Conocimientos vigentes en torno a la hemorragia digestiva alta varicosa
Resumen
Las hemorragias que ocurren en el tubo digestivo y en particular las de origen varicoso, constituyen una urgencia médico quirúrgica; a pesar de los avances científico tecnológicos actuales, su pronóstico continúa reservado. Esta revisión, se realizó con el propósito de profundizar en diversos aspectos cognoscitivos vigentes sobre la hemorragia digestiva varicosa. Se llevó a cabo una revisión documental mediante búsqueda temática digital de artículos nacionales y foráneos, publicados en español e inglés durante la presente centuria, concernientes a la hemorragia digestiva varicosa. Existe diversidad de criterios en torno al diagnóstico y tratamiento del sangrado digestivo alto varicoso. Se evidencia la necesidad de una unidad de atención a estos pacientes en los hospitales, la disponibilidad de endoscopia digestiva superior a tiempo completo y de un equipo multidisciplinario para brindar una terapia integradora. El acto operatorio programado solo debe ejecutarse en la clase Child-Pugh ideal, pero como las intervenciones suelen ser urgentes en estadio B o C, se elevan las probabilidades de complicaciones y muerte. Las várices esofagogástricas, a pesar de considerarse una causa infrecuente de hemorragia digestiva alta, tiene por lo general un desenlace tórpido en quienes la presentan, de manera que el diagnóstico y tratamiento adecuados constituyen un verdadero desafío para cualquier servicio quirúrgico.Descargas
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1. Tripathi D, Stanley AJ, Hayes PC. UK guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut [Internet]. 2015 [cited 2017 oct 27];64:1680-704. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25887380
2. Harrison's. Principios de Medicina Interna. 15a. ed. New York: McGraw-Hill, 2001:2561-6.
3. Cuba. Ministerio de Salud Pública. Anuario estadístico de salud 2016. La Habana: Dirección Nacional de Registros Médicos y Estadísticas de Salud; 2017.
4. Almeida Varela R, Pérez Suárez F, Díaz Elías JO, Martínez Hernández JA. Comportamiento de la hemorragia digestiva alta en el Hospital Universitario «Calixto García». Rev Cubana Cir [Internet]. 2011 [citado 27 oct 2017];50(1):40-53. Disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0034-74932011000100004&lng=es
5. Ratib S, Fleming KM, Crooks CJ, Aithal GP, West J. 1 and 5 year survival estimates for people with cirrhosis of the liver in England, 1998-2009: a large population study. J Hepatol [Internet]. 2014 [cited 2017 Oct 28];60:282-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24128415
6. Moreau R, Jalan R, Gines P. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology. 2013;144:1426-37.
7. Zipprich A, Garcia-Tsao G, Rogowski S, Fleig Wolfgang E, Seufferlein T,Dollinger Matthias M. Prognostic indicators of survival in patients with compensated and decompensated cirrhosis. Liver Int [Internet]. 2012 [cited 2017 Oct 28];32(9):1407-14. Available in: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3713489/
8. Motola-Kuba M, Escobedo-Arzate A, Tellez-Ávila F, Altamirano J, Aguilar Olivo N, González-Angulo A, et al. Validation of prognostic scores for clinical outcomes in cirrhotic patients with acute variceal bleeding. Annals of Hepatology [Internet]. 2016 [cited 2017 Oct 28];15(6):895-901. Available from: http://www.annalsofhepatology.com/revista/numeros/2016/HP166-10-Validation%20(F_141016V)_PROTEGIDO.pdf
9. Seo YS, Park SY, Kim MY, Kim JH, Park JY, Yim HJ, et al. Lack of difference among terlipressin, somatostatin, and octreotide in the control of acute gastroesophageal variceal hemorrhage. Hepatology. 2014;60:954-63.
