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Zhang YH, Hu B. Future directions of noninvasive prediction of esophageal variceal bleeding: No worry about the present computed tomography inefficiency. World J Gastrointest Endosc 2024; 16:108-111. [PMID: 38577650 PMCID: PMC10989247 DOI: 10.4253/wjge.v16.i3.108] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/16/2024] [Accepted: 02/06/2024] [Indexed: 03/14/2024] Open
Abstract
In this editorial, we comment on the minireview by Martino A, published in the recent issue of World Journal of Gastrointestinal Endoscopy 2023; 15 (12): 681-689. We focused mainly on the possibility of replacing the hepatic venous pressure gradient (HVPG) and endoscopy with noninvasive methods for predicting esophageal variceal bleeding. The risk factors for bleeding were the size of the varices, the red sign and the Child-Pugh score. The intrinsic core factor that drove these changes was the HVPG. Therefore, the present studies investigating noninvasive methods, including computed tomography, magnetic resonance imaging, elastography, and laboratory tests, are working on correlating imaging or serum marker data with intravenous pressure and clinical outcomes, such as bleeding. A single parameter is usually not enough to construct an efficient model. Therefore, multiple factors were used in most of the studies to construct predictive models. Encouraging results have been obtained, in which bleeding prediction was partly reached. However, these methods are not satisfactory enough to replace invasive methods, due to the many drawbacks of different studies. There is still plenty of room for future improvement. Prediction of the precise timing of bleeding using various models, and extracting the texture of variceal walls using high-definition imaging modalities to predict the red sign are interesting directions to lay investment on.
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Affiliation(s)
- Yu-Hang Zhang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Bing Hu
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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Gu W, Kimmann M, Laleman W, Praktiknjo M, Trebicka J. To TIPS or Not to TIPS in High Risk of Variceal Rebleeding and Acute-on-Chronic Liver Failure. Semin Liver Dis 2023; 43:189-205. [PMID: 37286178 DOI: 10.1055/a-2107-0576] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Variceal bleeding is a consequence of severe portal hypertension in patients with liver cirrhosis. Although the rate of bleeding has decreased over time, variceal bleeding in the presence of acute-on-chronic liver failure (ACLF) carries a high risk of treatment failure and short-term mortality. Treatment and/or removal of precipitating events (mainly bacterial infection and alcoholic hepatitis) and decrease of portal pressure may improve outcome of patients with acute decompensation or ACLF. Transjugular intrahepatic portosystemic shunts (TIPSs), especially in the preemptive situation, have been found to efficiently control bleeding, prevent rebleeding, and reduce short-term mortality. Therefore, TIPS placement should be considered as an option in the management of ACLF patients with variceal bleeding.
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Affiliation(s)
- Wenyi Gu
- Department of Medical Clinic B, University Hospital Muenster, Muenster, Germany
- Medical Department I, Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Markus Kimmann
- Department of Medical Clinic B, University Hospital Muenster, Muenster, Germany
| | - Wim Laleman
- Department of Medical Clinic B, University Hospital Muenster, Muenster, Germany
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Michael Praktiknjo
- Department of Medical Clinic B, University Hospital Muenster, Muenster, Germany
| | - Jonel Trebicka
- Department of Medical Clinic B, University Hospital Muenster, Muenster, Germany
- European Foundation for Study of Chronic Liver Failure, Barcelona, Spain
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
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Lu SW, Pai CP, Yang TH, Lu JX, Hsiao CH, Yen CC. Clinical characteristics and risk factors for 30-day mortality in esophageal cancer patients with upper gastrointestinal bleeding: a multicenter study. Front Oncol 2023; 13:1184710. [PMID: 37213275 PMCID: PMC10198378 DOI: 10.3389/fonc.2023.1184710] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 04/17/2023] [Indexed: 05/23/2023] Open
Abstract
Background Esophageal cancer is a highly malignant neoplasm with poor prognosis. Of its patients, upper gastrointestinal bleeding (UGIB) is one of the most challenging and threatening conditions in the emergency department (ED). However, no previous studies have analyzed the etiologies and clinical outcomes in this specific population. This study aimed to identify the clinical characteristics and risk factors for 30-day mortality in esophageal cancer patients with UGIB. Methods This retrospective cohort study enrolled 249 adult patients with esophageal cancer presenting with UGIB in the ED. Patients was divided into the survivor and non-survivor groups, and their demographic information, medical history, comorbidities, laboratory parameters, and clinical findings were recorded. The factors associated with 30-day mortality were identified using Cox's proportional hazard model. Results Among the 249 patients in this study, 30-day mortality occurred in 47 patients (18.9%). The most common causes of UGIB were tumor ulcer (53.8%), followed by gastric/duodenal ulcer (14.5%), and arterial-esophageal fistula (AEF) (12.0%). Multivariate analyses indicated that underweight (HR = 2.02, p = 0.044), history of chronic kidney disease (HR = 6.39, p < 0.001), active bleeding (HR = 2.24, p = 0.039), AEF (HR = 2.23, p = 0.046), and metastatic lymph nodes (HR = 2.99, p = 0.021) were independent risk factors for 30-day mortality. Conclusions The most common cause of UGIB in esophageal cancer patients was tumor ulcer. AEF, accounting for 12% of UGIB in our study, is not an uncommon cause. Underweight, underlying chronic kidney disease, active bleeding, AEF, and tumor N stage > 0 were independent risk factors for 30-day mortality.
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Affiliation(s)
- Sz-Wei Lu
- Department of Emergency Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
- Department of Emergency Medicine, Tri-Service General Hospital SongShan Branch, National Defense Medical Center, Taipei, Taiwan
| | - Chu-Pin Pai
- Division of Thoracic Surgery, Department of Surgery, Luodong Poh-Ai Hospital, Ilan, Taiwan
| | - Ting-Hao Yang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Jian-Xun Lu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Chien-Han Hsiao
- Department of Linguistics, Indiana University, Bloomington, IN, United States
| | - Chieh-Ching Yen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Department of Emergency Medicine, New Taipei Municipal Tucheng Hospital, New Taipei City, Taiwan
- *Correspondence: Chieh-Ching Yen,
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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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Singh SP, Wadhawan M, Acharya SK, Bopanna S, Madan K, Sahoo MK, Bhat N, Misra SP, Duseja A, Mukund A, Anand AC, Goel A, Satyaprakash BS, Varghese J, Panigrahi MK, Tandan M, Mohapatra MK, Puri P, Rathi PM, Wadhwa RP, Taneja S, Thomas V, Bhatia V. Management of portal hypertensive upper gastrointestinal bleeding: Report of the Coorg Consensus workshop of the Indian Society of Gastroenterology Task Force on Upper Gastrointestinal Bleeding. Indian J Gastroenterol 2021; 40:519-540. [PMID: 34890020 DOI: 10.1007/s12664-021-01169-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/09/2021] [Indexed: 02/04/2023]
Abstract
Portal hypertensive bleeding is a major complication of portal hypertension (PHT) with high morbidity and mortality. A lot of advances have been made in our understanding of screening, risk stratification, and management strategies for portal hypertensive bleeding including acute variceal bleeding leading to improved overall outcomes in patients with PHT. A number of guidelines on variceal bleeding have been published by various societies in the past few years. The Indian Society of Gastroenterology (ISG) Task Force on Upper Gastrointestinal Bleeding (UGIB) felt that it was necessary to bring out a standard practice guidance document for the use of Indian health care providers especially physicians, gastroenterologists, and hepatologists. For this purpose, an expert group meeting was convened by the ISG Task Force to deliberate on this matter and write a consensus guidance document for Indian practice. The delegates including gastroenterologists, hepatologists, radiologists, and surgeons from different parts of the country participated in the consensus development meeting at Coorg in 2018. A core group was constituted which reviewed all published literature on portal hypertensive UGIB with special reference to the Indian scenario and prepared unambiguous statements on different aspects for voting and consensus in the whole group. This consensus was produced through a modified Delphi process and reflects our current understanding and recommendations for the diagnosis and management of portal hypertensive UGIB in Indians. Intended for use by the health care providers especially gastroenterologists and hepatologists, these consensus statements provide an evidence-based approach to risk stratification, diagnosis, and management of patients with portal hypertensive bleeding.
