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Alemu GS, Mengistu SB, Gedamu Y, Ayele E, Admas HA, Melese EB, Ayalew DG, Legese GL. Dose optimization of non-selective beta blockers among esophageal varices patients at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia: a hospital-based cross-sectional study. BMC Gastroenterol 2025; 25:100. [PMID: 39984863 PMCID: PMC11844126 DOI: 10.1186/s12876-025-03708-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2024] [Accepted: 02/18/2025] [Indexed: 02/23/2025] Open
Abstract
BACKGROUND Gastroesophageal varices are portosystemic collaterals formed due to portal hypertension. The primary consequence and leading cause of death in cases of gastroesophageal varices is bleeding. Although variceal hemorrhage mortality has decreased due to early diagnosis of gastroesophageal varices, prophylaxis, and therapy, these procedures are still difficult to perform in many underdeveloped nations. When the dose of nonselective b-blockers is optimized to the highest acceptable dosage to reach the therapeutic goal, the benefit of reducing the risk of variceal bleeding is greatest. B-blocker optimization is unknown in our nation and Africa. OBJECTIVE To assess the optimization rate of non-selective B-blockers and associated factors among esophageal varices patients following at the University of Gondar referral hospital. METHODS A hospital-based cross-sectional study was conducted at the University of Gondar referral hospital GI clinic, North West Ethiopia. A total of 150 patients were taken with consecutive sampling and the target populations of the study were all adult esophageal varices patients who were on non-selective B-blockers at the GI follow-up clinic. Data were collected with a structured questionnaire and both descriptive and analytical data analysis was performed. Frequency, tables, and graphs were used to represent the data. RESULTS A total of 150 patients were included in the study. From these 30.7% of patients took optimal doses of non-selective B -blockers. Patients with poor drug adherence (AOR = 4.293, [95% CI = 1.191-15.484], p-value = 0.026) and hospital admission in the last 01 year (AOR = 2.915, [95%CI = 1.076-7.893], P-value = 0.035) were significantly associated with sub-optimization of non-selective B- blockers. CONCLUSION Only one-third of patients received the optimal dose of non-selective B-blockers. Poor drug adherence and previous admission in the last year were significantly associated with sub-optimal dosing of non-selective B-blockers.
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Affiliation(s)
- Getachew Sahile Alemu
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, POBOX: 196, Gondar, Ethiopia.
| | - Segenet Bizuneh Mengistu
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, POBOX: 196, Gondar, Ethiopia
| | - Yonas Gedamu
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, POBOX: 196, Gondar, Ethiopia
| | - Eleni Ayele
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, POBOX: 196, Gondar, Ethiopia
| | - Hiwot Alemu Admas
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, POBOX: 196, Gondar, Ethiopia
| | - Endalkachew Belayneh Melese
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, POBOX: 196, Gondar, Ethiopia
| | - Desalew Getahun Ayalew
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, POBOX: 196, Gondar, Ethiopia
| | - Gebrehiwot Lema Legese
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, POBOX: 196, Gondar, Ethiopia
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Ryu H, Kim TU, Yoon KT, Hong YM. Predicting the risk of early bleeding following endoscopic variceal ligation in cirrhotic patients with computed tomography. BMC Gastroenterol 2023; 23:410. [PMID: 38001426 PMCID: PMC10668468 DOI: 10.1186/s12876-023-03038-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Life-threatening bleeding following endoscopic variceal ligation (EVL) in patients with cirrhosis rarely can occur. The present study aimed to evaluate the performance of computed tomography (CT) in predicting the risk of early bleeding following EVL in cirrhotic patients. METHODS We retrospectively investigated 285 cirrhotic patients who had undergone EVL. EVL was performed for prophylaxis or acute variceal bleeding. The patients were classified into 2 groups: early bleeding (< 14 days after EVL) and non-early bleeding. We compared baseline characteristics including CT findings between the patient groups. RESULTS Among the 285 patients who underwent EVL treatment, 19 patients (6.7%) experienced early bleeding. On average, these bleeding occurred 9.3 ± 3.5 days after the EVL, with a range of 3 to 13 days. Patients who experience early bleeding had a higher six-week bleeding-related mortality rate compared to those in the non-early bleeding group (31.6% vs. 10.2%; p = 0.014). There was a correlation between the grade of esophageal varix observed during endoscopy and the diameter of esophageal varix observed on CT (p < 0.001). The diameter of esophageal varix on CT was identified as the only significant predictive factor for early bleeding (p = 0.005). CONCLUSION A larger esophageal varix diameter observed on CT is associated with an increased risk of early bleeding after EVL treatment. Early identification of this high-risk group can provide a change of treatment strategies to improve patient outcomes.
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Affiliation(s)
- Hwaseong Ryu
- Department of Radiology, Pusan National University College of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Tae Un Kim
- Department of Radiology, Pusan National University College of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Ki Tae Yoon
- Department of Internal Medicine, Pusan National University College of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Young Mi Hong
- Department of Internal Medicine, Pusan National University College of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.
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Baye ML, Abay Z, Tesfaye T, Ahmed E, Arage G, Zewude EA, Anley DT. Gastroesophageal variceal hemorrhage in patients with chronic liver diseases attending university of Gondar Specialized comprehensive hospital in Ethiopia: Institutional based cross-sectional study. Heliyon 2023; 9:e15133. [PMID: 37095908 PMCID: PMC10121785 DOI: 10.1016/j.heliyon.2023.e15133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 03/16/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023] Open
Abstract
Introduction Rupture and bleeding from Gastroesophageal Varices (GEVs) are major complications among patients with chronic liver disease (CLD) and are associated with a high mortality rate. Hence, identifying factors of Gastroesophageal Variceal Hemorrhage (GEVH) is essential for the management and prevention of this fatal outcome. Objective To assess the prevalence of GEVH and its associated factors among patients with CLD in Northwest Ethiopia. Methods An institutional based cross-sectional study design was employed on a total of 262 patients. The data was entered into Epi-Data version 3.1, and then exported and analyzed using STATA version 14. The distribution of variables was checked using kolmogorov-smirnov test. Bivariable logistic regression model was fitted to select variables for multivariable analysis. In the final model, adjusted odds ratio with 95% confidence level and P-value less than 0.05 were used to assess degree of association. Results The mean age of the study subjects was found to be 37.76 years (SD ± 11.62). The prevalence of GEVH was found to be 52% (95% CI: 49.6-54.2). Patients with grade F2 and F3 varices have 3.41 times (AOR: 3.41, 95% CI: 2.33-4.74) and 3.33 times (AOR: 3.33, 95% CI: 2.55-4.12) higher odds of bleeding, respectively. Patients not taking beta blocker have 2.38 times (AOR: 2.38, 95% CI: 1.82-3.90) increased odds of bleeding. Patients with more than three years of duration of illness have 2 times (AOR: 2.19, 95% CI: 1.39-3.99) increased odds of bleeding. Patients with platelet number less than 50,000/μl have 3.46 times (AOR: 3.46, 95% CI: 2.55-4.17) higher odds of bleeding. Conclusion GEVH is found to be high in patients with CLD seen at university of Gondar Hospital. Higher grade of varices, non-use of beta blockers, presence of infection, platelet number and age are associated with higher occurrence of bleeding, pointing the possibility of averting this fatal complication, for most of the identified factors are preventable.