10. Parra Pérez VF, Raymundo Cajo RM, Gutiérrez de Aranguren CF. Factores relacionados a resangrado y mortalidad en pacientes cirróticos con hemorragia variceal aguda en el Hospital Hipólito Unanue, Lima, Perú. Rev Gastroenterol Perú [Internet]. 2013 [citado 28 de oct 2017];33(4):314-20. Disponible en: http://www.scielo.org.pe/scielo.php?script=sci_arttext&pid=S1022-51292013000400005
11. Khawaja A, Sonawalla AA, Somani SF, Abid S. Management of bleeding gastric varices: A single session of histoacryl injection may be sufficient. Eur J Gastroenterol Hepatol. 2014;26:661-7.
12. Kumar Amith S, Sibia Raminderpal S. Predictors of In-hospital Mortality among patients presenting with variceal gastrointestinal bleeding. Saudi J Gastroenterol [Internet]. Jan-Feb 2015 [cited 2017 Oct 28];21(1):43-6. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4355862/
13. Guy J, Peters MG. Liver disease in women: the influence of gender on epidemiology, natural history, and patient outcomes. Gastroenterol Hepatol (NY). 2013;9:633-9.
14. Triantos C, Kalafateli M. Endoscopic treatment of esophageal varices in patients with liver cirrhosis. World J Gastroenterol. 2014;20:13015-26.
15. Hwang JH, Shergill AK, Acosta RD, Chandrasekhara V, Chathadi KV, Decker GA, et al. The role of endoscopy in the management of variceal hemorrhage. Gastrointest Endosc [Internet]. 2014 [cited 2017 Oct 28];80(2):221-7. Available in: https://www.asge.org/docs/default-source/education/practice_guidelines/doc-2014_the-role-of-endoscopy-in-the-management-of-variceal-hemorrhage.pdf
16. Waghray A, Waghray N, Kyprianou A, Menon KVN. Variceal screening in cirrhotic patients. Hepatology.2014;60(S1):1594-9.
17. Sarin SK, Kumar A, Angus PW, et al. Diagnosis and management of acute variceal bleeding: Asian Pacific Association for Study of the Liver recommendations. Hepatol Int. 2011;5:607-24.
18. de Franchis R. Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;63:743-52.
19. Fortune B and Garcia-Tsao G. Current management strategies for acute esophageal variceal hemorrhage. Current Hepatitis Reports 2014 [cited 2017 Oct 28];13(1):35-42. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4061703/
20. García Pagán JC, Barrufet M, Cárdenas A. Management of gastric varices. Clin Gastroenterol Hepatol [Internet]. 2014 [citado 28/10/2017];12:919-28. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20196120
21. Bruno S, Crosignani A, Facciotto C, Rossi S, Roffi L, Redaelli A, et al. Sustained virologic response prevents the development of esophageal varices in compensated, Child-Pugh class A hepatitis C virus-induced cirrhosis. A 12-year prospective follow-up study. Hepatology. 2010;51:2069-76.
22. Chen WT, Lin CY, Sheen IS, Chang Wen H, Tsung-Nan L, Chun-Jung L. MELD score can predict early mortality in patients with rebleeding after band ligation for variceal bleeding. World J Gastroenterol [Internet]. 2011 [cited 2017 Oct 28];17(16):2120-5. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3084398/
