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Li J, Chen Z, Kuai Y, Zhang F, Li H, Kong D. Endoscopic clipping combined with cyanoacrylate injection vs. transjugular intrahepatic portosystemic shunt in the treatment of isolated gastric variceal bleeding: Randomized controlled trial. Dig Endosc 2025; 37:275-284. [PMID: 39253829 DOI: 10.1111/den.14916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 08/14/2024] [Indexed: 09/11/2024]
Abstract
OBJECTIVES Although the incidence of isolated gastric varices type 1 (IGV1) bleeding is low, the condition is highly dangerous and associated with high mortality, making its treatment challenging. We aimed to compare the safety and efficacy of endoscopic clipping combined with cyanoacrylate injection (EC-CYA) vs. transjugular intrahepatic portosystemic shunt (TIPS) in treating IGV1. METHODS In a single-center, randomized controlled trial, patients with IGV1 bleeding were randomly assigned to the EC-CYA group or TIPS group. The primary end-points were gastric variceal rebleeding rates and technical success. Secondary end-points included cumulative nonbleeding rates, mortality, and complications. RESULTS A total of 156 patients between January 2019 and April 2023 were selected and randomly assigned to the EC-CYA group (n = 76) and TIPS group (n = 80). The technical success rate was 100% for both groups. The rebleeding rates were 14.5% in the EC-CYA group and 8.8% in the TIPS group, showing no significant difference (P = 0.263). Kaplan-Meier analysis revealed that the cumulative nonbleeding rates at 6, 12, 24, and 36 months for the two groups lacked statistical significance (P = 0.344). Similarly, cumulative survival rates at 12, 24, and 36 months for the two groups were not statistically significant (P = 0.916). The bleeding rates from other causes were 13.2% and 6.3% for the respective groups, showing no significant difference (P = 0.144). No instances of ectopic embolism were observed in either group. The incidence of hepatic encephalopathy (HE) in the TIPS group was statistically higher than that in the EC-CYA group (P = 0.001). CONCLUSION Both groups are effective in controlling IGV1 bleeding. Notably, EC-CYA did not result in ectopic embolism, and the incidence of HE was lower than that observed with TIPS.
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Affiliation(s)
- Jing Li
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of Gastroenterology, First People's Hospital of Hefei, Hefei, China
| | - Zhaoyi Chen
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yaxian Kuai
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Fumin Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Huixian Li
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Derun Kong
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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Xiao Q, Ma C, Wang JC, Jin J, Kong DR. Application of a virtual ruler in predicting postoperative rebleeding from esophageal varices in patients with liver cirrhosis. J Gastrointest Surg 2024; 28:1586-1590. [PMID: 38986863 DOI: 10.1016/j.gassur.2024.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/19/2024] [Accepted: 07/05/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Esophageal variceal diameter (EVD) is one of the most important predictors of variceal bleeding, as well as an important predictor of the effectiveness of endoscopic esophageal varices (EV) treatments. EVD is currently determined using visual inspection by endoscopic operators, meaning that results can vary widely between operators. This approach also means that cases unsuitable for endoscopic variceal ligation (EVL) can be complicated by postoperative hemorrhage. Thus, the purpose of this study was to explore the value of a virtual ruler (VR) in predicting rebleeding after the endoscopic treatment of EV in patients with cirrhosis. METHODS We enrolled 588 patients with cirrhosis and EV (with and without gastric varices), who were treated with EVL or endoscopic injection sclerotherapy across 3 hospitals. We categorized participants into 2 groups, a nonbleeding group and a rebleeding group, according to whether they bled again after surgery. We compared basic demographic and clinical data, laboratory tests, EVD, and treatment modalities between the 2 groups. Potential risk factors for rebleeding after EV operations were analyzed using univariate and multivariable regression analyses. Correlations between esophageal variceal rebleeding and EVD were also analyzed, as was the consistency between visual EVD estimates and EVD measured using a VR. RESULTS Child-Pugh class, albumin (ALB) levels, prothrombin time (PT), EVD (visual value), EVD (VR value), red sign, and the number of laps used for EVL showed statistically significant differences between the rebleeding and nonbleeding groups. Univariate regression analysis showed that Child-Pugh classification, ALB levels, PT, EVD (VR value), and red sign were strongly associated with rebleeding after endoscopic treatment of EV, whereas multivariable regression analysis showed that Child-Pugh classification, ALB levels, and EVD (VR value) were predictive factors for rebleeding after endoscopic treatment of EV. Differences between visual EVD estimates and VR EVD measurements were large. (Kappa value: 0.391, P < .001). However, the 2 methods showed high agreement for EVD >1 cm (87/95) CONCLUSION: EVD (VR value) can more accurately predict rebleeding rates. It can also provide a basis for selecting appropriate endoscopic treatment modalities for EV and effectively circumvent postoperative EV rebleeding.
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Affiliation(s)
- Qiang Xiao
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Anhui, China; Department of Gastroenterology, The Second People's Hospital of Hefei (Hefei Hospital Affiliated to Anhui Medical University), Anhui, China
| | - Chao Ma
- Department of Gastroenterology, Fuyang Second People's Hospital, Anhui, China
| | - Jian-Chao Wang
- Department of Gastroenterology, The First Affiliated Hospital of Bengbu Medical University, Anhui, China
| | - Jing Jin
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Anhui, China
| | - De-Run Kong
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Anhui, China.
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Wong YJ, Abraldes JG. Pharmacologic Treatment of Portal Hypertension. Clin Liver Dis 2024; 28:417-435. [PMID: 38945635 DOI: 10.1016/j.cld.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Portal hypertension is the key mechanism driving the transition from compensated to decompensated cirrhosis. In this review, the authors described the pathophysiology of portal hypertension in cirrhosis and the rationale of pharmacologic treatment of portal hypertension. We discussed both etiologic and nonetiologic treatment of portal hypertension and the specific clinical scenarios how nonselective beta-blocker can be used in patients with cirrhosis. Finally, the authors summarized the evidence for emerging alternatives for portal hypertension in patients with cirrhosis.
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Affiliation(s)
- Yu Jun Wong
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Canada; Liver Unit, Division of Gastroenterology, University of Alberta, 1-38 Zeidler Ledcor Centre, 8540 112 Street Northwest, Edmonton, Alberta T6G 2X8, Canada
| | - Juan G Abraldes
- Liver Unit, Division of Gastroenterology, University of Alberta, 1-38 Zeidler Ledcor Centre, 8540 112 Street Northwest, Edmonton, Alberta T6G 2X8, Canada.
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Malik A, Asif M, Ud Din R, Khan A, Siddique M, Noor F, Mansoor H, Habib A. The Utility of the Platelet-Albumin-Bilirubin Score as a Non-invasive Predictor of Esophageal Varices and Variceal Hemorrhage in Patients With Liver Cirrhosis Compared to Child-Turcotte-Pugh and Model of End-Stage Liver Disease-Sodium Scores. Cureus 2024; 16:e62577. [PMID: 39027759 PMCID: PMC11255724 DOI: 10.7759/cureus.62577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2024] [Indexed: 07/20/2024] Open
Abstract
Introduction Research on non-invasive tools for detecting gastro-esophageal varices is underway. We investigated the Platelet-Albumin-Bilirubin (PALBI) score in comparison with the Child-Turcotte-Pugh (CTP) and MELD-Na (MELD-Na) scores in patients with liver cirrhosis. Methods Three hundred and twenty-three patients with liver cirrhosis were studied. The PALBI, CTP and MELD-Na scores were calculated and analyzed for gastroesophageal varices and their characteristics using SPSS version 26 (IBM Corp., Armonk, NY, USA). Results Two hundred and sixty-four patients had esophageal varices and 102 presented with variceal hemorrhage. Mean PALBI, CTP and MELD-Na scores were significantly higher for patients with varices versus without varices (p < 0.05). Unlike the mean MELD-Na score, the mean PALBI and CTP scores were significantly higher in patients with large high-risk varices as compared to patients with small low-risk varices (p < 0.05). The mean CTP scores were significantly higher in patients with variceal hemorrhage than those without hemorrhage (p < 0.05), while the difference between mean PALBI and MELD-Na was insignificant, in this regard. The PALBI score had better sensitivity than the CTP and MELD-Na scores in indicating the presence of varices but was similar to the CTP score in predicting high-risk varices. Conclusion The PALBI score proves to have good utility and efficiency in predicting varices in comparison to CTP and MELD-Na scores. It can determine high-risk stigmata of variceal hemorrhage with similar performance as the CTP Score.
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Affiliation(s)
- Ayesha Malik
- Gastroenterology and Hepatology, Combined Military Hospital, Lahore, PAK
| | - Mahrosh Asif
- Medicine, Combined Military Hospital, Lahore, PAK
| | - Rafi Ud Din
- Gastroenterology and Hepatology, Combined Military Hospital, Lahore, PAK
| | - Asma Khan
- Gastroenterology and Hepatology, Combined Military Hospital, Lahore, PAK
| | | | - Fnu Noor
- Gastroenterology and Hepatology, Combined Military Hospital, Lahore, PAK
| | - Hala Mansoor
- Medicine, Combined Military Hospital, Lahore, PAK
| | - Aamir Habib
- Medicine, Combined Military Hospital, Lahore, PAK
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Mathur N, Patel H, Mangalia R, Mehta A, Mathur M, Verma A, Patyal A. Correlation of non-invasive parameters with upper gastrointestinal endoscopy findings for presence and grading of gastroesophageal varices in liver cirrhosis patients. J Family Med Prim Care 2024; 13:1347-1353. [PMID: 38827664 PMCID: PMC11141970 DOI: 10.4103/jfmpc.jfmpc_702_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 11/27/2023] [Accepted: 11/30/2023] [Indexed: 06/04/2024] Open
Abstract
Background Development of esophageal varices is one of the major complications of liver cirrhosis, and endoscopy is used to see the presence, grading, and long-term monitoring of esophageal varices which is an invasive and unpleasant procedure. There is no adequate data available showing noninvasive methods can be used for the same. Methods Seventy patients with liver cirrhosis participated in the study. Factors like portal vein diameter, spleen size, platelet count, serum bilirubin, Child-Pugh score, prothrombin time (PT), and PT INR were observed and correlated endoscopically with the presence and grading of esophageal varices in all patients. Results The platelet count, portal vein diameter, serum bilirubin, spleen bipolar diameter, and PT had statistically significant correlations with the presence of varices. Among them, platelet count, portal vein diameter, and serum bilirubin also had statistically significant correlations with the grading of varices. Monitoring of these noninvasive parameters can help in monitoring variceal growth. Conclusions Noninvasive parameters can be used effectively to predict the presence and grading of esophageal varices and at the same time keep the rate of undiagnosed varices acceptably low. By using noninvasive parameters, patients can be benefited by decreasing the requirement of repeated endoscopic evaluation which is an unpleasant procedure and availability is also limited.