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Gralnek IM, Camus Duboc M, Garcia-Pagan JC, Fuccio L, Karstensen JG, Hucl T, Jovanovic I, Awadie H, Hernandez-Gea V, Tantau M, Ebigbo A, Ibrahim M, Vlachogiannakos J, Burgmans MC, Rosasco R, Triantafyllou K. Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54:1094-1120. [PMID: 36174643 DOI: 10.1055/a-1939-4887] [Citation(s) in RCA: 107] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
1: ESGE recommends that patients with compensated advanced chronic liver disease (ACLD; due to viruses, alcohol, and/or nonobese [BMI < 30 kg/m2] nonalcoholic steatohepatitis) and clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] > 10 mmHg and/or liver stiffness by transient elastography > 25 kPa) should receive, if no contraindications, nonselective beta blocker (NSBB) therapy (preferably carvedilol) to prevent the development of variceal bleeding.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in those patients unable to receive NSBB therapy with a screening upper gastrointestinal (GI) endoscopy that demonstrates high risk esophageal varices, endoscopic band ligation (EBL) is the endoscopic prophylactic treatment of choice. EBL should be repeated every 2-4 weeks until variceal eradication is achieved. Thereafter, surveillance EGD should be performed every 3-6 months in the first year following eradication.Strong recommendation, moderate quality evidence. 3: ESGE recommends, in hemodynamically stable patients with acute upper GI hemorrhage (UGIH) and no history of cardiovascular disease, a restrictive red blood cell (RBC) transfusion strategy, with a hemoglobin threshold of ≤ 70 g/L prompting RBC transfusion. A post-transfusion target hemoglobin of 70-90 g/L is desired.Strong recommendation, moderate quality evidence. 4 : ESGE recommends that patients with ACLD presenting with suspected acute variceal bleeding be risk stratified according to the Child-Pugh score and MELD score, and by documentation of active/inactive bleeding at the time of upper GI endoscopy.Strong recommendation, high quality of evidence. 5 : ESGE recommends the vasoactive agents terlipressin, octreotide, or somatostatin be initiated at the time of presentation in patients with suspected acute variceal bleeding and be continued for a duration of up to 5 days.Strong recommendation, high quality evidence. 6 : ESGE recommends antibiotic prophylaxis using ceftriaxone 1 g/day for up to 7 days for all patients with ACLD presenting with acute variceal hemorrhage, or in accordance with local antibiotic resistance and patient allergies.Strong recommendation, high quality evidence. 7 : ESGE recommends, in the absence of contraindications, intravenous erythromycin 250 mg be given 30-120 minutes prior to upper GI endoscopy in patients with suspected acute variceal hemorrhage.Strong recommendation, high quality evidence. 8 : ESGE recommends that, in patients with suspected variceal hemorrhage, endoscopic evaluation should take place within 12 hours from the time of patient presentation provided the patient has been hemodynamically resuscitated.Strong recommendation, moderate quality evidence. 9 : ESGE recommends EBL for the treatment of acute esophageal variceal hemorrhage (EVH).Strong recommendation, high quality evidence. 10 : ESGE recommends that, in patients at high risk for recurrent esophageal variceal bleeding following successful endoscopic hemostasis (Child-Pugh C ≤ 13 or Child-Pugh B > 7 with active EVH at the time of endoscopy despite vasoactive agents, or HVPG > 20 mmHg), pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours (preferably within 24 hours) must be considered.Strong recommendation, high quality evidence. 11 : ESGE recommends that, for persistent esophageal variceal bleeding despite vasoactive pharmacological and endoscopic hemostasis therapy, urgent rescue TIPS should be considered (where available).Strong recommendation, moderate quality evidence. 12 : ESGE recommends endoscopic cyanoacrylate injection for acute gastric (cardiofundal) variceal (GOV2, IGV1) hemorrhage.Strong recommendation, high quality evidence. 13: ESGE recommends endoscopic cyanoacrylate injection or EBL in patients with GOV1-specific bleeding.Strong recommendations, moderate quality evidence. 14: ESGE suggests urgent rescue TIPS or balloon-occluded retrograde transvenous obliteration (BRTO) for gastric variceal bleeding when there is a failure of endoscopic hemostasis or early recurrent bleeding.Weak recommendation, low quality evidence. 15: ESGE recommends that patients who have undergone EBL for acute EVH should be scheduled for follow-up EBLs at 1- to 4-weekly intervals to eradicate esophageal varices (secondary prophylaxis).Strong recommendation, moderate quality evidence. 16: ESGE recommends the use of NSBBs (propranolol or carvedilol) in combination with endoscopic therapy for secondary prophylaxis in EVH in patients with ACLD.Strong recommendation, high quality evidence.
