be treated, but treatment focuses on the prevention or management of complications, especially the potential bleeding of varices.

Along with medications, diet, endoscopic therapy, surgery, and radiology procedures all figure into the treatment or prevention of complications. Patients are treated based on their individual liver function. In cases of cirrhosis of the liver or what is referred to as non-cirrhotic causes of portal hypertension I was able to dig up some comparison statistics on the incidences of varical bleeding.  Regrettably I was unable to find out the actual differences in medication treatments between non-cirrhotic and cirrhotic patients, and I can only surmise at this time that it is dependent on a patients previous bleeding incidents or their potential to bleed?

Nadolol (Beta blockers) may be prescribed alone or in combination with endoscopic therapy to reduce the pressure in varices and in many cases prevent bleeding.  Lactulose is a drug prescribed to help treat a state of confusion or other mental changes associated with hepatic encephalopathy.  Hepatic encephalopathy takes place when toxins from the intestines which are normally removed by the liver accumulate in the blood and impair the function of brain cells. According to what I have learned, fortunately this type of encephalopathy is reversible.

I have only touched on a few of the main drugs used to treat portal hypertension, so for the sake of comparison allow me to list all the medications I have been prescribed for my particular case of portal hypertension:

Fragmin (Dalteparin– low molecular weight heparin) is a low molecular weight blood thinner – I have been injecting myself 2 times per day (12,500 iu) since early 2005. Fragmin is a derivative of heparin.  A study called the “CLOT” study commissioned in 2003, showed that in patients with malignancy and acute venous , dalteparin was more effective than coumadinin reducing the risk of recurrent embolic episodes. When it was first determined I had portal vein thrombosis back in 2002, I was initially prescribed Coumadin, which is still one of the most common blood thinners on the market.  Coumadin was not effective for me as I developed clots in the mesenteric artery (2004), and also clots to both lungs back dating back to February 2005.

Nadolol, as mentioned above, is commonly prescribed to combat the pressure in varices to prevent bleeding.   Initially I was prescribed 120 mg per day (about 5 year’s ago) and was titrated an additional 20 mg just a few year’s ago for a total of 140 mg per day.  Nadolol is of course the preferred treatment for esophageal varices as it is far less evasive then endoscopic treatments.

Pantoloc (or Pantoprazole) is a proton pump inhibitor which in my case was prescribed to reduce stomach acid and inhibit the risk of bleeding from the varices in my stomach.  Pantoloc is also prescribed for gastro esophageal reflux disease (GERD), and stomach ulcers.  I am currently taking 1 tablet – 40mg per day.

Simvastatin (trade name Zocor) was prescribed after I had an apparent transient ischemic attack (TIA) in November of 2005.   Some people consider a TIA to be  a mini-stroke, but, in reality it’s a stroke that corrected itself or improved functionality to the affected body part. Simvastatin is used to control elevated cholesterol levels in the arteries and to prevent cardiovascular disease.  Because I have an underlying clotting condition – this drug is also used as a preventative measure for any further episodes of this nature.   I take 1-20mg tablet per day.

Tryptophan is an essential amino acid that the body can’t produce on its own, but usually we get it in our diets.  The body in turn uses tryptophan to produce niacin, and serotonin.  Serotonin is thought to be useful in helping one get a healthy sleep and with that a stable mood.  In order for tryptophan in the diet to be converted to niacin, the body needs to have enough vitamin B6, iron, and riboflavin.  The amount of ferritin in your blood is directly related to the amount of iron stored in your body.  In my case, because my iron levels are often low, due to slow loss through the stomach varices, I need tryptophan to compensate.  Tryptophan is naturally found in many foods such as cheese, chicken, eggs, fish, milk, nuts, and turkey.  I also have quarterly iron infusion which helps keep the iron levels high.  I take 2-500mg tablets per day and only in the evening.

Gabapentin (Neurontin) was prescribed because I have experienced nerve pain, or as best as I can describe nerve “irritation” in my shoulders and back.  I first noticed this condition about 2 years ago, when I was undergoing PUVA (ultra violet light treatments) for psoriasis yet another condition that I believe I have due to an over active immune system.  Gabapentin was first developed for epilepsy, and is now widely prescribed for pain relieve – primarily neuropathic pain.  I take 2 – 600mg tablets per day.