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Affiliation(s)
- Navgeet Mathur
- Department of General Medicine, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
| | - Harsh Patel
- Department of General Medicine, GMERS Medical College and Hospital, Sola, Ahmedabad, Gujarat, India
| | - Ravi Mangalia
- Department of General Medicine, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
| | - Amit Mehta
- Department of General Medicine, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
| | - Medha Mathur
- Department of Community Medicine, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
| | - Anjana Verma
- Department of Community Medicine, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
| | - Ashish Patyal
- Department of Anesthesiology, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
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Martino A, Amitrano L, Guardascione M, Di Serafino M, Bennato R, Martino R, de Leone A, Orsini L, Romano L, Lombardi G. The role of computed tomography for the prediction of esophageal variceal bleeding: Current status and future perspectives. World J Gastrointest Endosc 2023; 15:681-689. [PMID: 38187916 PMCID: PMC10768040 DOI: 10.4253/wjge.v15.i12.681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/13/2023] [Accepted: 11/27/2023] [Indexed: 12/15/2023] Open
Abstract
Esophageal variceal bleeding (EVB) is one of the most common and severe complications related to portal hypertension (PH). Despite marked advances in its management during the last three decades, EVB is still associated with significant morbidity and mortality. The risk of first EVB is related to the severity of both PH and liver disease, and to the size and endoscopic appearance of esophageal varices. Indeed, hepatic venous pressure gradient (HVPG) and esophagogastroduodenoscopy (EGD) are currently recognized as the “gold standard” and the diagnostic reference standard for the prediction of EVB, respectively. However, HVPG is an invasive, expensive, and technically complex procedure, not widely available in clinical practice, whereas EGD is mainly limited by its invasive nature. In this scenario, computed tomography (CT) has been recently proposed as a promising modality for the non-invasive prediction of EVB. Although CT is only a diagnostic modality, thus being not capable of supplanting EGD or HVPG in providing therapeutic and physiological data, it could potentially assist liver disease scores, HVPG, and EGD in a more effective prediction of EVB. However, to date, evidence concerning the role of CT in this setting is still lacking. Our review aimed to summarize and discuss the current evidence concerning the role of CT in predicting the risk of EVB.
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Affiliation(s)
- Alberto Martino
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Lucio Amitrano
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Marianna Guardascione
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Marco Di Serafino
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Raffaele Bennato
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Rossana Martino
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Annalisa de Leone
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Luigi Orsini
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Luigia Romano
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Giovanni Lombardi
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
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Hou Y, Yu H, Zhang Q, Yang Y, Liu X, Wang X, Jiang Y. Machine learning-based model for predicting the esophagogastric variceal bleeding risk in liver cirrhosis patients. Diagn Pathol 2023; 18:29. [PMID: 36823660 PMCID: PMC9948468 DOI: 10.1186/s13000-023-01293-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 01/13/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Liver cirrhosis patients are at risk for esophagogastric variceal bleeding (EGVB). Herein, we aimed to estimate the EGVB risk in patients with liver cirrhosis using an artificial neural network (ANN). METHODS We included 999 liver cirrhosis patients hospitalized at the Beijing Ditan Hospital, Capital Medical University in the training cohort and 101 patients from Shuguang Hospital in the validation cohort. The factors independently affecting EGVB occurrence were determined via univariate analysis and used to develop an ANN model. RESULTS The 1-year cumulative EGVB incidence rates were 11.9 and 11.9% in the training and validation groups, respectively. A total of 12 independent risk factors, including gender, drinking and smoking history, decompensation, ascites, location and size of varices, alanine aminotransferase (ALT), γ-glutamyl transferase (GGT), hematocrit (HCT) and neutrophil-lymphocyte ratio (NLR) levels as well as red blood cell (RBC) count were evaluated and used to establish the ANN model, which estimated the 1-year EGVB risk. The ANN model had an area under the curve (AUC) of 0.959, which was significantly higher than the AUC for the North Italian Endoscopic Club (NIEC) (0.669) and revised North Italian Endoscopic Club (Rev-NIEC) indices (0.725) (all P < 0.001). Decision curve analyses revealed improved net benefits of the ANN compared to the NIEC and Rev-NIEC indices. CONCLUSIONS The ANN model accurately predicted the 1-year risk for EGVB in liver cirrhosis patients and might be used as a basis for risk-based EGVB surveillance strategies.
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Affiliation(s)
- Yixin Hou
- grid.24696.3f0000 0004 0369 153XCenter of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, No. 8 Jingshun East Road, Beijing, 100051 China
| | - Hao Yu
- grid.24696.3f0000 0004 0369 153XCenter of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, No. 8 Jingshun East Road, Beijing, 100051 China
| | - Qun Zhang
- grid.24696.3f0000 0004 0369 153XCenter of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, No. 8 Jingshun East Road, Beijing, 100051 China
| | - Yuying Yang
- grid.412585.f0000 0004 0604 8558Institute of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xiaoli Liu
- grid.24696.3f0000 0004 0369 153XCenter of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, No. 8 Jingshun East Road, Beijing, 100051 China
| | - Xianbo Wang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, No. 8 Jingshun East Road, Beijing, 100051, China.
| | - Yuyong Jiang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, No. 8 Jingshun East Road, Beijing, 100051, China.
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Liver and spleen stiffness for the diagnosis of oesophageal varices in adults with chronic liver disease. Cochrane Database Syst Rev 2023; 2023:CD015547. [PMCID: PMC9890918 DOI: 10.1002/14651858.cd015547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This is a protocol for a Cochrane Review (diagnostic). The objectives are as follows: To assess the diagnostic accuracy of liver stiffness and spleen stiffness, separately or in combination, as measured by vibration‐controlled transient elastography (VCTE) in detection of any oesophageal varices in adults with chronic liver disease. We will regard a combination of tests as positive when at least one is positive. To compare the diagnostic accuracy of individual tests (liver stiffness and spleen stiffness measured by VCTE) directly and versus the combination of both tests (considering positive when at least one is positive) in detecting any oesophageal varices. To assess the diagnostic accuracy of liver stiffness and spleen stiffness, separately or in combination, as measured by other elastography techniques (2D‐shear wave elastography (2D‐SWE), point shear wave elastography (pSWE), magnetic resonance elastography (MRE)) in detection of any oesophageal varices in adults with chronic liver disease. We will regard a combination of tests as positive when at least one is positive. To compare the diagnostic accuracy of liver stiffness and spleen stiffness measured by VCTE with other techniques (pSWE, 2D‐SWE, MRE) in detection of any oesophageal varices in adults with chronic liver disease.
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Zhang Q, Niu S, Yang L, Zhu B, Shi K, Zhang X, Zhang Y, Bi Y, Mu Y, Wang X. A novel prognostic model for predicting the risk of first variceal hemorrhage in patients with HBV-related cirrhosis. Front Cell Infect Microbiol 2023; 13:1062172. [PMID: 36733609 PMCID: PMC9886685 DOI: 10.3389/fcimb.2023.1062172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 01/03/2023] [Indexed: 01/18/2023] Open
Abstract
Background Variceal hemorrhage (VH) is a life-threatening complication of cirrhosis. An accurate VH risk evaluation is critical to determine appropriate prevention strategies. We aimed to develop an individualized prediction model to predict the risk of first VH in hepatitis B virus (HBV)-related cirrhotic patients. Methods A nomogram was developed based on a retrospective analysis of 527 consecutive HBV-related cirrhotic patients with gastroesophageal varices (GEVs). The nomogram evaluation was performed using the area under the receiver operating characteristic curve (AUC), concordance index (C-index), calibration plot, and decision curve analysis (DCA). The results were verified using an external cohort (n = 187). Results We developed a nomogram based on clinical and endoscopic features, including the size of varices, red wale marks, ascites, spleen thickness, γ-glutamyltransferase, and hematocrit. The C-index of the nomogram in the derivation and validation cohort was 0.806 and 0.820, respectively, and the calibration plot fitted well. Compared with those of the North Italian Endoscopic Club (NIEC) and revised NIEC indexes, the AUC (derivation cohort: 0.822 vs. 0.653 vs. 0.713; validation cohort: 0.846 vs. 0.685 vs. 0.747) and DCA curves of this nomogram were better. Further, based on the risk scores, patients were classified into low-, medium-, and high-risk groups, and significant differences were noted in VH incidence among the three risk groups (P <0.001 for each cohort). Conclusions An effective individualized nomogram to predict the risk of first VH in HBV-related GEV patients was established, which can assist clinicians in developing more appropriate prevention strategies.
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Affiliation(s)
- Qun Zhang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Shuaishuai Niu
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Li Yang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Bingbing Zhu
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Ke Shi
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Xiaohua Zhang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yi Zhang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yufei Bi
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yongping Mu
- Institute of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China,*Correspondence: Xianbo Wang, ; Yongping Mu,
| | - Xianbo Wang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China,*Correspondence: Xianbo Wang, ; Yongping Mu,
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Fauter M, Rossi G, Drissi-Bakhkhat A, Latournerie M, Gerfaud-Valentin M, Durieu I, Jamilloux Y, Bailly F, Mahevas M, Sève P. Hepatic sarcoidosis with symptomatic portal hypertension: A report of 12 cases with review of the literature. Front Med (Lausanne) 2022; 9:995042. [PMID: 36619642 PMCID: PMC9812951 DOI: 10.3389/fmed.2022.995042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Sarcoidosis is a systemic granulomatosis of unknown etiology, characterized by the presence of immune granulomas. Liver damage is a relatively common extra-pulmonary manifestation, occurring in 3.6-30% of cases. Some patients can develop symptomatic portal hypertension (PH). Few series have evaluated the prognosis of symptomatic PH as well as the efficacy and safety of specific treatment on this complication. Methods This is a multicenter retrospective study of cases of histologically proven hepatic sarcoidosis with symptomatic PH (ascites, digestive hemorrhage) and/or hepatic encephalopathy. Demographic characteristics, comorbidities, clinical manifestations of sarcoidosis, biological data, imaging study of the liver, treatment, and clinical outcomes were collected. Results Twelve patients were identified, with a mean follow-up of 140 months. The M/F ratio was 1 and Caucasian origin was the most represented (75%). Seven patients presented with hepatic comorbidities: metabolic syndrome, chronic alcoholism or chronic viral hepatitis. Apart from hepatic involvement, mediastino-pulmonary involvement was the most common followed by osteoarticular and skin. Liver damage was inaugural in two thirds of cases. Nine patients developed ascites, six presented esophageal varices complicated by gastrointestinal bleeding. Three patients presented with both ascites and variceal bleeding. One case of hepatic encephalopathy was observed. Five patients presented signs of hepatocellular insufficiency during follow-up, of whom three had hepatic comorbidities. Eight out of 12 patients required second-line treatment after failure of corticosteroids, three patients underwent ligation of esophageal varices but with recurrent digestive bleeding in all cases. Two patients benefited from a transjugular intrahepatic portosystemic shunt (TIPS), also with poor result. At the end of follow-up, five patients were alive and seven patients died. Two patients received a liver transplant, with good result and without recurrence of sarcoidosis on the transplant thereafter. Two patients had quiet sarcoidosis on low dose of corticosteroids and one patient was lost to follow-up. Conclusion Symptomatic PH related to hepatic sarcoidosis is a severe complication, with high morbidity and mortality, and frequent failure of specific treatments of PH. Early management of these patients, with detection of hepatic comorbidities seems important. In case of therapeutic failure, liver transplantation is an option to consider.