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Affiliation(s)
- Ian M Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine Technion Israel Institute of Technology, Haifa, Israel
| | - Marine Camus Duboc
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA) & Assistance Publique-Hôpitaux de Paris (AP-HP), Endoscopic Center, Saint Antoine Hospital, Paris, France
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, IRCSS-S. Orsola-Malpighi, Hospital, Bologna, Italy
| | - John Gásdal Karstensen
- Gastroenterology Unit, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Tomas Hucl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ivan Jovanovic
- Euromedik Health Care System, Visegradska General Hospital, Belgrade, Serbia
| | - Halim Awadie
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Marcel Tantau
- University of Medicine and Pharmacy 'Iuliu Hatieganu' Cluj-Napoca, Romania
| | - Alanna Ebigbo
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | | | - Jiannis Vlachogiannakos
- Academic Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Marc C Burgmans
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
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Ji K, Li X, Zhu H, Zhao S, Zhan P, Shi Y, Ye S, Xie B, Zhang Y, Yu P, Ren Z, Ding J, Han X, Li Z. A creatinine-based model for predicting recurrent bleeding after modified percutaneous transhepatic variceal embolization in patients with cirrhosis. J Interv Med 2022; 5:95-102. [PMID: 35936666 PMCID: PMC9348999 DOI: 10.1016/j.jimed.2022.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/07/2022] [Accepted: 03/10/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Patients who survive initial esophagogastric variceal bleeding (EVB) are at an increased risk of recurrent bleeding and death; however, a reliable predictive model is lacking. We aimed to develop a model for rebleeding prediction in patients with EVB after modified percutaneous transhepatic variceal embolization (PTVE) with cyanoacrylate. METHODS A total of 122 patients with EVB who underwent PTVE from January 2015 to November 2020 were enrolled. Multivariate logistic analyses were conducted to determine independent risk factors for nomogram construction. The discrimination, calibration, and clinical utility of the nomogram were compared with the Model for End-stage Liver Disease score (MELD) and the Child-Pugh model. Risk stratification was performed according to the nomogram. RESULTS Rebleeding within 3 months of PTVE occurred in 32 patients (26.2%). Independent rebleeding indicators included prior history of endoscopic therapy, Child-Pugh score, partial splenic embolization, and creatinine level. The nomogram incorporating these four predictors achieved excellent calibration and discriminatory abilities, with a concordance index of 0.85, which was confirmed to be 0.83 through bootstrapping validation. The nomogram demonstrated superior discrimination and clinical applicability than the MELD and Child-Pugh models. As shown in the Kaplan-Meier curves, high-risk patients had a high probability of rebleeding (P < 0.001). CONCLUSIONS The creatinine-based nomogram had a superior ability to predict rebleeding after PTVE in patients with EVB. Risk stratification may help identify high-risk patients and lead to the earlier implementation of aggressive treatments and formulation of intensive follow-up plans.
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Affiliation(s)
- Kun Ji
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Xin Li
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Hanlong Zhu
- Department of Gastroenterology and Hepatology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu Province, China
| | - Si Zhao
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu Province, China
| | - Pengchao Zhan
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yang Shi
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Shuwen Ye
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Bingcan Xie
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yuyuan Zhang
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Peng Yu
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Zhigang Ren
- Department of Infectious Diseases, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Juan Ding
- Department of Quality Control, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Xinwei Han
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Zhen Li
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
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Alia MSA, Elsawy AA, Elarabawy RA, Hegazy HM. Predictors of early rebleeding after endoscopic therapy of first variceal bleeding in liver cirrhosis. EGYPTIAN LIVER JOURNAL 2021. [DOI: 10.1186/s43066-021-00119-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Despite the great advancement in therapeutic modalities for esophageal varices, early variceal rebleeding still occurs at high rates leading to an exaggeration of the morbidity and mortality for cirrhotic patients, so meticulous follow-up with optimum prediction and proper preventive measures for early variceal rebleeding are mandatory for increasing survival of those patients. In this respect, we evaluated the clinical, laboratory, abdominal ultrasound, and endoscopic criteria of variceal cirrhotic patients as possible risk predictors of early variceal rebleeding after endoscopic control of first variceal bleeding. All included patients were followed up blindly for 12 weeks after endoscopic control of bleeding for ascertainment of first variceal rebleeding. The demographic, clinical, laboratory, abdominal ultrasound, and upper gastrointestinal endoscopic criteria were evaluated for all patients at first admission.
Results
By univariate regression analysis, the statistically significant predictors for early variceal rebleeding were serum albumin, serum bilirubin, prothrombin concentration, Child-Pugh score, platelet count, spleen diameter, ascites, portal vein diameter and velocity, variceal size, variceal location, and red color sign. By using multivariate regression analysis, the most independent significant predictors were Child-Pugh score (sig: 0.001 and OR: 1.661), platelets count (sig: 0.000 and OR: 0.956), portal vein velocity (sig: 0.000 and OR: 0.664), variceal grading (sig: 0.000 and OR: 3.964), and variceal red color sign (sig: 0.000 and OR: 4.964). We used the multivariate regression coefficients for the significant predictors to build up early variceal rebleeding risk (EVRR) score with a significant discriminatory performance (AUC: 0.965 and sig: 0.000).
Conclusion
Child-Pugh score, platelet count, portal vein velocity, variceal grading, and variceal red color sign are independent risk predictors for early variceal rebleeding after successful control of first variceal bleeding in cirrhotic patients. Our proposed EVRR score could be helpful for the prediction of early variceal rebleeding in cirrhotic patients after endoscopic control of acute variceal bleeding; however, it should be externally validated in large prospective studies.