23. Chile ChG, Turcotte JG. El hígado y la hipertensión portal. Barcelona: Ed. científico médica; 1967. p. 30.
24. Villanueva C, Colomo A, Bosch A. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368:11-21.
25. Girotra M, Raghavapuram S, Abraham RR. Management of gastric variceal bleeding: role of endoscopy and endoscopic ultrasound. World J Hepatol [Internet]. 2014 [cited 2017 Oct 28];6(3):130-6. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959113/
26. Moon Young Kim, Soon Ho Um, Soon Koo Baik, Yeon Seok Seo, Soo Young Park, Jung Il Lee, et al. Clinical features and outcomes of gastric variceal bleeding: retrospective Korean multicenter data. Clinical and Molecular Hepatology [Internet]. 2013 [cited 2017 Oct 28];19:36-44. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3622854/pdf/cmh-19-36.pdf http://dx.doi.org/10.3350/cmh.2013.19.1.36
27. Chueh-Ling Liu, Cheng-Kun Wu, Hon-Yi Shi, Wei-Chen Tai, Chih-Ming Liang, Shih-Cheng Yang, et al. Medical expenses in treating acute esophageal variceal bleeding. Medicine [Internet]. 2016 [cited 2017 Oct 28];95:28(e4215). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4956819/pdf/medi-95-e4215.pdf
28. Motola-Kuba M, Escobedo-Arzate A, Tellez-Ávila F, Altamirano J, Aguilar Olivo N, González-Angulo A, et al. Validation of pronostic scores for clinical outcomes in cirrhotic patients with acute variceal bleeding. Annals of Hepatology [Internet]. 2016 [cited 2017 Oct 28];15(6):895-901. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27740523
29. Ka Rham K, Chung Hwan J, Kyu Man Ch, Jin Woo W, Seon Young P, Sung Bum Ch, et al. Can proton pump inhibitors reduce rebleeding following histoacryl sclerotherapy for gastric variceal hemorrhage? Korean J Intern Med [Internet]. 2015 [cited 2017 Oct 28];30(5):593-601. Available from: http://dx.doi.org/10.3904/kjim.2015.30.5.593.
30. Hung TH, Tsai CC, Tseng CW, Tseng KC, Hsieh YH, Tsai CC. No difference in mortality between terlipressin and somatostatin treatments in cirrhotic patients with esophageal variceal bleeding and renal functional impairment. Eur J Gastroenterol Hepatol [Internet]. 2016 [cited 2017 Oct 22];28(11):1275-79. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27455080.
31. Rahimi RS, Guntipalli P, Rockey DC. Worldwide practices for pharmacologic therapy in esophageal variceal hemorrhage. Scand J Gastroenterol. 2014;49:131-7.
32. Escorsell A, Pavel O, Cárdenas A, Morillas R, Llop E, Villanueva C, et al. Esophageal balloon tamponade versus esophageal stent in controlling acute refractory variceal bleeding: a multicenter randomized, controlled trial. Hepatology [Internet]. 2016[cited 2017 Oct 22];63(6):1957-67. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26600191
33. Yang Z, Han G, Wu Q, Ye X, Jin Z, Yin Z, et al. Patency and clinical outcomes of transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene covered stents versus bare stents: a meta-analysis. J Gastroenterol Hepatol [Internet]. 2010 [cited 2017 Oct 28];25:1718-25. Available in: https://www.ncbi.nlm.nih.gov/pubmed/21039832
34. García-Pagán JC, Caca K, Bureau C, Laleman W, Appenrodt B, Luca A, et al. Early use of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in patients with cirrhosis and variceal bleeding. N Engl J Med [Internet]. 2010 [cited 2017 Oct 28];362:2370-9. Available from: http://www.nejm.org/doi/full/10.1056/NEJMoa0910102#t=article
35. Muller M, Seufferlein T, Perkhofer L, Wagner M, and Kleger A. Self-expandable metal stents for persisting esophageal variceal bleeding after band ligation or injection-therapy: a retrospective study. PLoS ONE [Internet]. 2015 [cited 2017 Dec 28];10(6):[about 21 p.]. Available from: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0126525
36. Naeshiro N, Aikata H, Kakizawa H, et al. Long-term outcome of patients with gastric varices treated by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 2014;29:1035-42.