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Affiliation(s)
- Maxime Fauter
- Department of Internal Medicine, Croix-Rousse Hospital, Lyon, France
| | - Geoffrey Rossi
- Department of Internal Medicine, Henri-Mondor Hospital, Assistance Publique – Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | | | - Marianne Latournerie
- Department of Hepato-Gastroenterology, Centre Hospitalier Universitaire Dijon Bourgogne, Dijon, France
| | | | - Isabelle Durieu
- Department of Internal Medicine, Centre Hospitalier Universitaire Lyon Sud, Pierre-Bénite, France,RESHAPE, INSERM U1290, Lyon University, University Claude-Bernard Lyon 1, Lyon, France
| | - Yvan Jamilloux
- Department of Internal Medicine, Croix-Rousse Hospital, Lyon, France,INSERM U1111, Centre International de Recherche en Infectiologie/International Research Center in Infectiology (CIRI), University Claude-Bernard Lyon 1, Villeurbanne, France
| | - François Bailly
- Department of Hepato-Gastroenterology, Croix-Rousse Hospital, Lyon, France
| | - Matthieu Mahevas
- Department of Internal Medicine, Henri-Mondor Hospital, Assistance Publique – Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Pascal Sève
- Department of Internal Medicine, Croix-Rousse Hospital, Lyon, France,RESHAPE, INSERM U1290, Lyon University, University Claude-Bernard Lyon 1, Lyon, France,Pôle IMER, Hospices Civils de Lyon, Lyon, France,*Correspondence: Pascal Sève,
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Wang J, Wang Z, Chen M, Xiao Y, Chen S, Wu L, Yao L, Jiang X, Li J, Xu M, Lin M, Zhu Y, Luo R, Zhang C, Li X, Yu H. An interpretable artificial intelligence system for detecting risk factors of gastroesophageal variceal bleeding. NPJ Digit Med 2022; 5:183. [PMID: 36536039 PMCID: PMC9763258 DOI: 10.1038/s41746-022-00729-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
Bleeding risk factors for gastroesophageal varices (GEV) detected by endoscopy in cirrhotic patients determine the prophylactical treatment patients will undergo in the following 2 years. We propose a methodology for measuring the risk factors. We create an artificial intelligence system (ENDOANGEL-GEV) containing six models to segment GEV and to classify the grades (grades 1-3) and red color signs (RC, RC0-RC3) of varices. It also summarizes changes in the above results with region in real time. ENDOANGEL-GEV is trained using 6034 images from 1156 cirrhotic patients across three hospitals (dataset 1) and validated on multicenter datasets with 11009 images from 141 videos (dataset 2) and in a prospective study recruiting 161 cirrhotic patients from Renmin Hospital of Wuhan University (dataset 3). In dataset 1, ENDOANGEL-GEV achieves intersection over union values of 0.8087 for segmenting esophageal varices and 0.8141 for gastric varices. In dataset 2, the system maintains fairly accuracy across images from three hospitals. In dataset 3, ENDOANGEL-GEV surpasses attended endoscopists in detecting RC of GEV and classifying grades (p < 0.001). When ranking the risk of patients combined with the Child‒Pugh score, ENDOANGEL-GEV outperforms endoscopists for esophageal varices (p < 0.001) and shows comparable performance for gastric varices (p = 0.152). Compared with endoscopists, ENDOANGEL-GEV may help 12.31% (16/130) more patients receive the right intervention. We establish an interpretable system for the endoscopic diagnosis and risk stratification of GEV. It will assist in detecting the first bleeding risk factors accurately and expanding the scope of quantitative measurement of diseases.
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Affiliation(s)
- Jing Wang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
- Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zhengqiang Wang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
- Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Mingkai Chen
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
- Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yong Xiao
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
- Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Shi Chen
- Department of Gastroenterology, Wuhan Puren Hospital, Wuhan, China
| | - Lianlian Wu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
- Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Liwen Yao
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
- Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiaoda Jiang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
- Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jiao Li
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
- Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Ming Xu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
- Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Mengjuan Lin
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
- Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yijie Zhu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
- Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Renquan Luo
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
- Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Chenxia Zhang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
- Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xun Li
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
- Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Honggang Yu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China.
- Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China.
- Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China.
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12
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Kondo T, Fujiwara K, Nakagawa M, Unozawa H, Iwanaga T, Sakuma T, Fujita N, Koroki K, Kanzaki H, Kobayashi K, Kiyono S, Nakamura M, Kanogawa N, Saito T, Ogasawara S, Suzuki E, Ooka Y, Nakamoto S, Chiba T, Arai M, Kato J, Kato N. The efficacy of contrast-enhanced computed tomography on the management of gastroesophageal varices in patients with hepatocellular carcinoma. Sci Rep 2022; 12:20726. [PMID: 36456830 PMCID: PMC9715668 DOI: 10.1038/s41598-022-25350-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022] Open
Abstract
The screening of gastroesophageal varices (GEV) is critical in hepatocellular carcinoma (HCC) management. Contrast-enhanced computed tomography (CECT) is often performed in patients with HCC. Therefore, this study aimed to examine the use of CECT in screening for GEV and predicting GEV bleeding. This retrospective study enrolled 312 consecutive patients who are initially diagnosed with HCC, measured the lower esophageal (EIV) and fundal intramural vessel (FIV) diameter on CECT, examined the changes after 1, 2, and 3 years, and verified the relationship with GEV bleeding. The EIV and FIV diameter on CECT correlates well with endoscopic variceal classification. EIV significantly worsened after 2 and 3 years. FIV showed worsening at both 1, 2, and 3 years. Cumulative GEV bleeding rates were 3.7% at 1 year and 6.2% at 3 years. The multivariate analysis revealed that EIV, FIV, and portal vein tumor thrombus were associated with GEV bleeding. Furthermore, EIV deterioration at 1, 2, and 3 years correlated with GEV bleeding. In conclusion, CECT is useful in variceal management during the longitudinal clinical course of HCC, and has the potential to decrease screening endoscopy. With deterioration in EIV, treatments should be considered due to a high-risk GEV bleeding.
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Affiliation(s)
- Takayuki Kondo
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan.
| | - Kisako Fujiwara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Miyuki Nakagawa
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Hidemi Unozawa
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Terunao Iwanaga
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Takafumi Sakuma
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Naoto Fujita
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Keisuke Koroki
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Hiroaki Kanzaki
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Kazufumi Kobayashi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
- Translational Research and Development Center, Chiba University Hospital, Chiba, Japan
| | - Soichiro Kiyono
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Masato Nakamura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Naoya Kanogawa
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Tomoko Saito
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Sadahisa Ogasawara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Eiichiro Suzuki
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Yoshihiko Ooka
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Shingo Nakamoto
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Tetsuhiro Chiba
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Makoto Arai
- Department of Gastroenterology, Tokyo Women's Medical University Yachiyo Medical Center, Chiba, Japan
| | - Jun Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
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13
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The Risk of Bleeding in Small/Straight Esophageal Varices with Red Color Sign on Endoscopy: A Retrospective Analysis from the Natural Course. Healthcare (Basel) 2022; 10:healthcare10071193. [PMID: 35885720 PMCID: PMC9322794 DOI: 10.3390/healthcare10071193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 11/17/2022] Open
Abstract
Red color sign-positive (RC-positive) esophageal varices present a high bleeding risk, necessitating prophylactic treatment. Among RC-positive esophageal varices, those classified morphologically as small straight varices (Form level 1: F1) are difficult to treat. Moreover, the appropriate time for therapeutic intervention remains undefined. This study assessed the bleeding risk in RC-positive F1 esophageal varices. After extracting 541 cases of F1 esophageal varices diagnosed during 1 January 2012−29 February 2020, 76 cases of RC-positive F1 esophageal varices were divided into two groups in terms of treatment intervention at diagnosis: 49 cases with (treatment group) and 27 cases without (follow-up group). We assessed the bleeding rates, bleeding-associated factors, and early-bleeding-associated factors. The treatment group’s bleeding rate was 10% (5/49). The follow-up group’s bleeding rate was 78% (21/24). The subsequent bleeding rate was low in the treatment group (p < 0.001). The median period of sustained absence of bleeding was longer in the treatment group than in the follow-up group (1156 [274−1582] days vs. 105 [1−336] days; p < 0.001). In the follow-up group, a significant number of bleedings had varices that included a hematocystic spot (HCS) as RC or combined with RC (p = 0.017). Early bleeding occurred often in varices that included HCS or combined with RC (p = 0.024). Red wale marking (RWM) only was not a factor of early bleeding (p = 0.012). In conclusion, RC-positive varices should be treated even as F1 varices. Patients with RWM only show the possibility of not accepting early treatment intervention. A fast response is crucially important in HCS cases because of its associated bleeding and early bleeding.
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14
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Risk Factors of Esophageal Bleeding in Children with Various Etiologies of Liver Cirrhosis – A Single-Center Report from Iran. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2022. [DOI: 10.2478/sjecr-2019-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Esophageal bleeding is a common complication in patients with liver cirrhosis. In thee present study, our aim was to divulge major factors predicting esophageal bleeding in Iranian children with liver cirrhosis. This was a cross-sectional study including 101 children < 18 years old referred to the Pediatric Endoscopy Unit of Nemazee Teaching Hospital of Shiraz from 2014 until 2016. Children with esophageal varices were included. The patients were divided into two groups including those with and without history of esophageal bleeding. Statistical methods were performed in SPSS 16 software. There were 49 boys and 52 girls. The mean age was 7.74±5.26 years old. A history of esophageal bleeding was observed in 53 (52.4%). In univariate analyses, significant relationships were found between esophageal bleeding and varices size (P=0.001), Child-Pugh score (P=0.01), age of bleeding initiation (P<0.001), serum creatinine (P=0.01), and serum sodium (P=0.002). There was no statistically significant difference in the mean of PELD/MELD score among children with (12.34±12) and without (14.61±17.51) history of esophageal bleeding (P=0.5). Among various etiologies of cirrhosis, a significant association was observed between autoimmune hepatitis and the history of esophageal bleeding (P=0.01). Regarding the clinical importance of esophageal bleedings in children with liver cirrhosis, it is recommended to further divulge the risk factors pre-disposing to this event.
