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Medical Care of the Liver Transplant Patient: Total Pre-, by Paul G Killenberg, Pierre-Alain Clavien

By Paul G Killenberg, Pierre-Alain Clavien

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Beta-adrenergic antagonists in the prevention of gastrointestinal rebleeding in patients with cirrhosis: a meta-analysis. Hepatology 1997;25:63–70. 53. Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding: a meta-analysis. Ann Intern Med 1995;123:280–287. 54. Lo G, Lai K, Cheng J, et al. Endoscopic variceal ligation plus nadolol and sucralfate compared with ligation alone for the prevention of variceal rebleeding: a prospective, randomized trial.

Lethargy or apathy 2. Minimal disorientation for time or place 3. Subtle personality change 4. Inappropriate behaviors 5. Impaired performance of subtraction Grade 3 1. Somnolence to semistupor but responsive to verbal stimuli 2. Confusion 3. Gross disorientation Grade 4 1. Coma (unresponsive to verbal or noxious stimuli) As soon as deterioration in the mental status is recognized, a search for a precipitating event should be immediately started. Among the factors are: 1. Renal and electrolyte abnormalities, especially uremia and hypokalemia and dehydration.

The first is to prevent the development or the growth of the varices and the second is to prevent variceal hemorrhage in patients with varices that have never bled (primary prophylaxis). Varices are present in about 50% of patients at the time of the initial diagnosis of cirrhosis. Several studies have demonstrated that the development of varices occurs when the portal pressure gradient (hepatic venous pressure gradient (HVPG)) increases above 10–12 mmHg [7]. A recent large multicenter randomized trial reported that an HVGP > 10 mmHg was accompanied by a faster development of varices, ascites, and death, emphasizing the prognostic value of HVGP measurements [8].

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