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Gao Z, Zhao J, Liu X, Li S, Wang M, Gao Y. Portal vein thrombosis associated with high 14-day and 6-week rebleeding in patients after oesophageal variceal band ligation: a retrospective, multicentre, nested case-control study. Hepatol Int 2021; 15:1183-1195. [PMID: 34292507 DOI: 10.1007/s12072-021-10224-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/18/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The association between prognosis of variceal bleeding and portal vein thrombosis (PVT) is unclear. In this multicentre study, we determined the effect of PVT on rebleeding and mortality in patients with acute variceal bleeding (AVB) after oesophageal variceal band ligation (EVL). METHODS Cirrhotic patients with AVB who had undergone EVL were included. The patients were allocated to either the PVT group or the control cirrhotic group (CCG) based on the presence or absence of PVT. One-year rebleeding episodes and mortality after EVL were recorded. RESULTS A total of 218 cirrhotic patients with AVB from 3 centres were included. Patients with PVT had a higher rate of 14-day and 6-week rebleeding than those without PVT (14-day: 8.26% vs. 1.83%, p = 0.03; 6-week: 11.92% vs. 1.83%, p = 0.003). The rates of 5-day failure (3.67% vs. 0.92%, p = 0.175), 1-year rebleeding (21.10% vs. 20.18%, p = 0.867), and 14-day, 6-week, and 1-year mortality were similar between the groups (14-day: 3.67% vs. 0.92%, p = 0.175; 6-week: 3.67% vs. 0.92%, p = 0.175; 1-year: 3.67% vs. 1.83%, p = 0.408). The Child-Pugh class [p = 0.022, hazard ratio (HR): 1.453; 95% confidence interval (CI) 1.056-1.998], PVT (p = 0.050, HR: 4.622, 95% CI 0.999-21.395), albumin < 30 g/L (p = 0.023, HR: 5.886, 95% CI 1.272-27.245), and number of bands (p = 0.010, HR: 1.207, 95% CI 1.046-1.393) were identified as the predictors for 14-day rebleeding; the multivariate analysis revealed only the number of bands (p = 0.009, HR: 1.247, 95% CI 1.056-1.473) as the independent factor. PVT (p = 0.012, HR: 6.732, 95% CI 1.519-29.835) and albumin < 30 g/L (p = 0.027, HR: 3.643, 95% CI 1.160-11.441) were identified as predictors for 6-week rebleeding; however, only PVT (p = 0.015, HR: 6.380, 95% CI 1.427-28.515) was found to be the independent factor in the multivariate analysis. Further analysis showed that superior mesenteric vein (SMV) thrombosis is the only risk factor predicting 6-week rebleeding in patients with PVT (p = 0.032, HR: 3.405, 95% CI 1.112-10.429). CONCLUSIONS PVT was associated with high 14-day and 6-week rebleeding in patients after EVL. SMV thrombosis was the only risk factor for 6-week rebleeding in patients with PVT. High albumin levels may serve as a protective factor for the 14-day and 6-week rebleeding risk. PVT was not responsible for mortality after EVL during 1-year follow-up.
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Affiliation(s)
- Zhanjuan Gao
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, People's Republic of China
- Department of Gastroenterology, Liaocheng People's Hospital, Liaocheng, Shandong Province, People's Republic of China
| | - Jingrun Zhao
- Department of Gastroenterology, Liaocheng People's Hospital, Liaocheng, Shandong Province, People's Republic of China
| | - Xiaofeng Liu
- Department of Gastroenterology, Chinese People's Liberation Army No.960 Hospital, Jinan, Shandong Province, People's Republic of China
| | - Senlin Li
- Department of Gastroenterology, Liaocheng People's Hospital, Liaocheng, Shandong Province, People's Republic of China
| | - Minghui Wang
- Department of Gastroenterology, Chinese People's Liberation Army No.960 Hospital, Jinan, Shandong Province, People's Republic of China
| | - Yanjing Gao
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, People's Republic of China.
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Kim SJ, Choi CW, Kang DH, Kim HW, Park SB, Hong YM, Yoon KT, Cho M, Nam HS, Islam SBU. Emergency endoscopic variceal ligation in cirrhotic patients with blood clots in the stomach but no active bleeding or stigmata increases the risk of rebleeding. Clin Mol Hepatol 2016; 22:466-476. [PMID: 28081590 PMCID: PMC5266350 DOI: 10.3350/cmh.2016.0063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 10/19/2016] [Accepted: 10/24/2016] [Indexed: 12/11/2022] Open
Abstract
Background/Aims This study aimed to evaluate the efficacy and safety of emergency variceal ligation for the prevention of rebleeding in cirrhotic patients who are found on initial endoscopy to have blood clots in the stomach but no actively bleeding esophageal and gastric varices or stigmata. Methods This study included 28 cirrhotic patients who underwent emergency prophylactic EVL and 41 who underwent an elective intervention between January 2009 and June 2014. Clinical outcomes were analyzed, including the rebleeding, 6-week mortality, and rebleeding-free survival rates. Results The rebleeding rate was higher in the emergency than in the elective group (28.6% vs. 7.3%, P=0.041). Multivariate analysis showed that emergency prophylactic EVL (odds ratio [OR] = 7.4, 95% confidence interval [CI]=1.634.8, P=0.012) and Child-Pugh score C (OR=10.6, 95% CI=1.4-80.8, P=0.022) were associated with rebleeding. In the emergency group, the gastric varices were associated with rebleeding (OR=12.0, 95% CI=1.7-83.5, P=0.012). Conclusion Emergency EVL may be associated with variceal rebleeding when blood clots are present in the stomach without active esophageal and gastric variceal bleeding or stigmata. Elective intervention should be considered as a safer strategy for preventing variceal rebleeding in this situation.
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Affiliation(s)
- Su Jin Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Cheol Woong Choi
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Dae Hwan Kang
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyung Wook Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Su Bum Park
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Young Mi Hong
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Ki Tae Yoon
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Mong Cho
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyung Seok Nam
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sm Bakhtiar Ui Islam
- Gene & Cell Therapy Research Center for Vessel-associated Diseases, Yangsan, Korea
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9
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Outcome of the Pediatric Patients with Portal Cavernoma: The Retrospective Study for 10 Years Focusing on Recurrent Variceal Bleeding. Gastroenterol Res Pract 2016; 2016:7953870. [PMID: 26949386 PMCID: PMC4754495 DOI: 10.1155/2016/7953870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 12/06/2015] [Accepted: 01/05/2016] [Indexed: 02/07/2023] Open
Abstract
Background. Portal cavernoma (PC) is the most critical condition with risk or variceal hemorrhage in pediatric patients. We retrospectively investigated the patients with PC focusing on the predictors for recurrent variceal bleeding. Methods. Between July 2003 and June 2013, we retrospectively enrolled all consecutive patients admitted to our department with a diagnosis of PC without abdominal malignancy or liver cirrhosis. The primary endpoint of this observational study was recurrent variceal bleeding. Independent predictors of recurrent variceal bleeding were identified using the logistic regression model. Results. A total of 157 patients were enrolled in the study. During the follow-up period, 24 patients exhibited onset of recurrent variceal bleeding. Acute variceal bleeding was subjected to conservative symptomatic treatment and emergency endoscopic sclerotherapy. Surgical procedure selection was based on the severity of vascular dilation and collateral circulation. Multivariate logistic regression analysis demonstrated that the presence of ascites, collateral circulation, and portal venous pressure were independent prognostic factors of recurrent variceal bleeding for patients with portal cavernoma. Conclusions. The presence of ascites, collateral circulation, and portal venous pressure evaluation are important and could predict the postsurgical recurrent variceal bleeding in patients with portal cavernoma.