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15
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Aggeletopoulou I, Triantos C. Endoscopic Management of Variceal Bleeding. GASTROINTESTINAL AND PANCREATICO-BILIARY DISEASES: ADVANCED DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2022:1059-1092. [DOI: 10.1007/978-3-030-56993-8_63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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16
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Efficacy of Endoscopic Band Ligation in the Treatment of Acute Esophageal Varicose Bleeding. JOURNAL OF CONTEMPORARY MEDICINE 2022. [DOI: 10.16899/jcm.1015238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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17
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Agarwal S, Sharma S, Kumar M, Venishetty S, Bhardwaj A, Kaushal K, Gopi S, Mohta S, Gunjan D, Saraya A, Sarin SK. Development of a machine learning model to predict bleed in esophageal varices in compensated advanced chronic liver disease: A proof of concept. J Gastroenterol Hepatol 2021; 36:2935-2942. [PMID: 34050561 DOI: 10.1111/jgh.15560] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/19/2021] [Accepted: 05/26/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Risk stratification beyond the endoscopic classification of esophageal varices (EVs) to predict first episode of variceal bleeding (VB) is currently limited in patients with compensated advanced chronic liver disease (cACLD). We aimed to assess if machine learning (ML) could be used for predicting future VB more accurately. METHODS In this retrospective analysis, data from patients of cACLD with EVs, laboratory parameters and liver stiffness measurement (LSM) were used to generate an extreme-gradient boosting (XGBoost) algorithm to predict the risk of VB. The performance characteristics of ML and endoscopic classification were compared in internal and external validation cohorts. Bleeding rates were estimated in subgroups identified upon risk stratification with combination of model and endoscopic classification. RESULTS Eight hundred twenty-eight patients of cACLD with EVs, predominantly related to non-alcoholic fatty liver disease (28.6%), alcohol (23.7%) and hepatitis B (23.1%) were included, with 455 (55%) having the high-risk varices. Over a median follow-up of 24 (12-43) months, 163 patients developed VB. The accuracy of machine learning (ML) based model to predict future VB was 98.7 (97.4-99.5)%, 93.7 (88.8-97.2)%, and 85.7 (82.1-90.5)% in derivation (n = 497), internal validation (n = 149), and external validation (n = 182) cohorts, respectively, which was better than endoscopic classification [58.9 (55.5-62.3)%] alone. Patients stratified high risk on both endoscopy and model had 1-year and 3-year bleeding rates of 31-43% and 64-85%, respectively, whereas those stratified as low risk on both had 1-year and 3-year bleeding rates of 0-1.6% and 0-3.4%, respectively. Endoscopic classification and LSM were the major determinants of model's performance. CONCLUSION Application of ML model improved the performance of endoscopic stratification to predict VB in patients with cACLD with EVs.
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Affiliation(s)
- Samagra Agarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Sanchit Sharma
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Manoj Kumar
- Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shantan Venishetty
- Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ankit Bhardwaj
- Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Kanav Kaushal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Srikanth Gopi
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Srikant Mohta
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
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18
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Lim J, Kim HI, Kim E, Kim J, An J, Chang S, Kim SO, Lee HC, Lee YS, Shim JH. Variceal bleeding is aggravated by portal venous invasion of hepatocellular carcinoma: a matched nested case-control study. BMC Cancer 2021; 21:11. [PMID: 33402105 PMCID: PMC7786454 DOI: 10.1186/s12885-020-07708-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 12/03/2020] [Indexed: 02/07/2023] Open
Abstract
Background We hypothesized that portal vein tumor thrombosis (PVTT) in hepatocellular carcinoma (HCC) increases portal pressure and causes esophageal varices and variceal bleedings. We examined the incidence of high-risk varices and variceal bleeding and determined the indications for variceal screening and prophylaxis. Methods This study included 1709 asymptomatic patients without any prior history of variceal hemorrhage or endoscopic prophylaxis who underwent upper endoscopy within 30 days before or after initial anti-HCC treatment. Of these patients, 206 had PVTT, and after 1:2 individual matching, 161 of them were matched with 309 patients without PVTT. High-risk varices were defined as large/medium varices or small varices with red-color signs and variceal bleeding. Bleeding rates from the varices were compared between matched pairs. Risk factors for variceal bleeding in the entire set of patients with PVTT were also explored. Results In the matched-pair analysis, the proportion of high-risk varices at screening (23.0% vs. 13.3%; P = 0.003) and the cumulative rate of variceal bleeding (4.5% vs. 0.4% at 1 year; P = 0.009) were significantly greater in the PVTT group. Prolonged prothrombin time, lower platelet count, presence of extrahepatic metastasis, and Vp4 PVTT were independent risk factors related to high-risk varices in the total set of 206 patients with PVTT (Adjusted odds ratios [95% CIs], 1.662 [1.151–2.401]; 0.985 [0.978–0.993]; 4.240 [1.783–10.084]; and 3.345 [1.457–7.680], respectively; Ps < 0.05). During a median follow-up of 43.2 months, 10 patients with PVTT experienced variceal bleeding episodes, 9 of whom (90%) had high-risk varices. Presence of high-risk varices and sorafenib use for HCC treatment were significant predictors of variceal bleeding in the complete set of patients with PVTT (Adjusted hazard ratios [95% CIs], 26.432 [3.230–216.289]; and 5.676 [1.273–25.300], respectively; Ps < 0.05). Conclusions PVTT in HCC appears to increase the likelihood of high-risk varices and variceal bleeding. In HCC patients with PVTT, endoscopic prevention could be considered, at least in high-risk variceal carriers taking sorafenib.
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Affiliation(s)
- Jihye Lim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Ha Il Kim
- Gastroenterology, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Eunju Kim
- Gastroenterology, Department of Internal Medicine, Haeundae Paik Hospital, College of Medicine, Inje University, Busan, Republic of Korea
| | - Jiyoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Jihyun An
- Gastroenterology, Hanyang University College of Medicine, Guri, Gyeonggi-do, Republic of Korea
| | - Seheon Chang
- Internal Medicine, Myongji St. Mary's Hospital, Seoul, Republic of Korea
| | - Seon-Ok Kim
- Biostatistics and Clinical Epidemiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Han Chu Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.,Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yung Sang Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.,Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ju Hyun Shim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea. .,Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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19
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Koya Y, Shibata M, Watanabe T, Kumei S, Miyagawa K, Oe S, Honma Y, Kume K, Yoshikawa I, Harada M. Influence of gastroesophageal flap valve on esophageal variceal bleeding in patients with liver cirrhosis. Dig Endosc 2021; 33:100-109. [PMID: 32274835 DOI: 10.1111/den.13685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 04/01/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Esophageal variceal bleeding can be fatal in patients with liver cirrhosis. The aim of this study was to investigate the relationship between gastroesophageal flap valve (GEFV) and esophageal variceal bleeding. METHODS Subjects were cirrhotic patients with endoscopically diagnosed esophageal varices treated at our hospital between 2005 and 2019, excluding those with F3 form and red color (RC) signs at first endoscopy. Sixty-five patients with normal GEFV (Hill grade I or II) and 42 with abnormal GEFV (Hill grade III or IV) were enrolled. Propensity score matching eliminated the baseline differences, resulting in a sample size of 30 patients per cohort. The primary endpoint was esophageal variceal bleeding, and the secondary endpoint was variceal bleeding or appearance of RC sign. We analyzed the cumulative incidences and predictors of each endpoint. RESULTS The 3-, 5-, and 10-year cumulative incidences of the primary endpoints were all 3.4% in the normal GEFV group, and 19.0%, 24.6% and 34.0% in the abnormal GEFV group, respectively (log-rank P = 0.011). Cumulative incidence of the secondary endpoint was 13.8%, 33.1% and 39.2% in the normal GEFV group, and 42.2%, 54.6% and 84.9% in the abnormal GEFV group, respectively (log-rank P = 0.001). In multivariate Cox regression analyses, hazard ratios of abnormal GEFV of the primary and secondary endpoints were 12.79 (95% confidence interval 1.331-122.8) and 3.600 (1.653-7.840), respectively. CONCLUSIONS Abnormal GEFV was an independent risk factor for esophageal variceal bleeding and appearance of RC sign.
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Affiliation(s)
- Yudai Koya
- Departments of, Department of, Third Department of Internal Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Michihiko Shibata
- Departments of, Department of, Third Department of Internal Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Tatsuyuki Watanabe
- Departments of, Department of, Third Department of Internal Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Shinsuke Kumei
- Departments of, Department of, Third Department of Internal Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Koichiro Miyagawa
- Departments of, Department of, Third Department of Internal Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Shinji Oe
- Departments of, Department of, Third Department of Internal Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Yuichi Honma
- Departments of, Department of, Third Department of Internal Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Keiichiro Kume
- Departments of, Department of, Third Department of Internal Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Ichiro Yoshikawa
- Department of, Endoscopy, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Masaru Harada
- Departments of, Department of, Third Department of Internal Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
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20
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Pandhi MB, Kuei AJ, Lipnik AJ, Gaba RC. Emergent Transjugular Intrahepatic Portosystemic Shunt Creation in Acute Variceal Bleeding. Semin Intervent Radiol 2020; 37:3-13. [PMID: 32139965 DOI: 10.1055/s-0039-3402015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Emergent transjugular intrahepatic portosystemic shunt (TIPS) creation is most commonly employed in the setting of acute variceal hemorrhage. Given a propensity for decompensation, these patients often require a multidisciplinary, multimodal approach involving prompt diagnosis, pharmacologic therapy, and endoscopic intervention. While successful in the majority of cases, failure to medically control initial bleeding can prompt interventional radiology consultation for emergent portal decompression via TIPS creation. This article discusses TIPS creation in emergent, acute variceal hemorrhage, reviewing the natural history of gastroesophageal varices, presentation and diagnosis of acute variceal hemorrhage, pharmacologic therapy, endoscopic approaches, patient selection and risk stratification for TIPS, technical considerations for TIPS creation, adjunctive embolotherapy, and the role of salvage TIPS versus early TIPS in acute variceal hemorrhage.
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Affiliation(s)
- Mithil B Pandhi
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew J Kuei
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew J Lipnik
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Ron C Gaba
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois.,Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Illinois
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21
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Alvi H, Zuberi BF, Rasheed T, Ibrahim MA. Evaluation of endoscopic variceal band ligation sessions in obliteration of esophageal varices. Pak J Med Sci 2020; 36:37-41. [PMID: 32063928 PMCID: PMC6994916 DOI: 10.12669/pjms.36.2.1144] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 10/14/2019] [Accepted: 10/19/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine number of sessions of Endoscopic variceal band ligation required to obliterate the esophageal varices. METHODS This study was conducted at Civil Hospital Karachi between June 2018 to April 2019. All patients undergoing endoscopic Variceal Band Ligation (EVBL) were inducted. Number of sessions of band ligation required to obliterate the varices were recorded. Number of EVBL sessions were correlated with Child-Pugh's Score and etiology of CLD by χ2 test, while it was compared with duration of Chronic Liver Disease (CLD) by One-way ANOVA test. RESULTS One hundred ninety-two patients fulfilling selection criteria were admitted after informed consent. These included 101 (52.6%) males and 91 (47.4%) females. Most common cause of cirrhosis was HCV (66.7%) in our patients. Most of the patients were in Child Class-B (71.9%). Majority of patients (52.6%) underwent 3 sessions of EVBL while 68 (35.4%) underwent 4 sessions of EVBL. Duration of CLD was analyzed with number of sessions of EVBL by One-Way ANOVA test and it showed significant more sessions of EVBL were done with longer duration of CLD (p <0.001). CONCLUSION Most patients underwent 3-4 sessions of EVBL for obliteration of varices. Number of EVBL sessions increased significantly with duration of disease.
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Affiliation(s)
- Haris Alvi
- Haris Alvi, Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Bader Faiyaz Zuberi
- Bader Faiyaz Zuberi, Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Tazeen Rasheed
- Tazeen Rasheed, Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Muhammad Asad Ibrahim
- Muhammad Asad Ibrahim, Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
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22
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Takehara T, Sakamori R. Remaining challenges for the noninvasive diagnosis of esophageal varices in liver cirrhosis. Esophagus 2020; 17:19-24. [PMID: 31620917 DOI: 10.1007/s10388-019-00699-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/01/2019] [Indexed: 02/07/2023]
Abstract
Although endoscopy is the recommended method for detecting esophageal varices, noninvasive methods for diagnosing esophageal varices are needed to avoid unnecessary invasive endoscopic examinations. In recent years, many studies have been performed to predict the presence of high-risk varices in noninvasive ways. The most widely used tools for noninvasive screening for esophageal varices are the Baveno VI and expanded Baveno VI criteria. Even these accepted criteria are not 100% accurate and have some limitations. Here, we summarize the current literature on the noninvasive diagnosis of esophageal varices in liver cirrhosis patients and highlight the remaining issues.