37. Komori Keishi, Kubokawa Masaru, Ihara Eikichi, Akahoshi Kazuya, Nakamura Kazuhiko, Motomura Kenta et al. Prognostic factors associated with mortality in patients with gastric fundal variceal bleeding. World J Gastroenterol [Internet]. 2017 [cited 2017 Oct 22];23(3):496-504. Available from: http://www.wjgnet.com/10079327/full/v23/i3/496.htm
38. Buchanan PM, Kramer JR, El-Serag HB, Asch SM, Assioun Y, Bacon BR, et al. The quality of care provided to patients with varices in the department of Veterans Affairs. Am J Gastroenterol [Internet]. 2014 [cited 2017 Oct 22];109(7):934-40. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24989087
39. Quevedo Guanche LL. Indicaciones y técnicas quirúrgicas del trasplante hepático. En: Cirugía hepática. La Habana: Editorial Ciencias Médicas; 2009. p. 43-61.
2. Harrison's. Principios de Medicina Interna. 15a. ed. New York: McGraw-Hill, 2001:2561-6.
3. Cuba. Ministerio de Salud Pública. Anuario estadístico de salud 2016. La Habana: Dirección Nacional de Registros Médicos y Estadísticas de Salud; 2017.
4. Almeida Varela R, Pérez Suárez F, Díaz Elías JO, Martínez Hernández JA. Comportamiento de la hemorragia digestiva alta en el Hospital Universitario «Calixto García». Rev Cubana Cir [Internet]. 2011 [citado 27 oct 2017];50(1):40-53. Disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0034-74932011000100004&lng=es
5. Ratib S, Fleming KM, Crooks CJ, Aithal GP, West J. 1 and 5 year survival estimates for people with cirrhosis of the liver in England, 1998-2009: a large population study. J Hepatol [Internet]. 2014 [cited 2017 Oct 28];60:282-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24128415
6. Moreau R, Jalan R, Gines P. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology. 2013;144:1426-37.
7. Zipprich A, Garcia-Tsao G, Rogowski S, Fleig Wolfgang E, Seufferlein T,Dollinger Matthias M. Prognostic indicators of survival in patients with compensated and decompensated cirrhosis. Liver Int [Internet]. 2012 [cited 2017 Oct 28];32(9):1407-14. Available in: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3713489/
8. Motola-Kuba M, Escobedo-Arzate A, Tellez-Ávila F, Altamirano J, Aguilar Olivo N, González-Angulo A, et al. Validation of prognostic scores for clinical outcomes in cirrhotic patients with acute variceal bleeding. Annals of Hepatology [Internet]. 2016 [cited 2017 Oct 28];15(6):895-901. Available from: http://www.annalsofhepatology.com/revista/numeros/2016/HP166-10-Validation%20(F_141016V)_PROTEGIDO.pdf
9. Seo YS, Park SY, Kim MY, Kim JH, Park JY, Yim HJ, et al. Lack of difference among terlipressin, somatostatin, and octreotide in the control of acute gastroesophageal variceal hemorrhage. Hepatology. 2014;60:954-63.
10. Parra Pérez VF, Raymundo Cajo RM, Gutiérrez de Aranguren CF. Factores relacionados a resangrado y mortalidad en pacientes cirróticos con hemorragia variceal aguda en el Hospital Hipólito Unanue, Lima, Perú. Rev Gastroenterol Perú [Internet]. 2013 [citado 28 de oct 2017];33(4):314-20. Disponible en: http://www.scielo.org.pe/scielo.php?script=sci_arttext&pid=S1022-51292013000400005
11. Khawaja A, Sonawalla AA, Somani SF, Abid S. Management of bleeding gastric varices: A single session of histoacryl injection may be sufficient. Eur J Gastroenterol Hepatol. 2014;26:661-7.
12. Kumar Amith S, Sibia Raminderpal S. Predictors of In-hospital Mortality among patients presenting with variceal gastrointestinal bleeding. Saudi J Gastroenterol [Internet]. Jan-Feb 2015 [cited 2017 Oct 28];21(1):43-6. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4355862/
13. Guy J, Peters MG. Liver disease in women: the influence of gender on epidemiology, natural history, and patient outcomes. Gastroenterol Hepatol (NY). 2013;9:633-9.