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10
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Nemiroski A, Ryou M, Thompson CC, Westervelt RM. Swallowable fluorometric capsule for wireless triage of gastrointestinal bleeding. LAB ON A CHIP 2015; 15:4479-4487. [PMID: 26490455 DOI: 10.1039/c5lc00770d] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Real-time detection of gastrointestinal bleeding remains a major challenge because there does not yet exist a minimally invasive technology that can both i) monitor for blood from an active hemorrhage and ii) uniquely distinguish it from blood left over from an inactive hemorrhage. Such a device would be an important tool for clinical triage. One promising solution, which we have proposed previously, is to inject a fluorescent dye into the blood stream and to use it as a distinctive marker of active bleeding by monitoring leakage into the gastrointestinal tract with a wireless fluorometer. This paper reports, for the first time to our knowledge, the development of a swallowable, wireless capsule with a built-in fluorometer capable of detecting fluorescein in blood, and intended for monitoring gastrointestinal bleeding in the stomach. The embedded, compact fluorometer uses pinholes to define a microliter sensing volume and to eliminate bulky optical components. The proof-of-concept capsule integrates optics, low-noise analog sensing electronics, a microcontroller, battery, and low power Zigbee radio, all into a cylindrical package measuring 11 mm × 27 mm and weighing 10 g. Bench-top experiments demonstrate wireless fluorometry with a limit-of-detection of 20 nM aqueous fluorescein. This device represents a major step towards a technology that would enable simple, rapid detection of active gastrointestinal bleeding, a capability that would save precious time and resources and, ultimately, reduce complications in patients.
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Affiliation(s)
- A Nemiroski
- Department of Chemistry and Chemical Biology, Harvard University, 12 Oxford St., Cambridge, MA 02138, USA.
| | - M Ryou
- Division of Gastroenterology, Brigham & Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - C C Thompson
- Division of Gastroenterology, Brigham & Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - R M Westervelt
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, 9 Oxford St., Cambridge, MA 02138, USA and Department of Physics, Harvard University, 9 Oxford St., Cambridge, MA 02138, USA.
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11
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Qi X, Su C, Ren W, Yang M, Jia J, Dai J, Xu W, Guo X. Association between portal vein thrombosis and risk of bleeding in liver cirrhosis: A systematic review of the literature. Clin Res Hepatol Gastroenterol 2015; 39:683-691. [PMID: 25956490 DOI: 10.1016/j.clinre.2015.02.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Revised: 01/29/2015] [Accepted: 02/21/2015] [Indexed: 02/07/2023]
Abstract
AIMS A systematic review of the literature was conducted to explore the association of portal vein thrombosis (PVT) with the risk of bleeding in liver cirrhosis. METHODS PubMed, EMBASE, and Cochrane library databases were searched for all relevant papers, which compared the prevalence of bleeding at baseline and/or incidence of bleeding during follow-up between cirrhotic patients with and without PVT. RESULTS Eighteen papers were eligible for this systematic review. The heterogeneity among studies was marked with regards to the treatment modalities, sources of bleeding, lengths of follow-up, and ways of data expression. But most of their findings were homozygous and suggested that the cirrhotic patients with PVT were more likely to have previous histories of bleeding at their admission and to develop de novo bleeding and/or rebleeding during the short- and long-term follow-up. The association of PVT with the risk of bleeding might be weakened in the multivariate analyses. Additionally, as for the cirrhotic patients with gastric variceal bleeding treated with medical/endoscopic therapy, the association of PVT with the risk of rebleeding remained controversial in 2 studies; as for the cirrhotic patients undergoing transjugular intrahepatic portosystemic shunts for the management of variceal bleeding, a pre-existing PVT was not associated with the risk of rebleeding. CONCLUSIONS Based on a systematic review of the literature, there was a positive association between the presence of PVT and risk of bleeding in liver cirrhosis in most of clinical conditions. However, whether PVT aggravated the development of bleeding during follow-up needed to be further explored.
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Affiliation(s)
- Xingshun Qi
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110840, China; Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China.
| | - Chunping Su
- Library of Fourth Military Medical University, Xi'an 710032, China
| | - Weirong Ren
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Digestive Diseases, Sanmenxia Central Hospital, Henan University of Science and Technology, Xiaoshan Road, Sanmenxia 472000, China
| | - Man Yang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Gastroenterology, Songgang People's Hospital, Shenzhen 518105, China
| | - Jia Jia
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Digestive Diseases, Shaanxi Provincial People's Hospital, Xi'an 710068, China
| | - Junna Dai
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110840, China
| | - Wenda Xu
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110840, China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110840, China.
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12
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Hung TH, Tseng CW, Tsai CC, Lay CJ, Tsai CC. A fourfold increase of oesophageal variceal bleeding in cirrhotic patients with a history of oesophageal variceal bleeding. Singapore Med J 2015; 57:511-3. [PMID: 26768323 DOI: 10.11622/smedj.2015177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Large, recent population-based data for evaluating the predictors of oesophageal variceal bleeding (OVB) among cirrhotic patients is still lacking. This study aimed to determine the cumulative incidence of OVB among cirrhotic patients and identify the predictors of OVB occurrence. METHODS Patient information on 38,172 cirrhotic patients without a history of OVB, who were discharged between 1 January 2007 and 31 December 2007, was obtained from the Taiwan National Health Insurance Database for this study. All patients were followed up for three years. Death was the competing risk when calculating the cumulative incidences and hazard ratios (HRs) of OVB. RESULTS OVB was present in 2,609 patients (OVB group) and absent in 35,563 patients (non-OVB group) at hospitalisation. During the three-year follow-up period, the cumulative incidence of OVB was 44.5% and 11.3% in the OVB and non-OVB group, respectively (p < 0.001). Modified Cox regression analysis showed that the HR of OVB history was 4.42 for OVB occurrence (95% confidence interval [CI] 4.13-4.74). Other predictors for OVB occurrence included hepatocellular carcinoma (HR 1.16, 95% CI 1.09-1.24), young age (HR 0.98, 95% CI 0.98-0.98), ascites (HR 1.46, 95% CI 1.37-1.56), alcohol-related disorders (HR 1.20, 95% CI 1.12-1.28), peptic ulcer bleeding (HR 1.26, 95% CI 1.13-1.41) and diabetes mellitus (HR 1.14, 95% CI 1.06-1.23). CONCLUSION Cirrhotic patients have a fourfold increased risk of future OVB following the first incidence of OVB.