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Affiliation(s)
- Shivaram P Singh
- Department of Gastroenterology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, 753 001, India.
| | - Manav Wadhawan
- Department of Hepatology and Liver Transplant, Institute of Liver and Digestive Diseases, BLK Super Specialty Hospital, Delhi, 110 005, India
| | - Subrat K Acharya
- Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, 751 024, India
| | - Sawan Bopanna
- Department of Gastroenterology and Hepatology, Fortis Flt. Lt. Rajan Dhall Hospital, Aruna Asaf Ali Marg, Vasant Kunj, New Delhi, 110 070, India
| | - Kaushal Madan
- Department of Gastroenterology and Hepatology, Max Smart Super Specialty Hospital, Saket, New Delhi, 110 017, India
| | - Manoj K Sahoo
- Department of Medical Gastroenterology, IMS and SUM Hospital, K8 Kalinga Nagar, Shampur, Bhubaneswar, 751 003, India
| | - Naresh Bhat
- Department of Gastroenterology and Hepatology, Aster CMI Hospital, Bangalore, 560 092, India
| | - Sri P Misra
- Department of Gastroenterology and Hepatology, Moti Lal Nehru Medical College, Allahabad, 211 001, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Amar Mukund
- Department of Radiology, Institute of Liver and Biliary Sciences, Sector D-1, Vasant Kunj, New Delhi, 110 070, India
| | - Anil C Anand
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Patia, Bhubaneswar, 751 024, India
| | - Ashish Goel
- Department of Hepatology, Christian Medical College, Vellore, 632 004, India
| | | | - Joy Varghese
- Department of Hepatology and Transplant Hepatology, Institute of Liver Disease and Transplantation, Gleneagles Global Health City, 439, Cheran Nagar, Chennai, 600 100, India
| | - Manas K Panigrahi
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, 751 019, India
| | - Manu Tandan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Somajiguda, Hyderabad, 500 082, India
| | - Mihir K Mohapatra
- Department of Surgical Gastroenterology, Srirama Chandra Bhanja Medical College, Cuttack, 753 007, India
| | - Pankaj Puri
- Department of Gastroenterology and Hepatology, Fortis Escorts Liver and Digestive Diseases Institute, Okhla Road, New Delhi, 110 025, India
| | - Pravin M Rathi
- Department of Gastroenterology, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, 400 008, India
| | - Rajkumar P Wadhwa
- Department of Gastroenterology, Apollo BGS Hospital, Adichuchanagiri Road, Kuvempunagar, Mysore, 570 023, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Varghese Thomas
- Department of Gastroenterology, Malabar Medical College Hospital, Modakkallur, Calicut, 673 321, India
| | - Vikram Bhatia
- Department of Hepatology, Institute of Liver and Biliary Sciences, Sector D-1, Vasant Kunj, New Delhi, 110 070, India
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Hu T, Stock S, Hong W, Chen Y. Modified 'sandwich' injection with or without ligation for variceal bleeding in patients with both esophageal and gastric varices: a retrospective cohort study. Scand J Gastroenterol 2020; 55:1219-1224. [PMID: 32780613 DOI: 10.1080/00365521.2020.1803959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Esophagogastric variceal bleeding (EGVB) is a serious disease with high mortality. Endoscopic therapy has long been shown to be effective but the optimum technique is still unclear. We aimed to investigate the efficacy, safety and predictive factors of 1-year rebleeding of modified 'sandwich' injection combined with esophageal variceal ligation (EVL) for treating EGVB. METHODS A retrospective analysis was performed of 100 patients with EGVB who underwent modified 'sandwich' injection with or without EVL (EVL + and EVL - group). Patient follow-up was 1 year. Outcomes such as control of bleeding, rebleeding, complication rate and mortality were compared. Further, prognostic factors for rebleeding at one year were estimated. RESULTS No significant differences between two groups regarding initial bleeding control, complications, 6-week rebleeding or mortality in 1-year were observed. Rebleeding rate at 1-year of EVL - group was significantly higher than EVL + group (40 vs 20%, p = .029). Independent predictors of rebleeding at 1-year were gender, bilirubin and whether EVL was combined with injection. CONCLUSIONS Based on this single-center retrospective study, both of the two kinds therapies appeared to have relatively favorable outcomes. With respect to the rebleeding rate at 1-year, modified 'sandwich' injection combined with EVL may be superior to modified 'sandwich' injection alone.
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Affiliation(s)
- Tingting Hu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Simon Stock
- Department of Surgery, World Mate Emergency Hospital, Battambang, Cambodia
| | - Wandong Hong
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yongping Chen
- Department of Infectious Diseases, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory for Accurate Diagnosis and Treatment of Chronic Liver Diseases, Wenzhou Medical University, Wenzhou, China.,Hepatology Institute of Wenzhou Medical University, Wenzhou, China
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Dunne PDJ, Sinha R, Stanley AJ, Lachlan N, Ireland H, Shams A, Kasthuri R, Forrest EH, Hayes PC. Randomised clinical trial: standard of care versus early-transjugular intrahepatic porto-systemic shunt (TIPSS) in patients with cirrhosis and oesophageal variceal bleeding. Aliment Pharmacol Ther 2020; 52:98-106. [PMID: 32452561 DOI: 10.1111/apt.15797] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 02/20/2020] [Accepted: 04/25/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Early-transjugular intrahepatic porto-systemic shunt (TIPSS) has been recommended in international guidelines for high-risk patients with oesophageal variceal bleeding. AIM To validate the results of a previous randomised control trial which supports use of early-TIPSS. METHODS In a two-centre open-label parallel-group randomised control trial, patients with cirrhosis and acute variceal bleeding were recruited following haemostasis with vaso-active drugs and endoscopic band ligation. Participants were randomised to standard of care or early-TIPSS. The primary outcome was 1-year survival, secondary outcomes included early and late rebleeding, and complications of portal hypertension. RESULTS Fifty-eight patients (58 ± 11.12 years; 32.7% female) were randomised. After one year, seven patients died in the standard of care group and six in the early-TIPSS group, a 1-year survival of 75.9% vs 79.3% respectively (P = 0.79). Variceal rebleeding occurred in eight patients in the standard of care group compared with three patients in the early-TIPSS group (P = 0.09). Not all participants randomised to early-TIPSS received the intervention in time. For those receiving TIPSS per-protocol, variceal rebleeding rates were reduced (0% vs 27.6%, P = 0.04) but this had no effect on survival (76.9% vs 75.9%, P = 0.91). Serious adverse events were similar in both treatment groups, except that rates of hepatic encephalopathy were higher in patients receiving TIPSS (46.1% vs 20.7%, P < 0.05). CONCLUSIONS Early-TIPSS reduced variceal rebleeding, increased encephalopathy but had no effect on survival in high-risk patients with oesophageal variceal bleeding. Early-TIPSS may not be feasible in many centres however, larger studies are needed. ClinicalTrials.gov reference: NCT02377141.
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Affiliation(s)
- Philip D J Dunne
- Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Rohit Sinha
- Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Neil Lachlan
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Hamish Ireland
- Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Aman Shams
- Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
- Department of Gastroenterology, Queen Margaret Hospital, Dunfermline, UK
| | - Ram Kasthuri
- Department of Radiology, Glasgow Royal Infirmary, Glasgow, UK
| | - Ewan H Forrest
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Peter C Hayes
- Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
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Lu Z, Sun X, Zhang W, Jin B, Han J, Wang Y, Han J, Ma X, Liu B, Wu L, Wu Q, Yu X, Li H. Second urgent endoscopy within 48-hour benefits cirrhosis patients with acute esophageal variceal bleeding. Medicine (Baltimore) 2020; 99:e19485. [PMID: 32176084 PMCID: PMC7440074 DOI: 10.1097/md.0000000000019485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Urgent endoscopy (UE) is important to the diagnosis and treatment of liver cirrhosis patients with esophageal variceal bleeding (EVB). It was reported that a second-look endoscopy may benefit acute upper gastrointestinal bleeding (UGIB) caused by peptic ulcer, while whether it could improve UGIB caused by liver cirrhosis associated EVB remains unclear. This study aimed to investigate the characteristics of second UE for liver cirrhosis with EVB and further examined the potential prognostic factors.Patients aged ≥18 years who underwent UE for EVB within 2 hours after the admission were included and divided into scheduled second-look group (n = 245) and uncontrolled bleeding group (n = 352) based on the indications for second UE within 48 hours after initial endoscopy. Demographic and clinical data were collected and analyzed. Univariate and multivariate analysis were used to identify the risk factors for prognosis. The value of different scoring system was compared.Statistical differences were found on history of bleeding and hepatocellular carcinoma, ascites, endoscopic type of bleeding, between scheduled second-look group and uncontrolled bleeding group. Univariate and multivariate logistic regression analysis confirmed that ascites, hemoglobin <60 g/L, AIMS65 score and failure to identify in initial UE were independent risk factors for bleeding uncontrolled after initial UE, and age, bilirubin level, initial unsatisfactory UE hemostasis, failure to identify bleeding on initial UE and tube/urgent TIPS suggested in initial UE were independent risk factors for 42-day mortality.A second-look UE could bring benefit for liver cirrhosis patients with EVB without increasing the complication rate.