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Affiliation(s)
- Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Ryotaro Sakamori
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
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23
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Kim BH, Chung JW, Lee CS, Jang ES, Jeong SH, Kim N, Kim JW. Liver volume index predicts the risk of esophageal variceal hemorrhage in cirrhotic patients on propranolol prophylaxis. Korean J Intern Med 2019; 34:1233-1243. [PMID: 30759966 PMCID: PMC6823564 DOI: 10.3904/kjim.2018.120] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 05/21/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND/AIMS Non-selective β-blockers (NSBBs) are used for primary prevention of esophageal variceal hemorrhage (VH) in patients with portal hypertension, but a significant number of patients develop VH while on NSBB therapy. In this study, we sought to determine whether liver volume can predict the risk of primary prophylaxis failure in cirrhotic patients on NSBB therapy. METHODS A retrospective cohort of 309 patients on prophylactic propranolol was analyzed. Liver volume was measured in portal venous phase images of multidetector computed tomography. Predictors of VH were assessed using a Cox proportional hazards model with competing-risks analysis. A nomogram was developed for estimation of the risk of primary prophylaxis failure. RESULTS During a median follow-up of 36 months, 37 patients on propranolol developed VH. Liver volume index, the ratio of measured-to-expected liver volume, was an independent predictor of VH (adjusted hazard ratio [HR], 2.70; 95% confidence interval [CI], 1.37 to 5.33; p = 0.004) as were the presence of large varices and the absence of ascites. A nomogram-based volume score of > 0.6 was predictive of prophylaxis failure (HR, 7.54; 95% CI, 2.88 to 19.73; p < 0.001). Time-dependent receiver operating characteristic curve analysis revealed that a nomogram-based risk score had significantly better discriminatory power than the North Italian Endoscopy Club index in predicting prophylaxis failure at 6 and 8 years. CONCLUSION Liver volume index is an independent predictor of first VH and a nomogram-based volume score stratifies the VH risk in cirrhotic patients on propranolol prophylaxis.
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Affiliation(s)
- Beom Hee Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung Wha Chung
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Chung Seop Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eun Sun Jang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sook-Hyang Jeong
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Nayoung Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Wook Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Correspondence to Jin-Wook Kim, M.D. Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea Tel: +82-31-787-7013 Fax: +82-31-787-4051 E-mail:
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24
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Elzeftawy A, Mansour L, Kobtan A, Mourad H, El-Kalla F. Evaluation of the blood ammonia level as a non-invasive predictor for the presence of esophageal varices and the risk of bleeding. TURKISH JOURNAL OF GASTROENTEROLOGY 2019; 30:59-65. [PMID: 30465524 DOI: 10.5152/tjg.2018.17894] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND/AIMS The development of esophageal varices (EV) and resultant bleeding are the most critical complications of portal hypertension. Upper gastrointestinal endoscopy is the gold standard for diagnosis of EV. To find a non-invasive method for diagnosis of EV and to predict the bleeding risk is appealing and would decrease the cost and discomfort of upper endoscopy. The aim of our study was to evaluate the blood ammonia level as a predictor of the presence of EV and of a high risk of bleeding. MATERIALS AND METHODS In this cross-sectional study, a total of 359 patients with cirrhosis were examined for the presence of EV by upper endoscopy. Abdominal ultrasonography, calculation of the Child-Pugh score, and measurement of blood ammonia were performed for each patient. RESULTS The blood ammonia level was significantly higher in patients with EV than in those without it (p<0.001), and in patients with a high risk of variceal bleeding than in those with a low risk (p=0.026). CONCLUSION An increased blood ammonia level and splenic vein diameter are predictors for the presence of EV and bleeding risk factors. The blood ammonia level may be clinically useful as it correlates with and is an independent predictor for both the endoscopic risk signs and risk factors of bleeding, and therefore, it could be used in patients with cirrhosis to decrease the number of screening endoscopies they are subjected to.
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Affiliation(s)
- Asmaa Elzeftawy
- Department of Tropical Medicine and Infectious Diseases, Tanta University School of Medicine, Tanta, Egypt
| | - Loai Mansour
- Department of Tropical Medicine and Infectious Diseases, Tanta University School of Medicine, Tanta, Egypt
| | - Abdelrahman Kobtan
- Department of Tropical Medicine and Infectious Diseases, Tanta University School of Medicine, Tanta, Egypt
| | - Heba Mourad
- Department of Clinical Pathology, Tanta University School of Medicine, Tanta, Egypt
| | - Ferial El-Kalla
- Department of Tropical Medicine and Infectious Diseases, Tanta University School of Medicine, Tanta, Egypt
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25
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Cucchiarelli S, Santopaolo F, Lamazza A, Lionetti R, Lenci I, Manzia TM, Angelico M, Milana M, Baiocchi L. Pitfalls in the reporting of upper endoscopy features in cirrhotic patients. Dig Liver Dis 2019; 51:382-385. [PMID: 30219669 DOI: 10.1016/j.dld.2018.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/08/2018] [Accepted: 08/10/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Upper endoscopy is the main tool for the accurate assessment of the risk of bleeding in cirrhotic patients. AIM To evaluate the diagnostic accuracy of upper endoscopy, in cirrhotic subjects, during common clinical practice. METHODS 120 endoscopic reports produced in different hospitals in our region were retrospectively and randomly selected. After a general evaluation, aimed at assessing the description of various endoscopic features, reports were evaluated by four expert endoscopists and four expert hepatologists. Experts were asked to fill in a questionnaire for each single endoscopic procedure, regarding the diagnostic accuracy of the report. RESULTS Endoscopic reports lacked descriptions of the size of esophageal varices and red signs in 14% and 29% of cases respectively. Presence (or absence) of gastric varices or portal hypertensive gastropathy were not reported in 62% and 34% of cases respectively. According to expert endoscopists 41% of the reports were incomplete, while, according to hepatologists, reports were incomplete and inadequate for clinical purposes in 36% of cases. CONCLUSION Our study clearly evidenced a significant lack of information in reports on upper endoscopy in cirrhotic patients, and supports the prompt adoption of corrective strategies.
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Affiliation(s)
| | | | | | - Raffaella Lionetti
- Infectious disease and Hepatology Unit, Lazzaro Spallanzani Hospital, Rome, Italy
| | - Ilaria Lenci
- Hepatology Unit, Tor Vergata University Hospital, Rome, Italy
| | | | - Mario Angelico
- Hepatology Unit, Tor Vergata University Hospital, Rome, Italy
| | - Martina Milana
- Hepatology Unit, Tor Vergata University Hospital, Rome, Italy
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26
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Lipnik AJ, Pandhi MB, Khabbaz RC, Gaba RC. Endovascular Treatment for Variceal Hemorrhage: TIPS, BRTO, and Combined Approaches. Semin Intervent Radiol 2018; 35:169-184. [PMID: 30087520 DOI: 10.1055/s-0038-1660795] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Variceal hemorrhage is a feared complication of portal hypertension, with high rates of morbidity and mortality. Optimal management requires a thoughtful, multidisciplinary approach. In cases of refractory or recurrent esophageal hemorrhage, endovascular approaches such as transjugular intrahepatic portosystemic shunt (TIPS) have a well-defined role. For hemorrhage related to gastric varices, the optimal treatment remains to be established; however, there is increasing adoption of balloon-occluded retrograde transvenous obliteration (BRTO). This article will review the concept, history, patient selection, basic technique, and outcomes for TIPS, BRTO, and combined TIPS + BRTO procedures for variceal hemorrhage.
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Affiliation(s)
- Andrew J Lipnik
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois.,Division of Interventional Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
| | - Mithil B Pandhi
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
| | - Ramzy C Khabbaz
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
| | - Ron C Gaba
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois.,Division of Interventional Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
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27
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Aggeletopoulou I, Konstantakis C, Manolakopoulos S, Triantos C. Role of band ligation for secondary prophylaxis of variceal bleeding. World J Gastroenterol 2018; 24:2902-2914. [PMID: 30018485 PMCID: PMC6048424 DOI: 10.3748/wjg.v24.i26.2902] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/05/2018] [Accepted: 06/25/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To summarize and critically examine the role of band ligation in secondary prophylaxis of variceal bleeding in patients with cirrhosis.
METHODS A literature review was performed using the MEDLINE and PubMed databases. The search terms consisted of the words “endoscopic band ligation” OR “variceal band ligation” OR “ligation” AND “secondary prophylaxis” OR “secondary prevention” AND “variceal bleeding” OR “variceal hemorrhage” AND “liver cirrhosis”. The data collected from relevant meta-analyses and from the most recent randomized studies that were not included in these meta-analyses were used to evaluate the role of endoscopic band ligation in an effort to demonstrate the most recent advances in the treatment of esophageal varices.
RESULTS This study included 11 meta-analyses published from 2002 to 2017 and 10 randomized trials published from 2010 to 2017 that evaluated the efficacy of band ligation in the secondary prophylaxis of variceal bleeding. Overall, the results proved that band ligation was superior to endoscopic sclerotherapy. Moreover, the use of β-blockers in combination with band ligation increased the treatment effectiveness, supporting the current recommendations for secondary prophylaxis of variceal bleeding. The use of transjugular intrahepatic portosystemic shunt was superior to combination therapy regarding rebleeding prophylaxis, with no difference in the survival rates; however, the results concerning the hepatic encephalopathy incidence were conflicting. Recent advances in the management of secondary prophylaxis of variceal bleeding have targeted a decrease in portal pressure based on the pathophysiological mechanisms of portal hypertension.
CONCLUSION This review suggests that future research should be conducted to enhance current interventions and/or to develop innovative treatment options with improved clinical endpoints.