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Affiliation(s)
- Tsung-Hsing Hung
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chih-Wei Tseng
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chih-Chun Tsai
- Department of Mathematics, Tamkang University, Tamsui, Taiwan
| | - Chorng-Jang Lay
- School of Medicine, Tzu Chi University, Hualien, Taiwan.,Division of Infectious Disease, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi, Taiwan
| | - Chen-Chi Tsai
- School of Medicine, Tzu Chi University, Hualien, Taiwan.,Division of Infectious Disease, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi, Taiwan
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13
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Zhao JR, Wang GC, Hu JH, Zhang CQ. Risk factors for early rebleeding and mortality in acute variceal hemorrhage. World J Gastroenterol 2014; 20:17941-17948. [PMID: 25548492 PMCID: PMC4273144 DOI: 10.3748/wjg.v20.i47.17941] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 07/16/2014] [Accepted: 08/28/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the risk factors for 6-wk rebleeding and mortality in acute variceal hemorrhage (AVH) patients treated by percutaneous transhepatic variceal embolization (PTVE).
METHODS: A retrospective cohort study of AVH patients who had undergone PTVE treatment was conducted between January 2010 and December 2012. Demographic information, medical histories, physical examination findings, and laboratory test results were collected. The PTVE procedure was performed as a rescue therapy for patients who failed endoscopic and pharmacologic treatment. Survival analysis was estimated using the Kaplan-Meier method and compared using the log-rank test. The multivariate analysis was performed using the Cox regression test to identify independent risk factors for rebleeding and mortality.
RESULTS: One hundred and one patients were included; 71 were males and the average age was 51 years. Twenty-one patients rebled within 6 wk. Patients with high-risk stigmata, PTVE with trunk obliteration, and a hepatic vein pressure gradient (HVPG) ≥ 20 mmHg were at increased risk for rebleeding (OR = 5.279, 95%CI: 2.782-38.454, P = 0.003; OR = 4.309, 95%CI: = 2.144-11.793, P < 0.001; and OR = 1.534, 95%CI: 1.062-2.216, P = 0.022, respectively). Thirteen patients died within 6 wk. A model for end-stage liver disease (MELD) score ≥ 18 and an HVPG ≥ 20 mmHg were associated with 6-wk mortality (OR = 2.162, 95%CI: 1.145-4.084, P = 0.017 and OR = 1.423, 95%CI: 1.222-1.657, P < 0.001, respectively).
CONCLUSION: MELD score and HVPG in combination allow for early identification of patients with AVH who are at substantially increased risk of death over the short term.
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14
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Incidence and predictors of rebleeding after band ligation of oesophageal varices. Arab J Gastroenterol 2014; 15:135-41. [DOI: 10.1016/j.ajg.2014.10.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Revised: 08/03/2014] [Accepted: 10/21/2014] [Indexed: 12/18/2022]
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15
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Abstract
Portal vein thrombosis (PVT) is a fairly common complication of liver cirrhosis. Importantly, occlusive PVT might influence the prognosis of patients with cirrhosis. Evidence from a randomized controlled trial has shown that anticoagulation can prevent the occurrence of PVT in patients with cirrhosis without prior PVT. Evidence from several case series has also demonstrated that anticoagulation can achieve portal vein recanalization in patients with cirrhosis and PVT. Early initiation of anticoagulation therapy and absence of previous portal hypertensive bleeding might be positively associated with a high rate of portal vein recanalization after anticoagulation. However, the possibility of spontaneous resolution of partial PVT questions the necessity of anticoagulation for the treatment of partial PVT. In addition, a relatively low recanalization rate of complete PVT after anticoagulation therapy suggests its limited usefulness in patients with complete PVT. Successful insertion of a transjugular intrahepatic portosystemic shunt (TIPS) not only recanalizes the thrombosed portal vein, but also relieves the symptomatic portal hypertension. However, the technical difficulty of TIPS potentially limits its widespread application, and the risk and benefits should be fully balanced. Notably, current recommendations regarding the management of PVT in liver cirrhosis are insufficient owing to low-quality evidence.
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Affiliation(s)
- Xingshun Qi
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 17 West Changle Road, Xi'an, 710032 China
| | - Guohong Han
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 17 West Changle Road, Xi'an, 710032 China
| | - Daiming Fan
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 17 West Changle Road, Xi'an, 710032 China
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16
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Dai YH, Gao Q, Wang J. Risk factors for early rebleeding after endoscopic variceal ligation: A Meta-analysis. Shijie Huaren Xiaohua Zazhi 2013; 21:2987-2993. [DOI: 10.11569/wcjd.v21.i28.2987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze risk factors for early rebleeding after endoscopic variceal ligation (EVL) to provide evidence for clinical use of preventive measures.
METHODS: Seven papers reporting risk factors for early rebleeding after EVL were analyzed by meta-analysis. Pooled odds ratio (OR), weighted mean difference (WMD) and 95% confidence interval (CI) were calculated.
RESULTS: Severe grade of esophageal varices (OR = 0.04, 95%CI: 0.02, 0.08), Child-Pugh classification C (OR = 0.03, 95%CI: 0.01, 0.07), presence of a moderate to large amount of ascites (OR = 0.00, 95%CI: 0.00, 0.01), thrombus of the portal vein (OR = 0.12, 95%CI: 0.07, 0.22), and a history of diabetes (OR = 0.36, 95%CI: 0.18, 0.72) were risk factors for early rebleeding after EVL. Moderate grade of esophageal varices (OR = 17.53, 95%CI: 8.51, 36.12), Child-Pugh classification A (OR = 4.24, 95%CI: 2.73, 6.58), Child-Pugh classification B (OR = 3.86, 95%CI: 2.55, 5.85), absence or presence of a small amount of ascites (OR = 245.37, 95%CI: 108.35, 555.64), small width of the portal vein (WMD = -2.45, 95%CI: -3.92, -0.99), few number of varices (WMD = -1.37, 95%CI: -1.72, -1.01), few number of ligated veins (WMD = -1.72, 95%CI: -1.95, -1.50), high level of hemoglobin (WMD = 13.72, 95%CI: 2.35, 25.09), short prothrombin time (PT) (WMD = -3.54, 95%CI: -4.84, -2.24), low level of alanine aminotransferase (WMD = -6.48, 95%CI: -11.59, -1.36), low level of total bilirubin (WMD = -8.01, 95%CI: -12.04, -3.98), high level of prothrombin activity (WMD = 11.03, 95%CI: 6.09, 15.96), and few number of bands used (WMD = -1.49, 95%CI: -1.64, -1.33) were protective factors for early rebleeding after EVL. Mild grade of esophageal varices had no significant correlation with early rebleeding after EVL.