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Affiliation(s)
- Zheng Lu
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Xiaotian Sun
- Department of Internal Medicine, Clinic of August First Film Studio, Beijing South Medical District, Chinese PLA General Hospital, Beijing, China
| | - Wenhui Zhang
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Bo Jin
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | | | - Yanling Wang
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Jun Han
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Xuemei Ma
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Bo Liu
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Libing Wu
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Qin Wu
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Xiaoli Yu
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Hanwei Li
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
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9
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Gado A, Ebeid B, Abdelmohsen A, Axon A. Predictors of mortality in patients with acute upper gastrointestinal hemorrhage who underwent endoscopy and confirmed to have variceal hemorrhage. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2014.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Ahmed Gado
- Department of Medicine, Bolak Eldakror Hospital, Giza, Egypt
| | - Basel Ebeid
- Department of Tropical Medicine and Infectious Diseases, Beny Suef University, Beny Suef, Egypt
| | - Aida Abdelmohsen
- Department of Community Medicine, National Research Center, Giza, Egypt
| | - Anthony Axon
- Department of Gastroenterology, The General Infirmary at Leeds, Leeds, United Kingdom
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10
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D'Amico G, D'Amico M, Malizia G. Refining early-TIPS criteria requires good quality prognostic studies. Liver Int 2018; 38:412-414. [PMID: 29469210 DOI: 10.1111/liv.13671] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
| | - Mario D'Amico
- Radiology Department, Ospedale Policlinico Maggiore, Milano, Italy
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Goenka MK, Goenka U, Tiwary IK, Rai V. Use of self-expanding metal stents for difficult variceal bleed. Indian J Gastroenterol 2017; 36:468-473. [PMID: 29368190 DOI: 10.1007/s12664-017-0800-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 11/05/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIM Patients with variceal band ligation (VBL)-induced ulcer bleeding and those with persisting bleeding in spite of VBL carry a high mortality. Balloon tamponade and transjugular intrahepatic portosystemic shunt have limitations in terms of complications, cost, and availability. The aim was to evaluate the efficacy of Sx-Ella Danis stent in persistent or complicated variceal bleeding. METHODS Twelve patients with either persistent variceal bleeding or VBL-induced ulcer bleeding were treated with the placement of Sx-Ella Danis stents. The patients were followed up for mortality, complications, and efficacy to control bleeding. RESULTS Stents were inserted successfully in all 12 patients (with immediate hemostasis). There was an immediate cessation of bleeding in all 12 patients with no stent-related complication. Five out of 12 patients died during 30 days post-procedure due to worsening encephalopathy or sepsis. Enteral feeding could be started in all 12 patients 6 h after stent placement. One patient had bleeding 10 days after stent removal and was re-stented but expired 7 days later. Stents were removed in eight patients at a mean duration of 17.5 days. (range 7 to 30 days). CONCLUSIONS Sx-Ella Danis stent is a useful modality to control persistent variceal bleeding as well VBL-related ulcer bleeding.
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Affiliation(s)
- M K Goenka
- Institute of Gastrosciences, Apollo Gleneagles Hospitals, Kolkata, 700 054, India.
| | - Usha Goenka
- Department of Clinical Imaging and Interventional Radiology, Apollo Gleneagles Hospitals, Kolkata, 700 054, India
| | - I K Tiwary
- Institute of Gastrosciences, Apollo Gleneagles Hospitals, Kolkata, 700 054, India
| | - Vijay Rai
- Institute of Gastrosciences, Apollo Gleneagles Hospitals, Kolkata, 700 054, India
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Tag-Adeen M, Alsenbesy M, Ghweil AA, Abd Elrazek MAH, Elgohary EA, Sallam MM, Ismael A, Nawara A. Liver stiffness measurement and spleen diameter as predictors for the presence of esophageal varices in chronic hepatitis C patients. Medicine (Baltimore) 2017; 96:e8621. [PMID: 29145280 PMCID: PMC5704825 DOI: 10.1097/md.0000000000008621] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Although it is an invasive and unpleasant procedure, esophagogastroduodenoscopy (EGD) is still the gold standard for esophageal varices (EV) detection. The aim of this study was to investigate liver stiffness measurement (LSM) and spleen diameter as simple noninvasive tools for EV prediction in chronic hepatitis C patients (CHC).A total of 123 Egyptian patients with CHC have been included and were classified based on screening EGD result into 2 groups; group A (without EV) and group B (with EV). Group (B) was subclassified according to EV grade into 4 subgroups: (B1, grade I), (B2, grade II), (B3, grade III), and (B4, grade IV). LSM was taken for each patient on the next day by an independent Fibroscan operator and correlated to the EGD result. Demographic, clinical, and biochemical data were recorded and analyzed using advanced data-mining computational technology.Mean LSM was 9.94 ± 6 kPa for group A and 33.32 ± 14 kPa for group B, whereas it was 21.22 ± 3, 25.72 ± 6, 33.82 ± 8, and 46.1 ± 15 kPa for subgroups B1, B2, B3, and B4, respectively. Mean spleen diameter was 11.09 ± 1.7 cm for group A and 16.58 ± 1.6 cm for group B. However, LSM ≥17 kPa was the only independent factor for EV prediction; splenic longitudinal span ≥15 cm was a complementary predictor when LSM was <17 kPa. The overall accuracy was 98.33 ± 3.33, Mikro = 98.26%.LSM ≥17 kPa and spleen diameter ≥15 cm is a simple noninvasive algorithm that could be used for prediction of EV and discrimination among its different grades.
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Affiliation(s)
- Mohammed Tag-Adeen
- Department of Internal Medicine, Qena School of Medicine, South Valley University, Qena
| | - Mohamed Alsenbesy
- Department of Internal Medicine, Qena School of Medicine, South Valley University, Qena
| | - Ali Abdelrahman Ghweil
- Department of Tropical Medicine and Gastroenterology, Qena School of Medicine, South Valley University, Qena
| | | | - Elsayed A. Elgohary
- Department of Internal Medicine, Zagazig School of Medicine, Zagazig University, As-Sharqia, Egypt
| | - Mohammad M. Sallam
- Department of Internal Medicine, Zagazig School of Medicine, Zagazig University, As-Sharqia, Egypt
| | - Ali Ismael
- Department of Internal Medicine, Zagazig School of Medicine, Zagazig University, As-Sharqia, Egypt
| | - Abdallah Nawara
- Department of Internal Medicine, Zagazig School of Medicine, Zagazig University, As-Sharqia, Egypt
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Austrian consensus guidelines on the management and treatment of portal hypertension (Billroth III). Wien Klin Wochenschr 2017; 129:135-158. [PMID: 29063233 PMCID: PMC5674135 DOI: 10.1007/s00508-017-1262-3] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/22/2017] [Indexed: 12/14/2022]
Abstract
The Billroth III guidelines were developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on 18 February 2017 in Vienna. Based on international guidelines and considering recent landmark studies, the Billroth III recommendations aim to help physicians in guiding diagnostic and therapeutic strategies in patients with portal hypertension.
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Barbu LA, Mărgăritescu ND, Şurlin MV. Diagnosis and Treatment Algorithms of Acute Variceal Bleeding. CURRENT HEALTH SCIENCES JOURNAL 2017; 43:191-200. [PMID: 30595875 PMCID: PMC6284844 DOI: 10.12865/chsj.43.03.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 09/09/2017] [Indexed: 12/11/2022]
Abstract
Esophageal varices are about 10%-15% of UGIB. Over 90% of patients with cirrhosis develop portal hypertension (PHT), but not all patients with PHT and liver cirrhosis have esophageal varices. At the time of diagnosis, only 60% of patients with cirrhosis have esophageal varices. In the case of variceal bleeding suspects, vasoactive drugs should be given as soon as possible and before endoscopy. Balloon tamponade is used to obtain temporary hemostasis by direct compression of hemorrhagic varices. The variceal band ligation is already the first place in the treatment and prevention of variceal bleeding, but also in rebleeding prevention. TIPS is used as a rescue therapy after failure of drug and endoscopic therapy. The mortality assigned to the hemorrhagic episode is substantially, estimated at 13-19% of the overall mortality in hepatic cirrhosis. Current recommendations for the treatment of acute variceal bleeding are the use of combination therapy: vasoactive drugs, balloon tamponade, elastic ligation and TIPS, whose staging is done in various diagnosis and treatment algorithms.
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Affiliation(s)
- L A Barbu
- PhD student, Department Surgery, University of Medicine and Pharmacy of Craiova, Romania
| | - N D Mărgăritescu
- Department Surgery, University of Medicine and Pharmacy of Craiova, Romania
| | - M V Şurlin
- Department Surgery, University of Medicine and Pharmacy of Craiova, Romania
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Shao XD, Qi XS, Guo XZ. Esophageal Stent for Refractory Variceal Bleeding: A Systemic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2016; 2016:4054513. [PMID: 27517043 PMCID: PMC4969514 DOI: 10.1155/2016/4054513] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 06/15/2016] [Accepted: 06/20/2016] [Indexed: 12/14/2022]
Abstract
Background. Preliminary studies suggest that covered self-expandable metal stents may be helpful in controlling esophageal variceal bleeding. Aims. To evaluate the effectiveness and safety of esophageal stent in refractory variceal bleeding in a systematic review and meta-analysis. Methods. A comprehensive literature search was conducted on PubMed, EMBASE, and Cochrane Library covering the period from January 1970 to December 2015. Data were selected and abstracted from eligible studies and were pooled using a random-effects model. Heterogeneity was assessed using I (2) test. Results. Five studies involving 80 patients were included in the analysis. The age of patients ranged from 18 to 91 years. The mean duration of follow-up was 46.8 d (range, 30-60 d). The success rate of stent deployment was 96.7% (95% CI: 91.6%-99.5%) and complete response to esophageal stenting was in 93.9% (95% CI: 82.2%-99.6%). The incidence of rebleeding was 13.2% (95% CI: 1.8%-32.8%) and the overall mortality was 34.5% (95% CI: 24.8%-44.8%). Most of patients (87.4%) died from hepatic or multiple organ failure, and only 12.6% of patients died from uncontrolled bleeding. There was no stent-related complication reported and the incidence of stent migration was 21.6% (95% CI: 4.7%-46.1%). Conclusion. Esophageal stent may be considered in patients with variceal bleeding refractory to conventional therapy.
