Özofagus Varislerinde Tanı ve Tedavi Yaklaşımları
Özet
Özofagus varisleri portal hipertansiyonun en önemli komplikasyonu olup siroz hastalarının yaklaşık yarısında görülür ve her yıl %5-15 oranında yeni varis oluşumu veya kötüleşme saptanır. Bu hemodinamik anormallikte hastaların üçte birinde kanama epizodu izlenir. Tanı ve takipte geçmişte rutin endoskopik taramalar önerilirken, günümüzde karaciğer-dalak sertliği ve trombosit sayısı gibi non-invaziv belirteçlerin kullanıldığı Baveno VI kriterleri öne çıkmaktadır. Primer profilakside non-selektif beta blokörler ve endoskopik bant ligasyonu tercih edilir. Akut kanama yönetiminde vazopressin yerine geçen terlipressin ve somatostatin gibi ilaçlarla farmakoterapi, endoskopik ligasyon kombinasyonu ve dirençli vakalarda Transjuguler İntrahepatik Portosistemik Şant (TIPS) uygulanır. Cerrahi tarafta, ensefalopati riskini azaltan kısmi ve selektif şantlar (distal splenorenal şant) ile akışı bozmayan özofagus devaskülarizasyonu (Sugiura prosedürü) seçenekler arasındadır. Günümüzde ileri evre karaciğer hastalığı ve sekelleri için en etkili cerrahi müdahale karaciğer naklidir. Nakil zamanlaması objektif MELD skoruna göre belirlenmekte ve gelişen yönetim stratejileri sayesinde ameliyat mortalitesi %10'un altında kalırken, 1 yıllık sağkalım %80'in, 5 yıllık sağkalım ise %60-65'in üzerine çıkmaktadır.
Esophageal varices represent the most significant complication of portal hypertension, occurring in approximately 50% of cirrhotic patients, with new or worsening varices developing at an annual rate of 5-15%. Bleeding episodes affect about one-third of these patients within this hemodynamic abnormality. While historical guidelines recommended universal endoscopic screening, contemporary practice utilizes non-invasive tools like liver/spleen stiffness and platelet counts under Baveno VI criteria. Primary prophylaxis involves non-selective beta-blockers and endoscopic band ligation. Acute hemorrhage management employs pharmacotherapy with portal pressure-reducing agents like terlipressin or somatostatin alongside endoscopic ligation, utilizing Transjugular Intrahepatic Portosystemic Shunt (TIPS) for refractory cases. Surgical decompressions include partial or selective shunts, such as the distal splenorenal shunt, and esophageal devascularization (Sugiura procedure) to minimize encephalopathy risks while maintaining portal flow. Currently, liver transplantation is the definitive intervention for end-stage liver disease and its sequelae. Allocation timing relies strictly on objective MELD scores, and advanced perioperative management has reduced hospital mortality below 10%, achieving 1-year and 5-year survival rates exceeding 80% and 60-65% respectively.
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