CONCLUSION: Improving Child-Pugh classification and blood coagulation function and decreasing the amount of ascites can reduce the risk for early rebleeding after EVL.
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17
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Narváez-Rivera RM, Cortez-Hernández CA, González-González JA, Tamayo-de la Cuesta JL, Zamarripa-Dorsey F, Torre-Delgadillo A, Rivera-Ramos JFJ, Vinageras-Barroso JI, Muneta-Kishigami JE, Blancas-Valencia JM, Antonio-Manrique M, Valdovinos-Andraca F, Brito-Lugo P, Hernández-Guerrero A, Bernal-Reyes R, Sobrino-Cossío S, Aceves-Tavares GR, Huerta-Guerrero HM, Moreno-Gómez N, Bosques-Padilla FJ. [Mexican consensus on portal hypertension]. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2013; 78:92-113. [PMID: 23664429 DOI: 10.1016/j.rgmx.2013.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Revised: 11/30/2012] [Accepted: 01/21/2013] [Indexed: 02/07/2023]
Abstract
The aim of the Mexican Consensus on Portal Hypertension was to develop documented guidelines to facilitate clinical practice when dealing with key events of the patient presenting with portal hypertension and variceal bleeding. The panel of experts was made up of Mexican gastroenterologists, hepatologists, and endoscopists, all distinguished professionals. The document analyzes themes of interest in the following modules: preprimary and primary prophylaxis, acute variceal hemorrhage, and secondary prophylaxis. The management of variceal bleeding has improved considerably in recent years. Current information indicates that the general management of the cirrhotic patient presenting with variceal bleeding should be carried out by a multidisciplinary team, with such an approach playing a major role in the final outcome. The combination of drug and endoscopic therapies is recommended for initial management; vasoactive drugs should be started as soon as variceal bleeding is suspected and maintained for 5 days. After the patient is stabilized, urgent diagnostic endoscopy should be carried out by a qualified endoscopist, who then performs the corresponding endoscopic variceal treatment. Antibiotic prophylaxis should be regarded as an integral part of treatment, started upon hospital admittance and continued for 5 days. If there is treatment failure, rescue therapies should be carried out immediately, taking into account that interventional radiology therapies are very effective in controlling refractory variceal bleeding. These guidelines have been developed for the purpose of achieving greater clinical efficacy and are based on the best evidence of portal hypertension that is presently available.
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Affiliation(s)
- R M Narváez-Rivera
- Servicio de Gastroenterología, Departamento de Medicina Interna, Hospital Universitario «Dr. José Eleuterio González», Monterrey, N.L., México
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Chang FF, Du YJ. Progress in prevention and treatment of rebleeding after endoscopic band ligation for esophageal variceal bleeding. Shijie Huaren Xiaohua Zazhi 2012; 20:2795-2799. [DOI: 10.11569/wcjd.v20.i29.2795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hemorrhage from esophageal varices is a serious and common complication of decompensated cirrhosis and carries a significant rate of morbidity and mortality. Endoscopic variceal ligation (EVL) is an effective treatment for esophageal varices; however, there is a very high rate of rebleeding. Prevention and treatment of rebleeding after EVL are important for improving survival in patients with liver cirrhosis. Currently, many measures, including endoscopy, surgery, medication, and a combination of them, have been developed to prevent the occurrence of rebleeding after EVL. Many clinical trials have been done to evaluate the effectiveness of various treatments, alone or in combination, for rebleeding.
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19
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Xu L, Ji F, Xu QW, Zhang MQ. Risk factors for predicting early variceal rebleeding after endoscopic variceal ligation. World J Gastroenterol 2011; 17:3347-52. [PMID: 21876624 PMCID: PMC3160540 DOI: 10.3748/wjg.v17.i28.3347] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Revised: 02/26/2011] [Accepted: 03/05/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze the clinical risk factors for early variceal rebleeding after endoscopic variceal ligation (EVL).
METHODS: 342 cirrhotic patients with esophageal varices who received elective EVL to prevent bleeding or rebleeding at our endoscopy center between January 2005 and July 2010. were included in this study. The early rebleeding cases after EVL were confirmed by clinical signs or endoscopy. A case-control study was performed comparing the patients presenting with early rebleeding with those without this complication.
RESULTS: The incidence of early rebleeding after EVL was 7.60%, and the morbidity of rebleeding was 26.9%. Stepwise multivariate logistic regression analysis showed that four variables were independent risk factors for early rebleeding: moderate to excessive ascites [odds ratio (OR) 62.83, 95% CI: 9.39-420.56, P < 0.001], the number of bands placed (OR 17.36, 95% CI: 4.00-75.34, P < 0.001), the extent of varices (OR 15.41, 95% CI: 2.84-83.52, P = 0.002) and prothrombin time (PT) > 18 s (OR 11.35, 95% CI: 1.93-66.70, P = 0.007).
CONCLUSION: The early rebleeding rate after EVL is mainly affected by the volume of ascites, number of rubber bands used to ligate, severity of varices and prolonged PT. Effective measures for prevention and treatment should be adopted before and after EVL.
