الفهرس 
machanism of varix
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Abstract
Portal hypertension is a world wide major public health problem . Variceal bleeding is the most serious complication which often induces a deterioration of the liver function and it results in a high mortality . This observation stimulated researches to gain more information with regard to pathogenesis, prevention and treatment of variceal bleeding .
Over the past few years, development of non-invasive techniques to measure variceal pressure which can explore the risk of variceal bleeding have questioned the utilisation of hepatic vein catheterisation, the golden standard in the past.
■ Treatment and prevention of variceal bleeding aimed to reduce oesophageal variceal
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■wall tension and the risk of varix rupture by decreasing portal and variceal pressures . Non-selective (3-blockers reduced variceal and portal pressures . Also, they reduced azygos blood flow which is considered as an index of gastroesophageal collateral blood flow . Therefore, they are commonly used for the primary and secondary prevention of variceal bleeding in portal hypertensive patients . The relationship between haemodynamic effects and clinical benefit from pharmacotherapy has not been established . There were a contradictory data |about the efficacy of combined therapy for treatment of portal hypertension .
During the last 10 years, liver transplantation became a common operation for end-stage hepatic disease and sclerotherapy became the first-line approach for acute variceal bleeding . Patients presenting with emergency bleeding failed to respond to sclerotherapy and high-risk patients who are not candidates for liver transplantation, need simple straight forward procedure that can prevent variceal bleeding without subjecting them to the complication of total portosystemic shunting . The optimal one would also preserve and |maintain portal perfusion over time thus maintaining an adequate amount of nutrient portal blood flow. Transjugular intrahepatic portosystemic shunt stent is a non-surgical calibrated porto-caval shunt for treatment of portal hypertension based on the creation of a parenchymal channel between hepatic vein and main branch of the portal vein*. TIPS reduces portal venous pressure and blood flow through gastroesophageal varices and reduces the risk of variceal bleeding . Major problems related to TIPS procedure are post TIPS encephalopathy, liver failure and stenosis of the shunt. Stenosis of the TIPS is the major factor limiting the clinical utility of this procedure . Therefore periodic screening for asymptomatic recurrence of portal hypertension is mandatory .
The aim of the present study is to evaluate the effect of pharmacotherapy on variceal and portal haemodynamics and portosystemic shunting in patients with portal hypertension and varices of different aetiology . Therefore, we evaluate whether the response of variceal pressure to pharmacotherapy reflects the clinical beneficial outcome of this treatment. Also we investigate the efficacy and outcome of TIPS in the treatment of acute uncontrolled variceal bleeding as well as its effect on portosystemic shunting . We further analysed the influence of the presence of spontaneous splenorenal shunt discovered during the TIPS procedure on the outcome after TIPS . Patients and methods:
The study population consisted of 188 patients with portal hypertension and varices of different aetiology . The patients were divided into two groups:
1-The first group (medical group) consisted of 109 patients . They received medical treatment (propranolol±nitrate) for primary or secondary prophylaxis of variceal bleeding . Time zero (to) represents the date when oral propranolol was started, consecutive to a VP measurement performed at baseline by using a pressure-sensitive gauge fixed on top of an endoscope . After 3 months, a second VP measurement was performed (13). Following the measurement, patients were subdivided according to the level of VP. If the level of VP was below or equal to 14 mm