Calcium plus D Since the Fragmin I take is a form of heparin, a risk of osteoporosis following long-term use cannot be ruled out.  I currently take 3 – 500mg tablets of calcium per day, and this brand has 125iu of vitamin D in it.  Vitamin D aids in the absorption of calcium in the body.  I also take an additional 1000iu of Vitamin D for a total of 1375iu per day.  In discussion with my family doctor this past week, he stated that a person can safely take up to 2000iu per day.  Vitamin D benefits are numerous, and there has recently been much research in the past few years’ that support that.  Here is one of those articles:

http://www.cbc.ca/health/story/2008/05/16/f-health-vitamin-d.html

Vitamin B-100 “B” vitamins are helpful in the body if a person has elevated levels of Homocysteine.  Elevated levels of homocysteine can cause the blood to clot more easily, and also can damage the lining of the arteries.  I was prescribed Vitamin B-100 (Vitamin B-50 works also) because my homocysteine levels were high.  As stated previously, I have an underlying clotting condition, whereby I not only have a clot to my liver, but also my spleen, and mesenteric arteries.  I take one tablet of vitamin B-100 per day, and have done so since 2002.

Imodium  (Loperamide) is an anti-diarrheal drug usually sold over the counter in most pharmacies.  I was prescribed this medication due to the high frequency of bowel eliminations I have within a single day. Imodium for me brings the rate down, but does not completely stop the process.  Because the arteries in my intestines are engorged with blood due to PVT, I do not have what is considered “normal” bowel movements.  (The all too frequent trips to the bathroom tend to wear on a person after awhile.  With those all too frequent trips come bleeding and sometimes it can be very discouraging).  I take 2 tablets in the morning, and 2 in the evening, and increase that amount during the day sometimes, depending on what happens.

Psyllium capsules (Brand name Metamucil) is used as a dietary fiber supplement.  Psyllium is mainly used for laxative purposes, but it can help reduce the symptoms of constipation and diarrhea.  In my particular case the gastroenterologist prescribe it to bulk up the stool, in order to decrease the frequency of elimination that is by far the most inconvenient and sometimes painful side effect of portal hypertension. I currently take 5 tablets per day and have done so now for a number of year’s now.

Dicetel (pinaverium bromide) is primarily prescribed for irritable bowel syndrome.  Dicetel helps relieve the symptoms of abdominal pain, bowel disturbances, and intestinal discomfort. It acts by relaxing the smooth muscle of the bowel.  The clots from portal hypertension cause congestion and subsequent pain in the lower intestines.   I was prescribed 3-50 mg tablets of Dicetel which I started last fall, but because the pain is vascular it is hard to treat and the verdict is still out as to whether or not this medication is working as it should.

Codeine Phosphate was prescribed last year for the pain as it is safer on the liver when compared to acetaminophen (Tylenol). As a precaution I will only use Tylenol (sparingly) during the day, say if I have to drive anywhere, or if I am doing something that requires mental alertness.  If at home when the pain starts (usually in the evenings),  I will use the codeine, or apply heat such as a  hot water bottle, or take a warm bath depending on the intensity of the pain. The prescribed dosage is 1 or 2 tablets (30 mg) taken every 4 to 6 hours as needed.

In conclusion … I want to say that I know I have not listed all the medications one can potentially be on for such a condition, but I have at least highlighted some of the meds that possibly may be helpful in your case?  If in doubt of course, always ask your doctor and if by chance there is something noteworthy regarding your case – please share your comments below!

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{ 4 comments… read them below or add one }

heart conditions May 14, 2013 at 8:58 am

Appreciating the commitment you put into your website and
detailed information you present. It’s awesome to come across a blog every once in a while that isn’t the same old rehashed material.
Excellent read! I’ve bookmarked your site and I’m adding your RSS feeds to my Google
account.

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Clint May 14, 2013 at 12:48 pm

Thanks you for your encouraging comment!