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20
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Ryou M, Nemiroski A, Azagury D, Shaikh SN, Ryan MB, Westervelt RM, Thompson CC. An implantable wireless biosensor for the immediate detection of upper GI bleeding: a new fluorescein-based tool for diagnosis and surveillance (with video). Gastrointest Endosc 2011; 74:189-194.e1. [PMID: 21704817 DOI: 10.1016/j.gie.2011.03.1182] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2010] [Accepted: 03/17/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Early recurrent hemorrhage after endoscopic intervention for acute upper GI bleeding (UGIB) can approach 20% and leads to increased morbidity and mortality. Little has changed over the past several decades regarding immediate posthemorrhage surveillance, and there has likewise been no significant improvement in outcomes. OBJECTIVE To develop and test an endoscopically implantable wireless biosensor for real-time detection of fluorescein-labeled blood in ex vivo and in vivo porcine models of UGIB. SETTING Animal laboratory. DESIGN Benchtop and acute animal studies. SUBJECTS Five pigs. INTERVENTIONS UGIB models were surgically created in living pigs. Biosensors were endoscopically deployed in the stomach using standard endoscopic clips. The ability to detect acute UGIB and estimated blood loss leading to biosensor activation were recorded. Feasibility of wireless data transmission out of the body to an external computer and cell phone was assessed. MAIN OUTCOME MEASUREMENTS Technical feasibility and immediate complications. RESULTS A porcine UGIB model was successfully created. Biosensors were able to detect all acute bleeding events and wirelessly transmit out of the body, and successfully sent an emergency text message to the intended cell phone in all cases. Average estimated blood loss leading to biosensor activation was 30 mL (10-75 mL). LIMITATIONS Animal study; small numbers. CONCLUSIONS An endoscopically implantable wireless biosensor successfully detected acute hemorrhage in a porcine UGIB model and sent an emergency cell-phone alert in real time.
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Affiliation(s)
- Marvin Ryou
- Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
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21
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Chen WT, Lin CY, Sheen IS, Huang CW, Lin TN, Lin CJ, Jeng WJ, Huang CH, Ho YP, Chiu CT. MELD score can predict early mortality in patients with rebleeding after band ligation for variceal bleeding. World J Gastroenterol 2011; 17:2120-2125. [PMID: 21547132 PMCID: PMC3084398 DOI: 10.3748/wjg.v17.i16.2120] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 12/01/2010] [Accepted: 12/08/2010] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the outcomes, as well as risk factors for 6-wk mortality, in patients with early rebleeding after endoscopic variceal band ligation (EVL) for esophageal variceal hemorrhage (EVH). METHODS Among 817 EVL procedures performed for EVH between January 2007 and December 2008, 128 patients with early rebleeding, defined as rebleeding within 6 wk after EVL, were enrolled for analysis. RESULT The rate of early rebleeding after EVL for acute EVH was 15.6% (128/817). The 5-d, 6-wk, 3-mo, and 6-mo mortality rates were 7.8%, 38.3%, 55.5%, and 58.6%, respectively, in these early rebleeding patients. The use of beta-blockers, occurrence of hypovolemic shock, and higher model for end-stage liver disease (MELD) score at the time of rebleeding were independent predictors for 6-wk mortality. A cut-off value of 21.5 for the MELD score was found with an area under ROC curve of 0.862 (P < 0.001). The sensitivity, specificity, positive predictive value, and negative predictive value were 77.6%, 81%, 71.7%, and 85.3%, respectively. As for the 6-mo survival rate, patients with a MELD score ≥ 21.5 had a significantly lower survival rate than patients with a MELD score < 21.5 (P < 0.001). CONCLUSION This study demonstrated that the MELD score is an easy and powerful predictor for 6-wk mortality and outcomes of patients with early rebleeding after EVL for EVH.
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Independent factors associated with early outcome in Chinese cirrhotic patients after cessation of initial esophageal variceal hemorrhage. J Clin Gastroenterol 2010; 44:e123-7. [PMID: 20048682 DOI: 10.1097/mcg.0b013e3181c3fb22] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
UNLABELLED BACKGROUND, PURPOSE, AND METHOD: Cirrhotic patients with acute esophageal variceal (EV) hemorrhage are characterized by high mortality. This study was conducted to investigate the independent indicators of mortality in Chinese cirrhotic patients within 6 weeks after cessation of initial EV bleeding. Ninety-seven consecutive cirrhotic patients with EV bleeding but without evidence of infection who were admitted to our hospital between December 2006 and February 2009 were retrospectively analyzed. Ten patients who died and 87 patients who survived were enrolled in the mortality and survival groups, respectively. The characteristics and laboratory data at admission of patients in the 2 groups were compared. Time of death in the mortality group, rebleeding and infection in both the mortality and survival groups were also evaluated. RESULTS The incidence of mortality after cessation of initial EV bleeding was 10.3% (10/97). Incidences of infection and rebleeding were significantly higher in the mortality group than in the survival group (60% vs. 21%, 70% vs. 8%). Other parameters such as age, sex, etiology of liver cirrhosis, severity of liver disease (ascites, spleen diameter, platelet count, hepatocellular carcinoma, portal vein thrombosis), severity of EV bleeding (hemoglobin, blood pressure, requirements of blood transfusion), and differential vasoactive medications had no significant influence on incidence of mortality. All deaths were caused by rebleeding or sepsis, and all rebleeding occurred before infection. Most (67%) patients with rebleeding had postbanding ulcer bleeding. Generally, mortality, rebleeding, and infection occurred within 2 weeks after cessation of initial EV bleeding. CONCLUSIONS This study provides evidence that the incidence of early mortality after cessation of initial EV bleeding is significantly associated with bacterial infection and rebleeding. Rebleeding can increase the possibility of infection. Therefore, prevention of infection and rebleeding plays a major role in improving the early outcome in Chinese cirrhotic patients with EV bleeding.
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Abstract
Gastroesophageal variceal hemorrhage is a major complication of portal hypertension in 50% to 60% of patients with liver cirrhosis and is a frequent cause of mortality in these patients. The prevalence of variceal hemorrhage is approximately 5% to 15% yearly, and early variceal rebleeding has a rate of occurrence of 30% to 40% within the first 6 weeks. More than 50% of patients who survive after the first bleeding episode will experience recurrent bleeding within 1 year. Management of gastroesophageal varices should include prevention of initial and recurrent bleeding episodes and control of active hemorrhage. Therapies used in the management of gastroesophageal variceal hemorrhage may include pharmacologic therapy (vasoactive agents, nonselective b-blockers, and antibiotic prophylaxis), endoscopic therapy, transjugular intrahepatic portosystemic shunt, and shunt surgery. This article focuses primarily on pharmacologic management of acute variceal hemorrhage.
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Affiliation(s)
- Tram B Cat
- Critical Care, Department of Pharmacy, Antelope Valley Hospital, 1600 West Avenue, Lancaster, CA 93534, USA.
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