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Affiliation(s)
- Xiao-Dong Shao
- Department of Gastroenterology, General Hospital of Shenyang Military Area Command, Shenyang 110016, China
| | - Xing-Shun Qi
- Department of Gastroenterology, General Hospital of Shenyang Military Area Command, Shenyang 110016, China
| | - Xiao-Zhong Guo
- Department of Gastroenterology, General Hospital of Shenyang Military Area Command, Shenyang 110016, China
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Kumar A, Jha SK, Mittal VV, Sharma P, Sharma BC, Sarin SK. Addition of Somatostatin After Successful Endoscopic Variceal Ligation Does not Prevent Early Rebleeding in Comparison to Placebo: A Double Blind Randomized Controlled Trial. J Clin Exp Hepatol 2015; 5:204-12. [PMID: 26628838 PMCID: PMC4632096 DOI: 10.1016/j.jceh.2015.06.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 06/07/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Efficacy of endoscopic sclerotherapy in controlling acute variceal bleeding is significantly improved when vasoactive drug is added. Endoscopic variceal ligation (EVL) is superior to sclerotherapy. Whether efficacy of EVL will also improve with addition of somatostatin is not known. We compared EVL plus somatostatin versus EVL plus placebo in control of acute variceal bleeding. METHODS Consecutive cirrhotic patients with acute esophageal variceal bleeding were enrolled. After emergency EVL, patients were randomized to receive either somatostatin (250 mcg/hr) or placebo infusion. Primary endpoint was treatment failure within 5 days. Treatment failure was defined as fresh hematemesis ≥2 h after start of therapy, or a 3 gm drop in Hb, or death. RESULTS 61 patients were enrolled (EVL plus somatostatin group, n = 31 and EVL plus placebo group, n = 30). The baseline characteristics were similar. Within the initial 5-day period, the frequency of treatment failure was similar in both the groups (EVL plus somatostatin group 8/31 [26%] versus EVL plus placebo group 7/30 [23%]; P = 1.000). The mortality was also similar in the two groups (3/31 [10%] vs. 3/30 [10%]; P = 1.000). Baseline HVPG ≥19 mm Hg and active bleeding at index endoscopy were independent predictors of treatment failure. CONCLUSIONS Addition of somatostatin infusion to EVL therapy does not offer any advantage in control of acute variceal bleeding or reducing mortality. The reason for this may be its failure to maintain sustained reduction in portal pressure for five days. Active bleeding at index endoscopy and high baseline HVPG should help choose early alternative treatment options. Trial registered with ClincalTrials.gov vide NCT01267669.
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Affiliation(s)
- Ashish Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), New Delhi, India,Department of Gastroenterology, G B Pant Hospital, University of Delhi, New Delhi, India,Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India,Address for correspondence: Ashish Kumar, Associate Professor, Department of Gastroenterology & Hepatology, Ganga Ram Institute for Postgraduate Medical Education and Research (GRIPMER), Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India.
| | - Sanjeev K. Jha
- Department of Gastroenterology, G B Pant Hospital, University of Delhi, New Delhi, India
| | - Vibhu V. Mittal
- Department of Gastroenterology, G B Pant Hospital, University of Delhi, New Delhi, India
| | - Praveen Sharma
- Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), New Delhi, India,Department of Gastroenterology, G B Pant Hospital, University of Delhi, New Delhi, India,Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India
| | - Barjesh C. Sharma
- Department of Gastroenterology, G B Pant Hospital, University of Delhi, New Delhi, India
| | - Shiv K. Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), New Delhi, India,Department of Gastroenterology, G B Pant Hospital, University of Delhi, New Delhi, India
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Zhuang B, Li Z, Pang J, Li W, Huang P, Wang J, Zhou Y, Lin Q, Zhou Q, Ye X, Ye H, Liu Y, Zhang LM, Chen R. Nanocomplexation of thrombin with cationic amylose derivative for improved stability and hemostatic efficacy. Int J Nanomedicine 2015; 10:939-47. [PMID: 25673989 PMCID: PMC4321601 DOI: 10.2147/ijn.s72553] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
As a topical hemostatic agent, thrombin has wide application for many surgical treatments. However, native thrombin always suffers from its physical and chemical instabilities. In this work, a nanocomplexation strategy was developed for modifying the stability and hemostatic efficacy of thrombin, in which a water-soluble cationic amylose derivative containing poly(l-lysine) dendrons was prepared by a click reaction and then used to complex thrombin in an aqueous system. For resultant thrombin nanocomplexes, their morphology and particle size distribution were investigated. Their stabilities were studied in terms of activity retention percentages under different storage time, pH values, and illumination time. In addition, their ability to achieve in vitro fibrinogen and blood coagulation were evaluated. Via a rat hepatic hemorrhage model and a rat iliac artery hemorrhage model, these thrombin nanocomplexes were confirmed to have good tissue biocompatibility and in vivo hemostatic effectiveness.
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Affiliation(s)
- Baoxiong Zhuang
- Department of Hepato-Pancreato-Billiary Surgery, Department of Medical Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Zhihua Li
- Department of Hepato-Pancreato-Billiary Surgery, Department of Medical Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Jiadong Pang
- DSAPM Lab and PCFM Lab, Institute of Polymer Science, Department of Polymer and Materials Science, School of Chemistry and Chemical Engineering, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Wenbin Li
- Department of Hepato-Pancreato-Billiary Surgery, Department of Medical Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Pinbo Huang
- Department of Hepato-Pancreato-Billiary Surgery, Department of Medical Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Jie Wang
- Department of Hepato-Pancreato-Billiary Surgery, Department of Medical Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Yu Zhou
- Department of Hepato-Pancreato-Billiary Surgery, Department of Medical Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Qing Lin
- Department of Hepato-Pancreato-Billiary Surgery, Department of Medical Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Quanbo Zhou
- Department of Hepato-Pancreato-Billiary Surgery, Department of Medical Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Xiao Ye
- Department of Hepato-Pancreato-Billiary Surgery, Department of Medical Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Huilin Ye
- Department of Hepato-Pancreato-Billiary Surgery, Department of Medical Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Yimin Liu
- Department of Hepato-Pancreato-Billiary Surgery, Department of Medical Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Li-Ming Zhang
- DSAPM Lab and PCFM Lab, Institute of Polymer Science, Department of Polymer and Materials Science, School of Chemistry and Chemical Engineering, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Rufu Chen
- Department of Hepato-Pancreato-Billiary Surgery, Department of Medical Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
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Abstract
Acute variceal bleeding (AVB) is a milestone event for patients with portal hypertension. Esophageal varices bleed because of an increase in portal pressure that causes the variceal wall to rupture. AVB in a patient with cirrhosis and portal hypertension is associated with significant morbidity and mortality. The initial management of these patients includes proper resuscitation, antibiotic prophylaxis, pharmacologic therapy with vasoconstrictors, and endoscopic therapy. Intravascular fluid management, timing of endoscopy, and endoscopic technique are key in managing these patients. This article reviews the current endoscopic hemostatic strategies for patients with AVB.
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MELD-Na: effective in predicting rebleeding in cirrhosis after cessation of esophageal variceal hemorrhage by endoscopic therapy. J Clin Gastroenterol 2014; 48:870-7. [PMID: 24296420 DOI: 10.1097/mcg.0000000000000043] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS There is no study verifying the predictive value of model for end-stage liver disease and sodium (MELD-Na) for rebleeding and its associated mortality in cirrhotic patients after cessation of acute esophageal variceal hemorrhage (AVH) by endoscopic therapy. This study aimed to determine the predictive value of MELD-Na by comparing with MELD or Child-Turcotte-Pugh (CTP) scores. PATIENTS AND METHODS Consecutive adult cirrhotic patients after cessation of AVH by endoscopic therapy (endoscopic variceal ligation or sclerotherapy injections) within 48 hours of admission admitted from 2003 to 2012 were analyzed. The clinical characteristics and laboratory data at admission were documented, based on which MELD-Na, MELD, and CTP scores were calculated. RESULTS Among 429 patients who had complete control of AVH, 97 patients (22.6%) suffered esophageal variceal rebleeding within 3 months and 206 patients (48.0%) within 1 year. Fifty-three patients (12.4%) died within 3 months and 98 patients (22.8%) within 1 year from rebleeding. The area under receiver operator characteristics curve of the MELD-Na score for predicting rebleeding and its associated mortality was significantly higher than that of the MELD and the CTP score (rebleeding: 0.83 vs. 0.77 vs. 0.69 for 3 months and 0.85 vs. 0.80 vs. 0.65 for 1 year, P<0.05; mortality: 0.81 vs. 0.75 vs. 0.66 for 3 months and 0.82 vs. 0.78 vs. 0.68 for 1 year, P<0.05). CONCLUSIONS The MELD-Na score is clinically useful in predicting 3-month and 1-year rebleeding and its associated mortality in cirrhotic patients after cessation of AVH by endoscopic therapy.