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Annette May 11, 2014 at 1:59 am

Hi came across this site on net and found it very Informative, have learned a lot from what Clint has spoken about regarding portal hypertension and various treatments, I have cirrohiss of liver, and after my first endoscopy in Jan 2013 endoscopist said no varices seen only two lesions that he took two biopsy’s of, in Feb 2013 I proceeded to have a massive upper GI bleed which nearly cost me my life, I had five varices banded, I am on propanol 80mg per day proton pump for acid iron pills and that’s all the meds I’m on, I have 6 monthly endoscopy s and scans on liver bloods taken, I am concerned as last endoscopy done in Jan 2014 it was noted I had grade 1 and 2 varices not banded I just don’t know why the grade 2 ones were not banded, I really live in fear over this, cannot get any answers until I see my gastroenterolgist which will be until June, I also have had argon plasma coagulation treatment in may 2013 I really don’t know why I had that and don’t know what good it did either, I know I just have to ask more questions, I don’t know what stage I am at either, my liver and sleen is enlarged, I went from being what I thought to healthy to cirrohiss and then nearly bleeding to death all in three months, what kind of questions do you think I need to ask my gastroenterolgist and heptologist about my condition Clint really I’m not thick just shell shocked really appreciate any advice thank you annette

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Clint May 11, 2014 at 2:38 pm

Annette,

Thank you for your post. I am sorry to learn of your current health situation. Cirrhosis of the liver is one of the main causes of portal vein thrombosis, however there are less common causes such as unknown genetic clotting disorders of which I have been diagnosed with. The treatment protocol is pretty much the same the world over, and it sounds like you may be on the right track? From what I know, varices are normally banded at the stage 3 level, but it may be dependant on the patient and their current condition or medications. If you are on anticoagulants (you only stated that you had an argon plasma coagulation treatment), the risk to bleed is higher, and when banding is done they will “slough” off leaving an ulceration which is again open to bleeding.

Through regular blood tests doctors should be able to determine what level of anticoagulants you need to be on, and also what dosage of a beta blocker you need to be on to keep the pressure down on those varices in the esophagus. These are 2 primary concerns. I have had portal hypertension for almost 12 years now, and I am on 160 mg of Nadalol (beta blocker) to stave off any potential bleeding, however I have grade 3 varices and my gastroenterologist hasn’t done any scopes on me since 2005, for fear of puncturing one of the varices.

Enlargement of the spleen is very common as the clot in the portal vein stops blood flow to the spleen. People can live without their spleens and often when they are damaged say in a vehicle accident, doctors will remove it. Although I had a doctor that originally wanted to remove mine, I fortunately got a second opinion and it stayed in! If the spleen is clotted or removed it increases your susceptibility to illness, so I try to eat properly and take vitamins to hopefully counter any impending illness. Illnesses, although not totally avoidable can cause further issues which sometimes can be fatal depending upon the severity, so I try to make sure my hands are clean at all times, and I stay away from people who are sick or show signs thereof. Coughing can agitate the varices in the esophagus and so I was told cause a bleed from the varices themselves. Please keep in mind when I tell you of all this stuff, that I am not trying to scare you, but only inform you of the facts. Also be encouraged that despite some close calls in the past, I have survived 12 years and actually feel relatively fine most of the time. I do not have cirrhosis, but over time my liver will deteriorate because of misdirected blood flow. I have peace about my health and I am thankful for the years I have lived through it albeit some close calls along the way!

Along with a list of medications I take each day (see below), I also was prescribed some Vitamin supplements which help in my overall health maintenance and quite possibly may also be of benefit to you in your situation. On a daily basis I take Vitamin B50 (hematologist prescribed to combat high homocysteine levels in blood) see: http://www.drweil.com/drw/u/ART03423/Elevated-Homocysteine.html I also take and not directly related to any blood disorder conditions the following: Vitamin D 4000IU, Calcium, Omega 3 (Cardiovascular), Probiotics (digestion), and Glucosamine Sulfate.

Medications:

DICETEL 50 MG TABLET
FRAGMIN 12,500 UNIT/ 2 per day (Anticoagulant injections)
GABAPENTIN 600 mg TABLET (Neurontin – nerve pain)
Loperamide HCL 2 mg Oral Tablet plus more as needed (overactive bowel due to engorged arteries in bowel from clots)
Pantoprazole Sodium 40 mg Oral Tablet, Delayed for stomach acid reduction
SIMVASTATIN 20 mg TABLET
TRYPTOPHAN 1000 MG TABLET
URSODIOL 500 mg TABLET
Nadalol 160 mg per day (beta blocker)

If I may ask, what was the cause of your cirrhosis? Are you close to a good medical centre? I hope you get the answers you need. You are in my thoughts and prayers.

Clint

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