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Affiliation(s)
| | | | - Spilios Manolakopoulos
- 2nd Department of Internal Medicine, Hippokration General Hospital of Athens, Athens 11527, Greece
| | - Christos Triantos
- Department of Gastroenterology, University Hospital of Patras, Patras 26504, Greece
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28
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Li T, Qu Y, Yang B, Xue Y, Wang L. Evaluation of large esophageal varices in cirrhotic patients by transient elastography: a meta-analysis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 108:464-72. [PMID: 27444047 DOI: 10.17235/reed.2016.3980/2015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Transient elastography (TE) has been shown to be a valuable tool for the prediction of large esophageal varices. However, the conclusions have not been always consistent throughout the different studies. Therefore, we performed a further meta-analysis in order to evaluate the diagnostic accuracy of transient elastography for the prediction of large esophageal varices. METHODS We performed a systematic literature search in PubMed, EMBASE, Web of Science, and CENTRAL in The Cochrane Library without time restriction. The strategy we used was "(fibroscan OR transient elastography OR stiffness) AND esophageal varices". Accuracy measures such as pooled sensitivity, specificity, among others, were calculated using Meta-DiSc statistical software. RESULTS Twenty studies (2,994 patients) were included in our meta-analysis. The values of pooled sensitivity, specificity, positive and negative likelihood ratios and diagnostic odds ratio were as follows: 0.81 (95% CI, 0.79-0.84), 0.71 (95% CI, 0.69-0.73), 2.63 (95% CI, 2.15-3.23), 0.27 (95% CI, 0.22-0.34) and 10.30 (95% CI, 7.33-14.47). The area under the receiver operating characteristics curve was 0.83. The Spearman correlation coefficient was 0.246 with a p-value of 0.296, indicating the absence of any significant threshold effects. In our subgroup analysis, the heterogeneity could be partially explained by the geographical origin of the study or etiology; or it could be partially explained blindingly, through the appropriate interval and cut-off value of the liver stiffness (LS). CONCLUSIONS Transient elastography could be used as a valuable non-invasive screening tool for the prediction of large esophageal varices. However, since LS cut-off values vary throughout the different studies and significant heterogeneity also exists among them, we need more reasonable approaches or flow diagram in order to improve the operability of this technology.
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Affiliation(s)
- Tao Li
- Department of Infectious Diseases and Hepatology, the Second Hospital of Shandong University, China
| | - Yundong Qu
- Department of Infectious Diseases and Hepatology, the Second Hospital of Shandong University, China
| | - Baohua Yang
- Department of Infectious Diseases and Hepatology, the Second Hospital of Shandong University, China
| | - Yan Xue
- Department of Infectious Diseases and Hepatology, the Second Hospital of Shandong University, China
| | - Lei Wang
- Department of Infectious Diseases and Hepatology, the Second Hospital of Shandong University, China
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29
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Pimenta JR, Ferreira AR, Fagundes EDT, Queiroz TCN, Baptista RAN, de Araújo Moreira EG, de Resende CB, Bittencourt PFS, Carvalho SD, Neto JAF, Penna FJ. Factors Associated With Bleeding Secondary to Rupture of Esophageal Varices in Children and Adolescents With Cirrhosis. J Pediatr Gastroenterol Nutr 2017; 64:e44-e48. [PMID: 27496799 DOI: 10.1097/mpg.0000000000001362] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Bleeding of esophageal varices is the main cause of morbidity and mortality in children with portal hypertension. It is important to understand the factors related with a bleeding episode to evaluate more effective primary prophylaxis. The present study aims to describe the endoscopic and laboratory findings associated with upper gastrointestinal bleeding (UGIB) secondary to esophageal varices. METHOD A cross-sectional study with 103 children and adolescents with cirrhosis, divided into a group that had experienced an episode of upper UGIB (35 patients) and a group without a history of UGIB (68 patients), was carried out. The esophageal and gastric varices were classified, and the portal hypertensive gastropathy, laboratory findings, and Child-Pugh classification were measured. RESULTS Factors observed in univariate analysis to be associated with UGIB were the presence of esophageal varices of medium caliber or larger, portal hypertensive gastropathy, presence of red spots on esophageal varices, Child-Pugh class B or C, and hypoalbuminemia (P < 0.05). After multivariate logistic regression analysis, the significant factors were the presence of red spots on esophageal varices and the presence of gastric varices. When separated the autoimmune hepatitis, nonbiliary atresia patients (all patients except the patients with biliary atresia), and biliary atresia groups the findings in the univariate analysis were the presence of esophageal varices of medium or larger caliber, presence of red spots on varices, and presence of gastric varices in the autoimmune hepatitis patients and nonbiliary atresia patients and presence of red spots on esophageal varices, presence of gastric varices, and Child-Pugh classification B or C in biliary atresia group (P < 0.05). After multivariate logistic regression analysis, no statistical significance was found for any factor analyzed in any groups. CONCLUSIONS The presence of gastric varices and red spots on esophageal varices were related to episodes of UGIB secondary to rupture of esophageal varices. When these findings are observed, indications for endoscopic primary prophylaxis should be evaluated. More studies are, however, necessary to better understand this problem.
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Affiliation(s)
- Júlio R Pimenta
- *Pediatric Gastroenterology Group, Hospital das Clínicas da UFMG †School of Medicine of UFMG ‡Department of Pediatrics, Faculdade de Medicina da UFMG, Belo Horizonte, Brazil
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30
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Karatzas A, Triantos C, Kalafateli M, Marzigie M, Labropoulou-Karatza C, Thomopoulos K, Petsas T, Kalogeropoulou C. Multidetector computed tomography versus platelet/spleen diameter ratio as methods for the detection of gastroesophageal varices. Ann Gastroenterol 2016; 29:71-8. [PMID: 26751694 PMCID: PMC4700850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND All patients with liver cirrhosis should undergo screening endoscopy, but there are limitations and this approach places a heavy burden upon endoscopy units. The aim of this study was to compare multidetector computed tomography (MDCT) and the platelet/spleen diameter ratio as non-invasive methods for the detection of gastroesophageal varices. METHODS The study included 38 cirrhotics who underwent upper gastrointestinal (GI) endoscopy and MDCT within one month. Two radiologists reviewed the scans, in order to determine the presence and the size of varices. Blood tests and measurement of the spleen maximum diameter were also carried out and the platelet/spleen diameter ratio was calculated. Endoscopy was considered the gold standard and the results of the two methods were compared to it. RESULTS Varices were detected by upper GI endoscopy in 24 of 38 patients. The mean sensitivity and specificity of MDCT for the two observers was 86.1% and 57.1% respectively. In patients with large varices (>5 mm), the sensitivity was 100% (4/4). Using 909 as a cut-off value of the platelet/spleen diameter ratio this method yielded a sensitivity of 56.5% and a specificity of 35.7%. The difference in sensitivity and specificity between the two methods was statistically significant P<0.05. CONCLUSION MDCT was accurate for the detection of gastroesophageal varices, especially those with clinically significant size (>5 mm), and superior to platelet/spleen diameter ratio. MDCT could replace, in selected patients, upper GI endoscopy as a method for detecting gastroesophageal varices in cirrhotic patients.
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Affiliation(s)
- Andreas Karatzas
- Department of Radiology (Andreas Karatzas, Theodoros Petsas, Christina Kalogeropoulou)
| | - Christos Triantos
- Department of Gastroenterology (Christos Triantos, Maria Kalafateli, Misiel Marzigie, Konstantinos Thomopoulos)
| | - Maria Kalafateli
- Department of Gastroenterology (Christos Triantos, Maria Kalafateli, Misiel Marzigie, Konstantinos Thomopoulos)
| | - Misiel Marzigie
- Department of Gastroenterology (Christos Triantos, Maria Kalafateli, Misiel Marzigie, Konstantinos Thomopoulos)
| | | | - Konstantinos Thomopoulos
- Department of Gastroenterology (Christos Triantos, Maria Kalafateli, Misiel Marzigie, Konstantinos Thomopoulos)
| | - Theodoros Petsas
- Department of Radiology (Andreas Karatzas, Theodoros Petsas, Christina Kalogeropoulou)
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31
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Shaukat A, Church TR, Shanley R, Kauff ND, O'Brien MJ, Mills GM, Jordan PA, Allen JA, Kim A, Feld AD, Zauber AG, Winawer SJ. Development and validation of a clinical score for predicting risk of adenoma at screening colonoscopy. Cancer Epidemiol Biomarkers Prev 2015; 24:913-20. [PMID: 25800242 DOI: 10.1158/1055-9965.epi-14-1321] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 02/09/2015] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Currently, no clinical tools use demographic and risk factor information to predict the risk of finding an adenoma in individuals undergoing colon cancer screening. Such a tool would be valuable for identifying those who would most benefit from screening colonoscopy. METHODS We used baseline data from men and women who underwent screening colonoscopy from the randomized, multicenter National Colonoscopy Study (NCS) to develop and validate an adenoma risk model. The study, conducted at three sites in the United States (Minneapolis, MN; Seattle, WA; and Shreveport, LA) asked all participants to complete baseline questionnaires on clinical risk factors and family history. Model parameters estimated from logistic regression yielded an area under the receiver operating characteristic curve (AUROCC) used to assess prediction. RESULTS Five hundred forty-one subjects were included in the development model, and 1,334 in the validation of the risk score. Variables in the prediction of adenoma risk for colonoscopy screening were age (likelihood ratio test for overall contribution to model, P < 0.001), male sex (P < 0.001), body mass index (P < 0.001), family history of at least one first-degree relative with colorectal cancer (P = 0.036), and smoking history (P < 0.001). The adjusted AUROCC of 0.67 [95% confidence interval (CI), 0.61-0.74] for the derivation cohort was not statistically significantly different from that in the validation cohort. The adjusted AUROCC for the entire cohort was 0.64 (95% CI, 0.60-0.67). CONCLUSION We developed and validated a simple well-calibrated risk score. IMPACT This tool may be useful for estimating risk of adenomas in screening eligible men and women.
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Affiliation(s)
- Aasma Shaukat
- Section of Gastroenterology, VA Medical Center, Minneapolis, Minnesota. Department of Medicine, Yale University, New Haven, Connecticut.
| | - Timothy R Church
- Division of Environmental Health Sciences, University of Minnesota, Minneapolis, Minnesota
| | - Ryan Shanley
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota
| | - Noah D Kauff
- Ovarian Cancer Screening and Prevention, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Michael J O'Brien
- Department of Pathology and Laboratory Medicine, Boston University, Boston, Massachusetts
| | - Glenn M Mills
- Section of Hematology and Oncology, Louisiana State University Health, Shreveport, Louisiana
| | - Paul A Jordan
- Department of Medicine, Louisiana State University Health, Shreveport, Louisiana
| | - John A Allen
- Department of Medicine, Yale University, New Haven, Connecticut. Minnesota Gastroenterology, PA, Minneapolis, Minnesota
| | - Adam Kim
- Minnesota Gastroenterology, PA, Minneapolis, Minnesota
| | - Andrew D Feld
- Department of Gastroenterology, Group Health Cooperative, Seattle, Washington
| | - Ann Graham Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Sidney J Winawer
- Department of Gastroenterology and Nutrition Service, Memorial Sloan-Kettering Cancer Center, New York, New York
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Kondo T, Maruyama H, Kiyono S, Sekimoto T, Shimada T, Takahashi M, Okugawa H, Kobayashi S, Yoshizumi H, Yokosuka O. Similarities and differences in the clinical features between cardia varices and esophageal varices. J Gastroenterol Hepatol 2014; 29:1911-8. [PMID: 24909069 DOI: 10.1111/jgh.12647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Little is known about the clinical features of cardia varices (CV). The aim was to examine the background, bleeding risk, and post-treatment outcomes of CV in patients with portal hypertension. METHODS The subjects of this retrospective study were 277 patients (179 males, 98 females, 62.9 ± 11.5 years) with esophageal varices (EV). In patients with CV, there were 65 bleeders, and 95 patients received endoscopic treatment for primary or secondary prophylaxis. RESULTS There were 147 patients with CV (53.1%). The higher grade of EV (P < 0.01) and the lower grade of gastric fundal varices (FV) (P = 0.046) were significant factors for the presence of CV. Significant risk factors for bleeding were: the higher grade of EV (P < 0.01), red sign on EV (P < 0.01), lower albumin (P = 0.01), and Child-Pugh B/C (P < 0.01) for EV and red sign on CV (P < 0.01) and use of non-steroidal anti-inflammatory drugs (NSAIDs)/aspirin (P < 0.01) for CV. All CV disappeared by sclerotherapy combined with argon plasma coagulation or band ligation, and 20 patients (21.1%) in EV and 18 patients (18.9%) in CV had recurrences during the median observation period of 19.4 months. There was no significant difference in the cumulative survival rate between non-bleeders, bleeders from EV, and those from CV. CONCLUSIONS The CV were closely associated with advanced grade of EV and less-advanced grade of FV. Further, usage of NSAIDs/aspirin and red sign were significantly related to the bleeding from CV, suggesting the need for careful management.