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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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Jairath V, Rehal S, Logan R, Kahan B, Hearnshaw S, Stanworth S, Travis S, Murphy M, Palmer K, Burroughs A. Acute variceal haemorrhage in the United Kingdom: patient characteristics, management and outcomes in a nationwide audit. Dig Liver Dis 2014; 46:419-26. [PMID: 24433997 DOI: 10.1016/j.dld.2013.12.010] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 12/03/2013] [Accepted: 12/07/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite advances in treatment, acute variceal haemorrhage remains life-threatening. AIM To describe contemporary characteristics, management and outcomes of patients with cirrhosis and acute variceal haemorrhage and risk factors for rebleeding and mortality. METHODS Multi-centre clinical audit conducted in 212 UK hospitals. RESULTS In 526 cases of acute variceal haemorrhage, 66% underwent endoscopy within 24h with 64% (n=339) receiving endoscopic therapy. Prior to endoscopy, 57% (n=299) received proton pump inhibitors, 44% (n=232) vasopressors and 27% (n=144) antibiotics. 73% (n=386) received red cell transfusion, 35% (n=184) fresh frozen plasma and 14% (n=76) platelets, with widely varying transfusion thresholds. 26% (n=135) experienced further bleeding and 15% (n=80) died by day 30. The Model for End Stage Liver Disease score was the best predictor of mortality (area under the receiver operating curve=0.74, P<0.001). Neither the clinical nor full Rockall scores were useful predictors of outcome. Coagulopathy was strongly associated with rebleeding (odds ratio 2.23, 95% CI 1.22-4.07, P=0.01, up to day 30) and mortality (odds ratio 3.06, 95% CI 1.29-7.26, P=0.01). CONCLUSIONS Although mortality has improved following acute variceal haemorrhage, rebleeding rates remain appreciably high. There are notable deficiencies in the use of vasopressors and endoscopic therapy. More work is needed to understand the optimum transfusion strategies. Better risk stratification tools are required to identify patients needing more intensive support.
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Affiliation(s)
- Vipul Jairath
- NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK; Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK.
| | | | - Richard Logan
- Division of Epidemiology and Public Health & Nottingham Digestive Disease Centre, University of Nottingham, UK
| | | | | | | | - Simon Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - Michael Murphy
- NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK
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Grözinger G, Wiesinger B, Schmehl J, Kramer U, Mehra T, Grosse U, König C. Portosystemic pressure reduction achieved with TIPPS and impact of portosystemic collaterals for the prediction of the portosystemic-pressure gradient in cirrhotic patients. Eur J Radiol 2013; 82:2258-64. [DOI: 10.1016/j.ejrad.2013.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 07/27/2013] [Accepted: 08/09/2013] [Indexed: 02/07/2023]
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Zakaria MS, Hamza IM, Mohey MA, Hubamnn RG. The first Egyptian experience using new self-expandable metal stents in acute esophageal variceal bleeding: pilot study. Saudi J Gastroenterol 2013; 19:177-181. [PMID: 23828748 PMCID: PMC3745660 DOI: 10.4103/1319-3767.114516] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 03/26/2013] [Indexed: 12/13/2022] Open
Abstract
UNLABELLED BACKGROUND / AIM: Balloon tamponade has been widely available in emergency situations of acute variceal bleeding. To lessen the complications of Balloon tamponade, a new special type of stent for exclusive use in acute variceal bleeding has been developed. This study aims to investigate the effectiveness and safety of the new self-expandable metal stents (SEMS) in the initial control of acute variceal bleeding. We also hypothesized that using SEMS can bridge the acute bleeding episode converting endoscopic management by sclerotherapy or band ligation to an elective procedure. PATIENTS AND METHODS Twenty patients with acute variceal bleeding were included in the study and 16 of them were allocated to receive stent treatment. RESULTS Stent deployment was successful in 15 of 16 patients (93.75%). Technical errors were reported in 3 (18.75%) patients. Initial control of variceal bleeding was reported in 14 (out of 16) (87.5%) patients. The mean duration of the procedure was 10 (±6) min. Mortality was reported in 4 (25.0%) patients. CONCLUSION SEMS is a safe and effective mean to control acute variceal bleeding.
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Affiliation(s)
| | - Iman M. Hamza
- Department of Endemic Medicine, Cairo University, Cairo, Egypt
| | | | - Rainer G. Hubamnn
- Department of Internal Medicine, Allgemeines Krankenhaus der Stadt Linz, Linz, Austria
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Predictors of early re-bleeding and mortality after acute variceal haemorrhage. Arab J Gastroenterol 2013; 14:63-7. [PMID: 23820503 DOI: 10.1016/j.ajg.2013.05.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 03/26/2013] [Accepted: 05/07/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND STUDY AIMS Oesophageal variceal haemorrhage is a devastating complication of portal hypertension (PHT). This study was done to determine the risk factors for re-bleeding within 5 days and mortality up to 6 weeks in patients with cirrhosis and acute variceal haemorrhage (AVH). PATIENTS AND METHODS The study included 100 patients presenting with haematemesis and/or melena due to bleeding varices. All patients were subjected to full clinical assessment, routine laboratory investigations, calculation of the Child-Turcotte-Pugh (CTP) and model for end stage liver disease (MELD) scores, abdominal ultrasound and emergency upper gastrointestinal endoscopy. The patients were followed up since admission and up to 6 weeks for the occurrence of rebleeding (in the first 5days) and mortality (up to 6weeks) after the acute attack. RESULTS The patients were grouped into three groups: Group I: patients who survived more than 6 weeks following endoscopic management and did not rebleed during this period (75 patients). Group II: patients who died within 6 weeks of AVH (10 patients). Group III: patients who rebled or died within 5 days of AVH (15 patients). The mean MELD score was significantly higher in group II (18.29±0.66) and group III (18.73±0.89) as compared to group I (12.8±2.1) (p=0.001). Active bleeding at time of endoscopy was present in 8% of group I, 70% of group II and 53.3% of group III and the difference was statistically significant (p=0.003), while white nipple sign was present in 10.6% of group I, 90% of group II and 73.3% of group III and the difference was statistically significant (p=0.05). In conclusion high MELD score (>18), presence of active bleeding or white nipple sign at time of endoscopy are significant predictors for early rebleeding and mortality after AVH.
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Ozier Y, Cadic A, Dovergne A. Prise en charge des troubles de l’hémostase chez l’insuffisant hépatique. Transfus Clin Biol 2013; 20:249-54. [DOI: 10.1016/j.tracli.2013.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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27
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Austrian consensus on the definition and treatment of portal hypertension and its complications (Billroth II). Wien Klin Wochenschr 2013; 125:200-19. [PMID: 23579878 DOI: 10.1007/s00508-013-0337-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Accepted: 02/15/2013] [Indexed: 12/12/2022]
Abstract
In November 2004, the Austrian Society of Gastroenterology and Hepatology (ÖGGH) held for the first time a consensus meeting on the definitions and treatment of portal hypertension and its complications in the Billroth-Haus in Vienna, Austria (Billroth I-Meeting). This meeting was preceded by a meeting of international experts on portal hypertension with some of the proponents of the Baveno consensus conferences (http://www.oeggh.at/videos.asp). The consensus itself is based on the Baveno III consensus with regard to portal hypertensive bleeding and the suggestions of the International Ascites Club regarding the treatment of ascites. Those statements were modified by new knowledge derived from the recent literature and also by the current practice of medicine as agreed upon by the participants of the consensus meeting. In October 2011, the ÖGGH organized the second consensus meeting on portal hypertension and its complications in Vienna (Billroth II-Meeting). The Billroth II-Guidelines on the definitions and treatment of portal hypertension and its complications take into account the developments of the last 7 years, including the Baveno-V update and several key publications.
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Chen PH, Chen WC, Hou MC, Liu TT, Chang CJ, Liao WC, Su CW, Wang HM, Lin HC, Lee FY, Lee SD. Delayed endoscopy increases re-bleeding and mortality in patients with hematemesis and active esophageal variceal bleeding: a cohort study. J Hepatol 2012; 57:1207-13. [PMID: 22885718 DOI: 10.1016/j.jhep.2012.07.038] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 07/11/2012] [Accepted: 07/18/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Active bleeding is a poor prognostic indicator in patients with acute esophageal variceal bleeding. This study aimed at determining indicators of 6-week re-bleeding and mortality in patients with "active" esophageal variceal bleeding, particularly emphasizing the presenting symptoms and timing of endoscopy to define the treatment strategy. METHODS From July 2005 to December 2009, cirrhotic patients with endoscopy-proven active esophageal variceal bleeding were evaluated. Cox proportional hazards regression analysis was used to determine the indicators of 6-week re-bleeding and mortality. Outcome comparisons were performed by Kaplan-Meier method and log rank test. RESULTS In 101 patients, the overall 6-week and 3-month re-bleeding rates were 25.7% (n=26) and 29.7% (n=30), respectively. The overall 6-week and 3-month mortality was 31.7% (n=32) and 38.6% (n=39), respectively. Door-to-endoscopy time (hr), MELD score, and portal vein thrombosis were indicators of 6-week re-bleeding, while hematemesis upon arrival, MELD score, and hepatocellular carcinoma were indicators of 6-week mortality. Overall mortality was poorer in hematemesis than in non-hematemesis patients (39.7% vs. 10.7%, p=0.007). In hematemesis patients, 6-week re-bleeding rate (18.9% vs. 38.9%, p=0.028) and mortality (27% vs. 52.8%, p=0.031) were lower in those with early (≤ 12 h) than delayed (>12h) endoscopy. In non-hematemesis patients, early and delayed endoscopy had no difference on 6-week re-bleeding rate (17.6% vs. 18.2%, p=0.944) and mortality (11.8% vs. 9.1%, p=0.861). CONCLUSIONS It is likely that early endoscopy (≤ 12 h) is associated with a better outcome in hematemesis patients, but a randomized trial with larger case numbers is required before making a firm conclusion.
