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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