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Affiliation(s)
- Takayuki Kondo
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, Chiba, Japan
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Parvinian A, Gaba RC. Outcomes of TIPS for Treatment of Gastroesophageal Variceal Hemorrhage. Semin Intervent Radiol 2014; 31:252-7. [PMID: 25177086 DOI: 10.1055/s-0034-1382793] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Variceal hemorrhage is a life-threatening complication of cirrhosis that requires a multidisciplinary approach to management. The transjugular intrahepatic portosystemic shunt (TIPS) procedure is a minimally invasive image-guided intervention used for secondary prevention of bleeding and as salvage therapy in acute hemorrhage. This review focuses on the role of TIPS in the setting of variceal hemorrhage, with emphasis on the pathophysiology and conventional management of variceal hemorrhage, current and emerging indications for TIPS creation, TIPS clinical outcomes, and the role of adjuvant embolotherapy.
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Affiliation(s)
- Ahmad Parvinian
- Division of Interventional Radiology, Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Ron C Gaba
- Division of Interventional Radiology, Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
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Di Pascoli L, Buja A, Bolognesi M, Montagnese S, Gatta A, Gregori D, Merkel C. Cost-effectiveness analysis of beta-blockers vs endoscopic surveillance in patients with cirrhosis and small varices. World J Gastroenterol 2014; 20:10464-10469. [PMID: 25132763 PMCID: PMC4130854 DOI: 10.3748/wjg.v20.i30.10464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 02/09/2014] [Accepted: 05/05/2014] [Indexed: 02/07/2023] Open
Abstract
AIM: To evaluate the most cost-effectiveness strategy for preventing variceal growth and bleeding in patients with cirrhosis and small esophageal varices.
METHODS: A stochastic analysis based on decision trees was performed to compare the cost-effectiveness of beta-blockers therapy starting from a diagnosis of small varices (Strategy 1) with that of endoscopic surveillance followed by beta-blockers treatment when large varices are demonstrated (Strategy 2), for preventing variceal growth, bleeding and death in patients with cirrhosis and small esophageal varices. The basic nodes of the tree were gastrointestinal endoscopy, inpatient admission and treatment for bleeding, as required. All estimates were performed using a Monte Carlo microsimulation technique, consisting in simulating observations from known probability distributions depicted in the model. Eight-hundred-thousand simulations were performed to obtain the final estimates. All estimates were then subjected to Monte Carlo Probabilistic sensitivity analysis, to assess the impact of the variability of such estimates on the outcome distributions.
RESULTS: The event rate (considered as progression of varices or bleeding or death) in Strategy 1 [24.09% (95%CI: 14.89%-33.29%)] was significantly lower than in Strategy 2 [60.00% (95%CI: 48.91%-71.08%)]. The mean cost (up to the first event) associated with Strategy 1 [823 £ (95%CI: 106 £-2036 £)] was not significantly different from that of Strategy 2 [799 £ (95%CI: 0 £-3498 £)]. The cost-effectiveness ratio with respect to this endpoint was equal to 50.26 £ (95%CI: -504.37 £-604.89 £) per event avoided over the four-year follow-up. When bleeding episodes/deaths in subjects whose varices had grown were included, the mean cost associated with Strategy 1 was 1028 £ (95%CI: 122 £-2581 £), while 1699 £ (95%CI: 171 £-4674 £) in Strategy 2.
CONCLUSION: Beta-blocker therapy turn out to be more effective and less expensive than endoscopic surveillance for primary prophylaxis of bleeding in patients with cirrhosis and small varices.
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Nusrat S, Khan MS, Fazili J, Madhoun MF. Cirrhosis and its complications: Evidence based treatment. World J Gastroenterol 2014; 20:5442-5460. [PMID: 24833875 PMCID: PMC4017060 DOI: 10.3748/wjg.v20.i18.5442] [Citation(s) in RCA: 155] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 01/17/2014] [Accepted: 02/20/2014] [Indexed: 02/06/2023] Open
Abstract
Cirrhosis results from progressive fibrosis and is the final outcome of all chronic liver disease. It is among the ten leading causes of death in United States. Cirrhosis can result in portal hypertension and/or hepatic dysfunction. Both of these either alone or in combination can lead to many complications, including ascites, varices, hepatic encephalopathy, hepatocellular carcinoma, hepatopulmonary syndrome, and coagulation disorders. Cirrhosis and its complications not only impair quality of life but also decrease survival. Managing patients with cirrhosis can be a challenge and requires an organized and systematic approach. Increasing physicians’ knowledge about prevention and treatment of these potential complications is important to improve patient outcomes. A literature search of the published data was performed to provide a comprehensive review regarding the management of cirrhosis and its complications.
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36
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Prophylactic impact of endoscopic treatment for esophageal varices in liver resection: a prospective study. J Gastroenterol 2014; 49:917-22. [PMID: 23775207 DOI: 10.1007/s00535-013-0841-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 05/21/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Prophylactic treatment for esophageal varices has been performed without adequate supporting evidence. We assessed the feasibility of prophylactic and follow-up treatment for high-risk esophageal varices in patients with hepatocellular carcinoma (HCC). METHODS Patients with HCC were screened prospectively and followed up for esophageal varices and gastroduodenal ulceration. High-risk esophageal varices (huge F3 varices or intermediate F2 varices positive for red color signs) were treated prophylactically. Follow-up endoscopy was performed to assess the impact of prophylaxis and changes in varices at 1 week, 1 month, and 6 months after operation. If high-risk varices were found during follow-up, secondary prophylaxis was performed according to the same criteria. RESULTS Among 251 patients with HCC, 81 (32.3 %) had esophageal varices on screening endoscopy. Prophylactic endoscopic treatment was required by 13 patients (1 with F3 varices and 12 with F2 varices positive for red color signs). Ten varices worsened, and 4 varices progressed to high-risk varices requiring endoscopic treatment. No F0 or F1 varices at screening endoscopy progressed to high-risk varices, and no bleeding event occurred during 6 months of preplanned follow-up. A preoperative platelet count of less than 10 × 10(4)/μL (odds ratio: 4.21, 95 % confidence interval 3.11-10.6; p < 0.001), the presence of splenomegaly (2.87, 2.16-21.8; p = 0.011), and an indocyanine green retention rate at 15 min of greater than 30 % (2.31, 1.88-24.6; p = 0.026) were independent predictors of worsening varices. CONCLUSIONS Our protocol for prophylactic and follow-up treatment of high-risk esophageal varices was feasible in patients with HCC.
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Zardi EM, Di Matteo FM, Pacella CM, Sanyal AJ. Invasive and non-invasive techniques for detecting portal hypertension and predicting variceal bleeding in cirrhosis: a review. Ann Med 2014; 46:8-17. [PMID: 24328372 PMCID: PMC4904298 DOI: 10.3109/07853890.2013.857831] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Portal hypertension is a severe syndrome that may derive from pre-sinusoidal, sinusoidal, and post-sinusoidal causes. As a consequence, several complications (i.e. ascites, oesophageal varices) may develop. In sinusoidal portal hypertension, hepatic venous pressure gradient (HVPG) is a reliable method for defining the grade of portal pressure, establishing the effectiveness of the treatment, and predicting the occurrence of complications; however, some questions exist regarding its ability to discriminate bleeding from non-bleeding varices in cirrhotic patients. Other imaging techniques (transient elastography, endoscopy, endosonography, and duplex Doppler sonography) for assessing causes and complications of portal hypertensive syndrome are available and may be valuable for the management of these patients. In this review, we evaluate invasive and non-invasive techniques currently employed to obtain a clinical prediction of deadly complications, such as variceal bleeding in patients affected by sinusoidal portal hypertension, in order to create a diagnostic algorithm to manage them. Again, HVPG appears to be the reference standard to evaluate portal hypertension and monitor the response to treatment, but its ability to predict several complications and support management decisions might be further improved through the diagnostic combination with other imaging techniques.
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Affiliation(s)
- Enrico Maria Zardi
- Department of Clinical Medicine, 'Campus Bio-Medico' University , Rome , Italy
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38
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Yoshida H, Mamada Y, Taniai N, Yoshioka M, Hirakata A, Kawano Y, Mizuguchi Y, Shimizu T, Ueda J, Uchida E. Risk factors for bleeding esophagogastric varices. J NIPPON MED SCH 2014; 80:252-9. [PMID: 23995567 DOI: 10.1272/jnms.80.252] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Bleeding from gastric varices (GVs) is generally considered more severe than that from esophageal varices (EVs) but occurs less frequently. We review the risk factors for bleeding EVs and GVs. GVs were divided into 2 groups: cardiac varices (CVs, Lg-c) and fundal varices (FVs), i.e., varices involving the fundus alone (Lg-f) or varices involving both the cardia and fundus (Lg-cf). Elevated pressure in the portal vein is a risk factor for bleeding EVs. The portal pressure in patients with GVs and a gastrorenal shunt is lower than that in patients with EVs. The large size of varices is a risk factor for bleeding EVs. Red color signs are elevated red areas that are important for predicting the risk of variceal bleeding, and red wale markings, dilated venules oriented longitudinally on the mucosal surface, have been considered to be the sign with the highest risk. Red color signs are rare in FVs, possibly because of the pronounced thickness of the mucosal layer. Bleeding EVs are not associated with use of antiulcer drugs or nonsteroidal anti-inflammatory drugs (NSAIDs). Although, in patients with bleeding GVs, "occasional" use of an oral NSAID is an important step leading to variceal hemorrhage, especially from FVs, even if the mucosa is protected by antiulcer drugs. Constipation, vomiting, severe coughing, and excessive consumption of alcohol may precipitate rupture of EVs.
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Affiliation(s)
- Hiroshi Yoshida
- Department of Surgery, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan.