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Affiliation(s)
- Ping-Hsien Chen
- Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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Amitrano L, Guardascione MA, Manguso F, Bennato R, Bove A, DeNucci C, Lombardi G, Martino R, Menchise A, Orsini L, Picascia S, Riccio E. The effectiveness of current acute variceal bleed treatments in unselected cirrhotic patients: refining short-term prognosis and risk factors. Am J Gastroenterol 2012; 107:1872-1878. [PMID: 23007003 DOI: 10.1038/ajg.2012.313] [Citation(s) in RCA: 133] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The mortality from esophageal variceal hemorrhage in liver cirrhosis patients remains approximately 15-20%. Predictors of short-term outcomes, such as the hepatic venous pressure gradient, are often unavailable in the acute setting. Clinical variables seem to have a similar predictive performance, but some variables including active bleeding during endoscopy have not been reevaluated after the utilization of endoscopic banding as endoscopic procedure. In addition, patients with severe liver failure are often excluded from clinical trials. The aim of this study was to prospectively reevaluate the risk factors affecting a 5-day failure after acute variceal bleeding in unselected cirrhotic patients, managed with the current standard treatment using vasoactive drugs, band ligation, and antibiotics. METHODS One hundred and eighty five patients with liver cirrhosis and variceal bleeding admitted from January 2010 to July 2011 were evaluated. RESULTS Hepatocellular carcinoma was present in 28.1% of cases and portal vein thrombosis (PVT) was present in 17.3% of cases. Band ligation was feasible in 92.4% of cases. Five-day failure occurred in 16.8% of cases; 12 patients (6.5%) experienced failure to control bleeding or early rebleeding, and 66.7% of patients died within 5 days. The overall 5-day mortality rate was 14.6%. By multivariate analysis, we determined that Child-Pugh class C, a white blood cell count over 10 × 10(9)/l, and the presence of PVT were the only independent predictors of the 5-day failure. CONCLUSIONS The prognosis of a consistent group of liver cirrhosis patients with variceal bleeding remains poor. The current treatment is highly effective in controlling variceal bleeding, but mortality is related mainly to the severity of liver failure.
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Affiliation(s)
- Lucio Amitrano
- Gastroenterology Unit, AORN A. Cardarelli, Naples, Italy.
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Poza Cordon J, Froilan Torres C, Burgos García A, Gea Rodriguez F, Suárez de Parga JM. Endoscopic management of esophageal varices. World J Gastrointest Endosc 2012; 4:312-22. [PMID: 22816012 PMCID: PMC3399010 DOI: 10.4253/wjge.v4.i7.312] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 05/10/2012] [Accepted: 07/01/2012] [Indexed: 02/05/2023] Open
Abstract
The rupture of gastric varices results in variceal hemorrhage, which is one the most lethal complications of cirrhosis. Endoscopic therapies for varices aim to reduce variceal wall tension by obliteration of the varix. The two principal methods available for esophageal varices are endoscopic sclerotherapy (EST) and band ligation (EBL). The advantages of EST are that it is cheap and easy to use, and the injection catheter fits through the working channel of a diagnostic gastroscope. Endoscopic variceal ligation obliterates varices by causing mechanical strangulation with rubber bands. The following review aims to describe the utility of EBL and EST in different situations, such as acute bleeding, primary and secondary prophylaxis
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Affiliation(s)
- Joaquin Poza Cordon
- Joaquin Poza Cordon, Consuelo Froilan Torres, Aurora Burgos García, Francisco Gea Rodriguez, Jose Manuel Suárez de Parga, Hospital Universitario la Paz, 28046 Madrid, Spain
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Bosch J, Abraldes JG, Albillos A, Aracil C, Bañares R, Berzigotti A, Calleja JL, de la Peña J, Escorsell A, García-Pagán JC, Genescà J, Hernández-Guerra M, Ripoll C, Planas R, Villanueva C. Hipertensión portal: recomendaciones para su evaluación y tratamiento. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 35:421-50. [DOI: 10.1016/j.gastrohep.2012.02.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 02/15/2012] [Indexed: 12/16/2022]
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Chang CJ, Hou MC, Liao WC, Lee FY, Lin HC, Lee SD. Risk factors of early re-bleeding and mortality in patients with ruptured gastric varices and concomitant hepatocellular carcinoma. J Gastroenterol 2012; 47:531-9. [PMID: 22223176 DOI: 10.1007/s00535-011-0518-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 11/23/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND Most studies of prognostic factors after a variceal hemorrhage have either excluded or only involved a few patients with bleeding from gastric variceal bleeding (GVB) and hepatocellular carcinoma (HCC). We have investigated risk factors for early re-bleeding and mortality in patients with GVB and HCC and attempted to determine the effect of HCC characteristics on portal hypertension-related re-bleeding. METHODS This was a retrospective study of data complied on 109 patients with GVB and concomitant HCC in prospectively collected databases. HCC patients were divided into those with recently developed HCC (rd-HCC; HCC diagnosed within 2 months before or after GVB) and those with previously diagnosed HCC (pd-HCC; HCC diagnosed 2 months before GVB). Predictors for 5-day portal hypertension re-bleeding, 30-day and 5-year mortality were analyzed. RESULTS The cumulative 5-day re-bleeding rates in the rd-HCC group versus the pd-HCC group was 23.5 versus 10.0% (P = 0.019). rd-HCC, a high model for end-stage liver disease (MELD) score (>15), and active bleeding were predictors for 5-day re-bleeding. The cumulative 30-day and 5-year survival for the rd-HCC group versus the pd-HCC group were 76.0 versus 76.5% (P = 0.980) and 16.0 versus 4.7% (P = 0.099), respectively. Advanced tumor stage, high MELD score (>15), and elevated alanine transaminase were predictors of mortality. CONCLUSION Patients with GVB and concomitant HCC are associated with poor outcomes. Recently developed HCC, a high MELD score, active bleeding, advanced tumor stage, and elevated alanine transaminase are poor prognostic predictors. Apart from pharmacological and endoscopic treatments for GVB, careful investigation of a recently developed HCC in these patients is mandatory.
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Affiliation(s)
- Chen-Jung Chang
- School of Medicine, National Yang Ming University, Taipei, Taiwan
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Kalambokis GN, Mouzaki A, Rodi M, Tsianos EV. Rifaximin improves thrombocytopenia in patients with alcoholic cirrhosis in association with reduction of endotoxaemia. Liver Int 2012; 32:467-75. [PMID: 22098272 DOI: 10.1111/j.1478-3231.2011.02650.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 08/25/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Thrombocytopenia is a major haematological disorder of cirrhosis with unclear pathogenesis. Endotoxaemia resulting from intestinal bacterial overgrowth could reduce platelet counts directly or through cytokine release. AIMS To correlate endotoxaemia with platelet counts and study the effects of intestinal decontamination with rifaximin on thrombocytopenia in relation to changes in endotoxin and cytokine concentrations in patients with alcoholic cirrhosis. METHODS Platelet counts, plasma endotoxin levels and serum interleukin-1 (IL-1), interleukin-6 (IL-6) and tumour necrosis factor-α (TNF-α) levels were measured in 23 thrombocytopenic cirrhotic patients (platelet count<150 000/μl) before and after 4-week treatment with rifaximin 1200 mg/d (n = 13) or no treatment (n = 10) and at baseline in 10 cirrhotic patients without thrombocytopenia; spleen size was measured at baseline in all patients. RESULTS Endotoxin and IL-6 levels were significantly higher in patients with thrombocytopenia than in those without thrombocytopenia (2.76 ± 0.69 vs. 0.64 ± 0.09 EU/ml; P < 0.001 and 24.26 ± 3.38 vs. 2.66 ± 0.74 pg/ml; P = 0.001 respectively). Platelet counts were inversely correlated with endotoxin levels (r = -0.589; P = 0.003), Child-Pugh score (r = -0.625; P = 0.001), IL-6 levels (r = -0.464; P = 0.02) and spleen size (r = -0.455; P = 0.02) in patients with thrombocytopenia. Following rifaximin, platelet counts increased significantly (83 100 ± 9700 vs. 99 600 ± 11 200/μl; P = 0.006) in line with significant reductions in endotoxin (1.28 ± 0.41 vs. 2.54 ± 0.86 EU/ml; P = 0.005), IL-1 (3.1 ± 0.5 vs. 4.4 ± 1.2 pg/ml; P = 0.04), IL-6 (12.8 ± 2.5 vs. 21.1 ± 4.2 pg/ml; P = 0.01) and TNF-α (3.6 ± 1.3 vs. 5.8 ± 1.7; P = 0.02) levels. Platelet count changes were correlated with the changes in endotoxin (r = 0.573; P = 0.04), TNF-α (r = 0.554; P = 0.05) and IL-6 (r = 0.495; P = 0.07) levels. CONCLUSIONS Rifaximin improves cirrhosis-related thrombocytopenia and this could be related with the reduction of endotoxaemia.