14. Triantos C, Kalafateli M. Endoscopic treatment of esophageal varices in patients with liver cirrhosis. World J Gastroenterol. 2014;20:13015-26.
15. Hwang JH, Shergill AK, Acosta RD, Chandrasekhara V, Chathadi KV, Decker GA, et al. The role of endoscopy in the management of variceal hemorrhage. Gastrointest Endosc [Internet]. 2014 [cited 2017 Oct 28];80(2):221-7. Available in: https://www.asge.org/docs/default-source/education/practice_guidelines/doc-2014_the-role-of-endoscopy-in-the-management-of-variceal-hemorrhage.pdf
16. Waghray A, Waghray N, Kyprianou A, Menon KVN. Variceal screening in cirrhotic patients. Hepatology.2014;60(S1):1594-9.
17. Sarin SK, Kumar A, Angus PW, et al. Diagnosis and management of acute variceal bleeding: Asian Pacific Association for Study of the Liver recommendations. Hepatol Int. 2011;5:607-24.
18. de Franchis R. Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;63:743-52.
19. Fortune B and Garcia-Tsao G. Current management strategies for acute esophageal variceal hemorrhage. Current Hepatitis Reports 2014 [cited 2017 Oct 28];13(1):35-42. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4061703/
20. García Pagán JC, Barrufet M, Cárdenas A. Management of gastric varices. Clin Gastroenterol Hepatol [Internet]. 2014 [citado 28/10/2017];12:919-28. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20196120
21. Bruno S, Crosignani A, Facciotto C, Rossi S, Roffi L, Redaelli A, et al. Sustained virologic response prevents the development of esophageal varices in compensated, Child-Pugh class A hepatitis C virus-induced cirrhosis. A 12-year prospective follow-up study. Hepatology. 2010;51:2069-76.
22. Chen WT, Lin CY, Sheen IS, Chang Wen H, Tsung-Nan L, Chun-Jung L. MELD score can predict early mortality in patients with rebleeding after band ligation for variceal bleeding. World J Gastroenterol [Internet]. 2011 [cited 2017 Oct 28];17(16):2120-5. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3084398/
23. Chile ChG, Turcotte JG. El hígado y la hipertensión portal. Barcelona: Ed. científico médica; 1967. p. 30.
24. Villanueva C, Colomo A, Bosch A. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368:11-21.
25. Girotra M, Raghavapuram S, Abraham RR. Management of gastric variceal bleeding: role of endoscopy and endoscopic ultrasound. World J Hepatol [Internet]. 2014 [cited 2017 Oct 28];6(3):130-6. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959113/
26. Moon Young Kim, Soon Ho Um, Soon Koo Baik, Yeon Seok Seo, Soo Young Park, Jung Il Lee, et al. Clinical features and outcomes of gastric variceal bleeding: retrospective Korean multicenter data. Clinical and Molecular Hepatology [Internet]. 2013 [cited 2017 Oct 28];19:36-44. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3622854/pdf/cmh-19-36.pdf http://dx.doi.org/10.3350/cmh.2013.19.1.36
27. Chueh-Ling Liu, Cheng-Kun Wu, Hon-Yi Shi, Wei-Chen Tai, Chih-Ming Liang, Shih-Cheng Yang, et al. Medical expenses in treating acute esophageal variceal bleeding. Medicine [Internet]. 2016 [cited 2017 Oct 28];95:28(e4215). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4956819/pdf/medi-95-e4215.pdf
28. Motola-Kuba M, Escobedo-Arzate A, Tellez-Ávila F, Altamirano J, Aguilar Olivo N, González-Angulo A, et al. Validation of pronostic scores for clinical outcomes in cirrhotic patients with acute variceal bleeding. Annals of Hepatology [Internet]. 2016 [cited 2017 Oct 28];15(6):895-901. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27740523
29. Ka Rham K, Chung Hwan J, Kyu Man Ch, Jin Woo W, Seon Young P, Sung Bum Ch, et al. Can proton pump inhibitors reduce rebleeding following histoacryl sclerotherapy for gastric variceal hemorrhage? Korean J Intern Med [Internet]. 2015 [cited 2017 Oct 28];30(5):593-601. Available from: http://dx.doi.org/10.3904/kjim.2015.30.5.593.
