RESUMO
BACKGROUND & AIMS: Esophageal variceal bleed is a major problem in patients with cirrhosis. Endoscopic variceal ligation (EVL) has been shown to be equal to or better than propranolol in preventing first bleed. Carvedilol is a non-selective ß blocker with alpha-1 adrenergic blocker activity. Hemodynamic studies have shown carvedilol to be more effective than propranolol at reducing portal pressure. We compared efficacy of carvedilol with EVL for primary prophylaxis of esophageal variceal bleed. METHODS: Cirrhotic patients with esophageal varices were randomized to carvedilol 12.5mg daily or EVL at three university hospitals of Pakistan. End points were esophageal variceal bleeding, death or liver transplant. RESULTS: Two hundred and nine patients were evaluated. Eighty two and eighty six patients were randomized in carvedilol and EVL arms respectively. Mean age was 48 ± 12.2 years; 122 (72.7%) were males; 89.9% had viral cirrhosis; mean Child-Pugh score was 7.3 ± 1.6 and mean follow up was 13.3 ± 12.1 months (range 1-50 months). Both EVL and carvedilol groups had comparable variceal bleeding rates (8.5% vs. 6.9%), bleed related mortality (4.6% vs. 4.9%) and overall mortality (12.8% vs. 19.5%) respectively. Adverse events in carvedilol group were hypotension (n=2), requiring cessation of therapy, while transient nausea (n=18) and dyspnea (n=30) resolved spontaneously. In the EVL arm, post banding ulcer bleed (n=1) and chest pain (n=17), were termed as serious adverse events while transient dysphagia (n=58) resolved without treatment. CONCLUSIONS: Although our study is underpowered, the findings suggest that carvedilol is probably not superior to EVL in preventing first variceal bleed in patients with viral cirrhosis.
Assuntos
Carbazóis/uso terapêutico , Varizes Esofágicas e Gástricas/tratamento farmacológico , Varizes Esofágicas e Gástricas/cirurgia , Hemorragia Gastrointestinal/prevenção & controle , Propanolaminas/uso terapêutico , Antagonistas de Receptores Adrenérgicos alfa 1/efeitos adversos , Antagonistas de Receptores Adrenérgicos alfa 1/uso terapêutico , Antagonistas Adrenérgicos beta/efeitos adversos , Antagonistas Adrenérgicos beta/uso terapêutico , Adulto , Carbazóis/efeitos adversos , Carvedilol , Varizes Esofágicas e Gástricas/etiologia , Feminino , Hemorragia Gastrointestinal/mortalidade , Hepatite Viral Humana/complicações , Humanos , Hipertensão Portal/complicações , Ligadura/efeitos adversos , Ligadura/métodos , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade , Propanolaminas/efeitos adversosRESUMO
The authors present the case of a 45-year-old lady who presented to the emergency department with sudden onset of right hemiparesis, numbness, dysarthria, dysmetria, left upper motor neuron facial palsy and left extensor plantar. Initial laboratory investigations, ECG and MR angiography were normal. MRI brain revealed multiple ischaemic strokes in middle cerebral artery and posterior cerebral artery territory. Transthoracic echocardiography revealed large mobile mass in left atrium which was resected and the patient remained well postoperatively. Anticoagulants do not play any protective role making resection as the only effective treatment.
Assuntos
Isquemia Encefálica/etiologia , Átrios do Coração , Neoplasias Cardíacas/complicações , Mixoma/complicações , Acidente Vascular Cerebral/etiologia , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/terapia , Ecocardiografia , Feminino , Neoplasias Cardíacas/diagnóstico por imagem , Neoplasias Cardíacas/cirurgia , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Mixoma/diagnóstico por imagem , Mixoma/cirurgia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapiaRESUMO
We present the case of a 28-year-old gentleman who presented with weakness and wasting in the right arm. He complained about painful cramps in his left leg but there were no sensory, visual or swallowing problems. Neurological examination was significant for asymmetric weakness of both upper and lower limbs and deep tendon reflexes were asymmetrically brisk. Initial laboratory investigations, MRI brain and MRI spine were normal. Electromyography revealed active denervation and chronic neurogenic motor unit action potential. Myokymic discharges were noted in the left deltoid muscle.