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Abstract
Cirrhosis is the leading cause of portal hypertension worldwide, with the development of bleeding gastroesophageal varices being one of the most life-threatening consequences. Endoscopy plays an indispensible role in the diagnosis, staging, and prophylactic or active management of varices. With the expected future refinements in endoscopic technology, capsule endoscopy may one day replace traditional gastroscopy as a diagnostic modality, whereas endoscopic ultrasound may more precisely guide interventional therapy for gastric varices.
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Hsu YC, Chung CS, Wang HP. Application of endoscopy in improving survival of cirrhotic patients with acute variceal hemorrhage. Int J Hepatol 2011; 2011:893973. [PMID: 21994875 PMCID: PMC3170849 DOI: 10.4061/2011/893973] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 05/12/2011] [Indexed: 12/21/2022] Open
Abstract
Playing a central role in the modern multidisciplinary management of acute gastroesophageal variceal hemorrhage, endoscopy is essential to stratify patient at risk, control active hemorrhage, and prevent first as well as recurrent bleeding. Before endoscopic procedure, antibiotic prophylaxis along with vasoactive medication is now routine practice. Intravenous erythromycin effectively cleanses stomach and may improve the quality of endoscopy. The timing of endoscopy should be on an urgent basis as delay for more than 15 hours after presentation is associated with mortality. Active variceal bleeding on endoscopy in a patient with hepatic decompensation heralds poor prognosis and mandates consideration of aggressive strategy with early portosystemic shunting. Band ligation has become the preferred modality to control and prevent bleeding from esophageal varices, although occasionally sclerotherapy may still be used to achieve hemostasis. Addition of pharmacotherapy with nonselective beta blockade to endoscopic ligation has become the current standard of care in the setting of secondary prophylaxis but remains controversial with inconsistent data for the purpose of primary prophylaxis. Gastric varices extending from esophagus may be treated like esophageal varices, whereas variceal obliteration by tissue glue is the endoscopic therapy of choice to control and prevent bleeding from fundic and isolated gastric varices.
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Affiliation(s)
- Yao-Chun Hsu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung 824, Taiwan
| | - Chen-Shuan Chung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei 220, Taiwan
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University College of Medicine, National Taiwan University Hospital, Taipei 100, Taiwan,Department of Internal Medicine, National Taiwan University Hospital, 7, Chung-Shan South Road, Taipei 100, Taiwan,*Hsiu-Po Wang:
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Abstract
SummaryChronic liver disease is increasingly prevalent and, as the population ages, geriatricians will see an increasing burden. We present an overview of the investigation and management of older adults with chronic parenchymal liver disease and highlight the potential roles of transjugular intrahepatic portosytemic shunts and orthotopic liver transplantation.
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Rössle M, Grandt D. Early transjugular intrahepatic portosystemic shunt in patients with cirrhosis and variceal bleeding. Hepatology 2010; 52:1847-50. [PMID: 21038419 DOI: 10.1002/hep.23982] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Martin Rössle
- Praxiszentrum and University Hospital Freiberg, Germany
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38
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39
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Hsu YC, Liou JM, Chung CS, Tseng CH, Lin TL, Chen CC, Wu MS, Wang HP. Early risk stratification with simple clinical parameters for cirrhotic patients with acute upper gastrointestinal bleeding. Am J Emerg Med 2010; 28:884-90. [DOI: 10.1016/j.ajem.2009.04.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2009] [Revised: 04/24/2009] [Accepted: 04/24/2009] [Indexed: 12/12/2022] Open
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Augustin S, González A, Genescà J. Acute esophageal variceal bleeding: Current strategies and new perspectives. World J Hepatol 2010; 2:261-74. [PMID: 21161008 PMCID: PMC2998973 DOI: 10.4254/wjh.v2.i7.261] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Revised: 06/14/2010] [Accepted: 06/21/2010] [Indexed: 02/06/2023] Open
Abstract
Management of acute variceal bleeding has greatly improved over recent years. Available data indicates that general management of the bleeding cirrhotic patient by an experienced multidisciplinary team plays a major role in the final outcome of this complication. It is currently recommended to combine pharmacological and endoscopic therapies for the initial treatment of the acute bleeding. Vasoactive drugs (preferable somatostatin or terlipressin) should be started as soon as a variceal bleeding is suspected (ideally during transfer to hospital) and maintained afterwards for 2-5 d. After stabilizing the patient with cautious fluid and blood support, an emergency diagnostic endoscopy should be done and, as soon as a skilled endoscopist is available, an endoscopic variceal treatment (ligation as first choice, sclerotherapy if endoscopic variceal ligation not feasible) should be performed. Antibiotic prophylaxis must be regarded as an integral part of the treatment of acute variceal bleeding and should be started at admission and maintained for at least 7 d. In case of failure to control the acute bleeding, rescue therapies should be immediately started. Shunt therapies (especially transjugular intrahepatic portosystemic shunt) are very effective at controlling treatment failures after an acute variceal bleeding. Therapeutic developments and increasing knowledge in the prognosis of this complication may allow optimization of the management strategy by adapting the different treatments to the expected risk of complications for each patient in the near future. Theoretically, this approach would allow the initiation of early aggressive treatments in high-risk patients and spare low-risk individuals unnecessary procedures. Current research efforts will hopefully clarify this hypothesis and help to further improve the outcomes of the severe complication of cirrhosis.
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Affiliation(s)
- Salvador Augustin
- Salvador Augustin, Antonio González, Joan Genescà, Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona 08035, Spain
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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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García-Pagán JC, Caca K, Bureau C, Laleman W, Appenrodt B, Luca A, Abraldes JG, Nevens F, Vinel JP, Mössner J, Bosch J. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 2010; 362:2370-9. [PMID: 20573925 DOI: 10.1056/nejmoa0910102] [Citation(s) in RCA: 833] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients with cirrhosis in Child-Pugh class C or those in class B who have persistent bleeding at endoscopy are at high risk for treatment failure and a poor prognosis, even if they have undergone rescue treatment with a transjugular intrahepatic portosystemic shunt (TIPS). This study evaluated the earlier use of TIPS in such patients. METHODS We randomly assigned, within 24 hours after admission, a total of 63 patients with cirrhosis and acute variceal bleeding who had been treated with vasoactive drugs plus endoscopic therapy to treatment with a polytetrafluoroethylene-covered stent within 72 hours after randomization (early-TIPS group, 32 patients) or continuation of vasoactive-drug therapy, followed after 3 to 5 days by treatment with propranolol or nadolol and long-term endoscopic band ligation (EBL), with insertion of a TIPS if needed as rescue therapy (pharmacotherapy-EBL group, 31 patients). RESULTS During a median follow-up of 16 months, rebleeding or failure to control bleeding occurred in 14 patients in the pharmacotherapy-EBL group as compared with 1 patient in the early-TIPS group (P=0.001). The 1-year actuarial probability of remaining free of this composite end point was 50% in the pharmacotherapy-EBL group versus 97% in the early-TIPS group (P<0.001). Sixteen patients died (12 in the pharmacotherapy-EBL group and 4 in the early-TIPS group, P=0.01). The 1-year actuarial survival was 61% in the pharmacotherapy-EBL group versus 86% in the early-TIPS group (P<0.001). Seven patients in the pharmacotherapy-EBL group received TIPS as rescue therapy, but four died. The number of days in the intensive care unit and the percentage of time in the hospital during follow-up were significantly higher in the pharmacotherapy-EBL group than in the early-TIPS group. No significant differences were observed between the two treatment groups with respect to serious adverse events. CONCLUSIONS In these patients with cirrhosis who were hospitalized for acute variceal bleeding and at high risk for treatment failure, the early use of TIPS was associated with significant reductions in treatment failure and in mortality. (Current Controlled Trials number, ISRCTN58150114.)
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Affiliation(s)
- Juan Carlos García-Pagán
- Hepatic Hemodynamic Laboratory, Liver Unit, Institut de Malalties Digestives i Metaboliques, University of Barcelona, Barcelona, Spain.
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Abstract
Acute variceal bleeding is one of the most serious and feared complications of patients with portal hypertension. The most common cause of portal hypertension is advanced liver disease. Patients with esophageal and gastric varices may bleed because of a progressive increase in portal pressure that causes them to grow and finally rupture. This article will review the current management strategies for acute variceal bleeding with emphasis on endoscopic therapy for the acute episode.