30. Hung TH, Tsai CC, Tseng CW, Tseng KC, Hsieh YH, Tsai CC. No difference in mortality between terlipressin and somatostatin treatments in cirrhotic patients with esophageal variceal bleeding and renal functional impairment. Eur J Gastroenterol Hepatol [Internet]. 2016 [cited 2017 Oct 22];28(11):1275-79. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27455080.
31. Rahimi RS, Guntipalli P, Rockey DC. Worldwide practices for pharmacologic therapy in esophageal variceal hemorrhage. Scand J Gastroenterol. 2014;49:131-7.
32. Escorsell A, Pavel O, Cárdenas A, Morillas R, Llop E, Villanueva C, et al. Esophageal balloon tamponade versus esophageal stent in controlling acute refractory variceal bleeding: a multicenter randomized, controlled trial. Hepatology [Internet]. 2016[cited 2017 Oct 22];63(6):1957-67. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26600191
33. Yang Z, Han G, Wu Q, Ye X, Jin Z, Yin Z, et al. Patency and clinical outcomes of transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene covered stents versus bare stents: a meta-analysis. J Gastroenterol Hepatol [Internet]. 2010 [cited 2017 Oct 28];25:1718-25. Available in: https://www.ncbi.nlm.nih.gov/pubmed/21039832
34. García-Pagán JC, Caca K, Bureau C, Laleman W, Appenrodt B, Luca A, et al. Early use of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in patients with cirrhosis and variceal bleeding. N Engl J Med [Internet]. 2010 [cited 2017 Oct 28];362:2370-9. Available from: http://www.nejm.org/doi/full/10.1056/NEJMoa0910102#t=article
35. Muller M, Seufferlein T, Perkhofer L, Wagner M, and Kleger A. Self-expandable metal stents for persisting esophageal variceal bleeding after band ligation or injection-therapy: a retrospective study. PLoS ONE [Internet]. 2015 [cited 2017 Dec 28];10(6):[about 21 p.]. Available from: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0126525
36. Naeshiro N, Aikata H, Kakizawa H, et al. Long-term outcome of patients with gastric varices treated by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 2014;29:1035-42.
37. Komori Keishi, Kubokawa Masaru, Ihara Eikichi, Akahoshi Kazuya, Nakamura Kazuhiko, Motomura Kenta et al. Prognostic factors associated with mortality in patients with gastric fundal variceal bleeding. World J Gastroenterol [Internet]. 2017 [cited 2017 Oct 22];23(3):496-504. Available from: http://www.wjgnet.com/10079327/full/v23/i3/496.htm
38. Buchanan PM, Kramer JR, El-Serag HB, Asch SM, Assioun Y, Bacon BR, et al. The quality of care provided to patients with varices in the department of Veterans Affairs. Am J Gastroenterol [Internet]. 2014 [cited 2017 Oct 22];109(7):934-40. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24989087
39. Quevedo Guanche LL. Indicaciones y técnicas quirúrgicas del trasplante hepático. En: Cirugía hepática. La Habana: Editorial Ciencias Médicas; 2009. p. 43-61.
Publicado
03/16/2018
Cómo citar
1.
Moreira Barinaga OM, Rodríguez Fernández Z, Manzano Horta E, Rodríguez Hung S, Nazario Dolz AM, Maurelo Martínez Pinillo I. Conocimientos vigentes en torno a la hemorragia digestiva alta varicosa. Rev Cubana Med Milit [Internet]. 16 de marzo de 2018 [citado 29 de diciembre de 2024];47(3):328-40. Disponible en: https://revmedmilitar.sld.cu/index.php/mil/article/view/103
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