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Affiliation(s)
- Andrés Cárdenas
- GI Unit / Institut Clinic de Malalties Digestives i Metaboliques, University of Barcelona, Hospital Clinic, Spain.
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Wright G, Lewis H, Hogan B, Burroughs A, Patch D, O'Beirne J. A self-expanding metal stent for complicated variceal hemorrhage: experience at a single center. Gastrointest Endosc 2010; 71:71-8. [PMID: 19879564 DOI: 10.1016/j.gie.2009.07.028] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Accepted: 07/15/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Refractory variceal bleeding is associated with a high mortality. Existing salvage techniques such as transjugular intrahepatic portosystemic shunt (TIPS) and balloon tamponade (BT) have important limitations and may not be appropriate for all patients. OBJECTIVE To evaluate the safety and efficacy of a novel removable self-expanding metal stent in the management of refractory variceal bleeding. DESIGN Case series. SETTING Tertiary referral liver center. PATIENTS Ten patients with variceal hemorrhage with contraindications to TIPS insertion or BT. INTERVENTIONS Insertion of a self-expanding metal stent (SX-Ella DANIS stent). MAIN OUTCOME MEASURES Survival, failure to control bleeding, and complications. RESULTS Stent insertion was successful in 9 of 10 patients. Failure to control bleeding was observed in 3 patients (2 with gastric varices), with control of bleeding in the remainder. Overall survival at 42 days was 50%. Six patients survived the acute bleeding episode and had stents removed endoscopically at a median of 9 days after insertion. One patient had a minor ulceration of the esophagus caused by stent insertion. CONCLUSIONS Insertion of the SX-Ella DANIS stent in patients with refractory variceal bleeding or complications of previous therapy is effective for the control of bleeding. Stent insertion can be achieved in the majority of patients without fluoroscopic control and without major complications. In selected patients, SX-Ella DANIS stent insertion offers an alternative to other methods of salvage such as BT and TIPS and could be considered a substitute for BT after a prospective trial.
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Affiliation(s)
- Gavin Wright
- Sheila Sherlock Liver Centre, Royal Free Hospital, London, United Kingdom
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Krige JEJ, Kotze UK, Distiller G, Shaw JM, Bornman PC. Predictive factors for rebleeding and death in alcoholic cirrhotic patients with acute variceal bleeding: a multivariate analysis. World J Surg 2009; 33:2127-35. [PMID: 19672651 DOI: 10.1007/s00268-009-0172-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Bleeding from esophageal varices is a leading cause of death in alcoholic cirrhotic patients. The aim of the present single-center study was to identify risk factors predictive of variceal rebleeding and death within 6 weeks of initial treatment. METHODS Univariate and multivariate analyses were performed on 310 prospectively documented alcoholic cirrhotic patients with acute variceal hemorrhage (AVH) who underwent 786 endoscopic variceal injection treatments between January 1984 and December 2006. All injections were administered during the first 6 weeks after the patients were treated for their first variceal bleed. RESULTS Seventy-five (24.2%) patients experienced a rebleed, 38 within 5 days of the initial treatment and 37 within 6 weeks of their initial treatment. Of the 15 variables studied and included in a multivariate analysis using a logistic regression model, a bilirubin level >51 mmol/l and transfusion of >6 units of blood during the initial hospital admission were predictors of variceal rebleeding within the first 6 weeks. Seventy-seven (24.8%) patients died, 29 (9.3%) within 5 days and 48 (15.4%) between 6 and 42 days after the initial treatment. Stepwise multivariate logistic regression analysis showed that six variables were predictors of death within the first 6 weeks: encephalopathy, ascites, bilirubin level >51 mmol/l, international normalized ratio (INR) >2.3, albumin <25 g/l, and the need for balloon tube tamponade. CONCLUSIONS Survival was influenced by the severity of liver failure, with most deaths occurring in Child-Pugh grade C patients. Patients with AVH and encephalopathy, ascites, bilirubin levels >51 mmol/l, INR >2.3, albumin <25 g/l and who require balloon tube tamponade are at increased risk of dying within the first 6 weeks. Bilirubin levels >51 mmol/l and transfusion of >6 units of blood were predictors of variceal rebleeding.
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Affiliation(s)
- Jake E J Krige
- Department of Surgery J45OMB, Groote Schuur Hospital, Anzio Road, Observatory 7925, Cape Town, South Africa.
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Tripathi D. Therapies for bleeding gastric varices: is the fog starting to clear? Gastrointest Endosc 2009; 70:888-891. [PMID: 19879402 DOI: 10.1016/j.gie.2009.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2009] [Accepted: 06/06/2009] [Indexed: 02/08/2023]
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Endoscopy timing in acute variceal hemorrhage: perhaps not the sooner the better, but delay not justified. Am J Gastroenterol 2009; 104:2629-30; author reply 2630-1. [PMID: 19806094 DOI: 10.1038/ajg.2009.432] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Hsu YC, Chung CS, Tseng CH, Lin TL, Liou JM, Wu MS, Hu FC, Wang HP. Delayed endoscopy as a risk factor for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage. J Gastroenterol Hepatol 2009; 24:1294-9. [PMID: 19682197 DOI: 10.1111/j.1440-1746.2009.05903.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Risk factors for mortality in acute variceal hemorrhage remain incompletely understood. Whether endoscopy timing is associated with risk of mortality has not been investigated. We aimed to investigate risk factors for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage, with emphasis on endoscopy timing. METHODS Three hundred and eleven (73% male and 23% female) consecutive cirrhotic patients presenting with acute variceal hemorrhage from July 2004 to July 2007 were investigated. The univariate association of endoscopy timing as the predictor for in-hospital mortality was examined. Independent risk factors for mortality were determined by multivariate logistic regression analysis consisting of clinical, laboratory and endoscopic parameters. RESULTS Twenty-five (8.04%) patients died within admission. By plotting the receiver operating curve of endoscopy timing for mortality, we selected 15 h as the optimal cut-off point to define delayed endoscopy. Multivariate regression analysis revealed that independent risk factors predictive for in-hospital mortality included delayed endoscopy performed 15 h after admission (adjusted odds ratio [aOR] = 3.67; 95% confidence interval [CI], 1.27-10.39), every point increment of model for end-stage liver disease (MELD) score (aOR = 1.16; 95% CI, 1.07-1.25), failure of the first endoscopy (aOR = 4.36; 95% CI, 1.54-12.30) and hematemesis as the chief complaint (compared with melena, aOR = 8.66; 95% CI, 1.06-70.94). CONCLUSION Delayed endoscopy for more than 15 h, high MELD score, failure of the first endoscopy and hematemesis are independent risk factors for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage.
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Affiliation(s)
- Yao-Chun Hsu
- Division of Gastroenterology, Department of Internal Medicine, Lotung Poh-Ai Hospital, Yilan, Taiwan
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Abstract
Patients with underlying liver disease often present for non-liver-related surgery and are at risk for postoperative decompensation. Several predictive models exist to determine the risk of morbidity and mortality after surgery in such patients, but the risk depends on the severity of liver disease and also the type and urgency of the surgery. Clinicians should be cognizant of the various risk assessment tools and incorporate them into their practice when encountering patients with liver disease undergoing surgery.
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Affiliation(s)
- Shahid M Malik
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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Vlachogiannakos J, Carpenter J, Goulis J, Triantos C, Patch D, Burroughs AK. Variceal bleeding in primary biliary cirrhosis patients: a subgroup with improved prognosis and a model to predict survival after first bleeding. Eur J Gastroenterol Hepatol 2009; 21:701-7. [PMID: 19293720 DOI: 10.1097/meg.0b013e328320005f] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Varices are a late complication in primary biliary cirrhosis (PBC). However, patients without clinical jaundice do bleed from varices; whether their prognosis differs is unknown. AIM Evaluate PBC patients, particularly those with bilirubin <or=34 micromol/l at the time of bleeding. PATIENTS/RESULTS One hundred and two variceal bleeders were present (median, follow-up 20.5 months, range 0-180), who at diagnosis had: pruritus (51%), fatigue (32%) and 23 (22.5%) variceal bleeding. Histologically advanced disease was present in 96 of 100 patients (stage 3: 14 and stage 4: 82); 83 died, 24 within 6 weeks of first bleeding. At the time of bleeding, 26 patients had bilirubin <or=34 micromol/l. In this group, 24 patients were stage 4, in 13 bleeding was the first presentation of PBC and they were older (59.4 vs. 55.4 years, P=0.09), had lower alkaline phosphatase (491.5 vs. 510, P=0.03) but similar albumin values, surviving a median 61 versus 12 months, compared with the 76 patients with bilirubin >34 micromol/l (P=0.001, log rank test). Hazard ratios (95% confidence intervals) for independent predictors of mortality after bleeding were: age 1.02 (1-1.05), log10 bilirubin 4.64 (2.56-8.41), ascites 2.13 (1.29-3.51) and hepatic encephalopathy 2.72 (1.56-4.74). CONCLUSION Variceal bleeding complicates histologically advanced PBC. A distinct subgroup with near normal bilirubin and lower alkaline phosphatase first presents with variceal bleeding in 50% of cases and has a better prognosis than jaundiced PBC variceal bleeders.
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