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Turon F, Casu S, Hernández-Gea V, Garcia-Pagán JC. Variceal and other portal hypertension related bleeding. Best Pract Res Clin Gastroenterol 2013; 27:649-64. [PMID: 24160925 DOI: 10.1016/j.bpg.2013.08.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 08/11/2013] [Indexed: 02/06/2023]
Abstract
Variceal bleeding is one of the commonest and most severe complications of liver cirrhosis. Even with the current best medical care, mortality from variceal bleeding is still around 20%. When cirrhosis is diagnosed, varices are present in about 30-40% of compensated patients and in 60% of those who present with ascites. Once varices have been diagnosed, the overall incidence of variceal bleeding is in the order of 25% at two years. Variceal size is the most useful predictor for variceal bleeding, other predictors are severity of liver dysfunction (Child-Pugh classification) and the presence of red wale marks on the variceal wall. The current consensus is that every cirrhotic patient should be endoscopically screened for varices at the time of diagnosis to detect those requiring prophylactic treatment. Non-selective beta-adrenergic blockers (NSBB) and endoscopic band ligation (EBL) have been shown effective in the prevention of first variceal bleeding. The current recommendation for treating acute variceal bleeding is to start vasoactive drug therapy early (ideally during the transferral or to arrival to hospital, even if active bleeding is only suspected) and performing EBL. Once bleeding is controlled, combination therapy with NSBB + EBL should be used to prevent rebleeding. In patients at high risk of treatment failure despite of using this approach, an early covered-TIPS within 72 h (ideally 24 h) should be considered. Data on management of gastric variceal bleeding is limited. No clear recommendation for primary prophylaxis can be done. In acute cardiofundal variceal bleeding, vasoactive agents together with cyanoacrylate (CA) injection seem to be the treatment of choice. Further CA injections and/or NSBB may be used to prevent rebleeding. TIPS or Balloon-occluded retrograde transvenous obliteration when TIPS is contraindicated may be used as a rescue therapy.
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Affiliation(s)
- Fanny Turon
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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40
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Merkel C, Montagnese S, Amodio P. Primary prophylaxis of bleeding from esophageal varices in cirrhosis. J Clin Exp Hepatol 2013; 3:198-203. [PMID: 25755501 PMCID: PMC3940186 DOI: 10.1016/j.jceh.2013.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 08/02/2013] [Indexed: 12/12/2022] Open
Abstract
Prophylaxis of the first bleeding from esophageal varices became a clinical option more than 20 years ago, and gained a large diffusion in the following years. It is based on the use of nonselective beta-blockers, which decreases portal pressure, or on the eradication of esophageal varices by endoscopic band ligation of varices. In patients with medium or large varices either of these treatments is indicated. In patients with small varices only medical treatment is feasible, and in patients with medium and large varices with contraindication or side-effects due to beta-blockers, only endoscopic band ligation may be used. In this review the rationale and the results of the prophylaxis of bleeding from esophageal varices are discussed.
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Affiliation(s)
- Carlo Merkel
- Department of Medicine DIMED, University of Padua, Via Giustiniani, 2, I-35126 Padova, Italy
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41
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Sakamoto Y, Oho K, Toyonaga A, Kumamoto M, Haruta T, Inoue H, Emori K, Tsuruta O, Sata M. Effect of Helicobacter pylori infection on esophagogastric variceal bleeding in patients with liver cirrhosis and portal hypertension. J Gastroenterol Hepatol 2013; 28:1444-9. [PMID: 23577833 DOI: 10.1111/jgh.12221] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/27/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Bleeding from esophageal and gastric varices is a fatal event in patients with liver cirrhosis and portal hypertension. However, the effects of Helicobacter pylori (H. pylori) infection on esophagogastric variceal bleeding are not known. The present study was aimed to elucidate the role of H. pylori infection in esophagogastric variceal bleeding. METHODS The subjects were 196 cirrhotic patients who were admitted to the Kurume University Hospital to treat their esophagogastric varices consisted of 95 with acute bleeding and 101 with nonbleeding but high risk of bleeding. For the diagnosis of H. pylori infection, a (13) C-urea breath test was used, and serum pepsinogen (PG) I and II levels and the PG I/II ratio were also measured. RESULTS Esophagogastric variceal bleeding was seen in 34.9% (n = 30) of the H. pylori-infected patients (n = 86) and in 59.1% (n = 65) of the noninfected patients (n = 110) (P < 0.0007). There was no significant difference in the infection rate between the bleeding sites of the esophagus and the stomach. The serum PG I and II levels and the PG I/II ratio were 65.6 ng/dL, 14.7 ng/dL, and 4.4, respectively, for the bleeding patients (n = 95), and 43.7 ng/dL, 17.7 ng/dL, and 3.1 for the nonbleeding patients (n = 101). Thus, the nonbleeding patients had significantly higher rate of H. pylori infection and lower acid secretion than bleeding patients (0.001). In addition, multivariate logistic regression analysis showed a significant negative association between H. pylori infection and esophagogastric variceal bleeding. CONCLUSIONS These results suggest that H. pylori infection has a protective effect against esophagogastric variceal bleeding through the induction of gastric mucosal atrophy and concomitant hypoacidity.
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Affiliation(s)
- Yoshihiro Sakamoto
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan; Division of GI Endoscopy, Digestive Disease Center, Kurume University Hospital, Kurume, Fukuoka, Japan
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Narváez-Rivera RM, Cortez-Hernández CA, González-González JA, Tamayo-de la Cuesta JL, Zamarripa-Dorsey F, Torre-Delgadillo A, Rivera-Ramos JFJ, Vinageras-Barroso JI, Muneta-Kishigami JE, Blancas-Valencia JM, Antonio-Manrique M, Valdovinos-Andraca F, Brito-Lugo P, Hernández-Guerrero A, Bernal-Reyes R, Sobrino-Cossío S, Aceves-Tavares GR, Huerta-Guerrero HM, Moreno-Gómez N, Bosques-Padilla FJ. [Mexican consensus on portal hypertension]. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2013; 78:92-113. [PMID: 23664429 DOI: 10.1016/j.rgmx.2013.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Revised: 11/30/2012] [Accepted: 01/21/2013] [Indexed: 02/07/2023]
Abstract
The aim of the Mexican Consensus on Portal Hypertension was to develop documented guidelines to facilitate clinical practice when dealing with key events of the patient presenting with portal hypertension and variceal bleeding. The panel of experts was made up of Mexican gastroenterologists, hepatologists, and endoscopists, all distinguished professionals. The document analyzes themes of interest in the following modules: preprimary and primary prophylaxis, acute variceal hemorrhage, and secondary prophylaxis. The management of variceal bleeding has improved considerably in recent years. Current information indicates that the general management of the cirrhotic patient presenting with variceal bleeding should be carried out by a multidisciplinary team, with such an approach playing a major role in the final outcome. The combination of drug and endoscopic therapies is recommended for initial management; vasoactive drugs should be started as soon as variceal bleeding is suspected and maintained for 5 days. After the patient is stabilized, urgent diagnostic endoscopy should be carried out by a qualified endoscopist, who then performs the corresponding endoscopic variceal treatment. Antibiotic prophylaxis should be regarded as an integral part of treatment, started upon hospital admittance and continued for 5 days. If there is treatment failure, rescue therapies should be carried out immediately, taking into account that interventional radiology therapies are very effective in controlling refractory variceal bleeding. These guidelines have been developed for the purpose of achieving greater clinical efficacy and are based on the best evidence of portal hypertension that is presently available.
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Affiliation(s)
- R M Narváez-Rivera
- Servicio de Gastroenterología, Departamento de Medicina Interna, Hospital Universitario «Dr. José Eleuterio González», Monterrey, N.L., México
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Simonetto DA, Shah VH. Primary prophylaxis of esophageal variceal bleeding. Clin Liver Dis (Hoboken) 2012; 1:147-150. [PMID: 31186875 PMCID: PMC6499289 DOI: 10.1002/cld.92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Douglas A. Simonetto
- Gastroenterology Research Unit, Advanced Liver Disease Study Group, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Vijay H. Shah
- Gastroenterology Research Unit, Advanced Liver Disease Study Group, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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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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45
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Ferro D, Angelico F, Caldwell SH, Violi F. Bleeding and thrombosis in cirrhotic patients: what really matters? Dig Liver Dis 2012; 44:275-279. [PMID: 22119620 DOI: 10.1016/j.dld.2011.10.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 10/13/2011] [Accepted: 10/20/2011] [Indexed: 12/11/2022]
Abstract
Bleeding complications, particularly in the gastro-intestinal tract, may complicate the clinical course of liver cirrhosis. Coexistence of abnormal global tests exploring the platelet and clotting systems generated the hypothesis that cirrhotic patients have "coagulopathy" predisposing to bleeding complications. Using more sophisticated laboratory methods this hypothesis has been partly confuted as cirrhotic patients actually disclose an ongoing prothrombotic state in the portal and systemic circulation that could predispose to thrombosis. Recent data of the literature support this hypothesis as portal vein thrombosis and peripheral thrombosis are frequent features of cirrhosis. We reviewed the literature data to assess the prevalence of bleeding and thrombotic complication in cirrhosis and the role of clotting activation in precipitating them. Whilst it appears scarcely relevant the interplay between the so called "coagulopathy" and bleeding, the interplay between clotting activation and thrombosis seems to be relevant but needs more accurate investigation in larger study populations.
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Affiliation(s)
- Domenico Ferro
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy
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46
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Esmat S, Omarn D, Rashid L. Can we consider the right hepatic lobe size/albumin ratio a noninvasive predictor of oesophageal varices in hepatitis C virus-related liver cirrhotic Egyptian patients? Eur J Intern Med 2012; 23:267-272. [PMID: 22385886 DOI: 10.1016/j.ejim.2011.11.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 10/22/2011] [Accepted: 11/17/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND The current guidelines recommend the screening of all cirrhotic patients by endoscopy, but repeated endoscopic examinations are unpleasant for patients and have a high cost impact and burden on endoscopic units. The aim of this study is to evaluate the optimal liver lobe size/albumin ratio and to compare this ratio with spleen size, platelet count and platelet count/spleen diameter ratio as potential noninvasive predictors of oesophageal varices in hepatitis C virus (HCV)-related liver cirrhosis in Egyptian patients. METHODS This prospective study included one hundred patients with HCV-related liver cirrhosis. All studied subjects underwent a detailed clinical examination, biochemical workup, upper gastrointestinal endoscopy and abdominal ultrasound. The platelet count/spleen diameter ratio and the right liver lobe/albumin concentration ratio for all patients were calculated. RESULTS The 4 predictors demonstrated a high statistically significant correlation with the presence and grade of oesophageal varices (P values<0.001). The platelet count/spleen diameter ratio had the highest accuracy, followed by the right liver lobe/albumin concentration ratio, spleen size and then platelet count. CONCLUSION The use of the studied noninvasive predictors, especially the platelet count/spleen diameter ratio and the right liver lobe/albumin concentration ratio, can help physicians by restricting the use of endoscopic screening only to patients presenting a high probability of oesophageal varices. This is especially useful in clinical settings where resources are limited and endoscopic facilities are not present in all areas. Such is the case in Egypt, where there is a large number of patients who require oesophageal screening for oesophageal varices.
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Affiliation(s)
- Serag Esmat
- Department of Internal Medicine, Faculty of Medicine, Cairo University, Egypt.
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Pathophysiology of portal hypertension and esophageal varices. Int J Hepatol 2012; 2012:895787. [PMID: 22666604 PMCID: PMC3362051 DOI: 10.1155/2012/895787] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Revised: 03/02/2012] [Accepted: 03/12/2012] [Indexed: 02/07/2023] Open
Abstract
Esophageal varices are the major complication of portal hypertension. It is detected in about 50% of cirrhosis patients, and approximately 5-15% of cirrhosis patients show newly formed varices or worsening of varices each year. The major therapeutic strategy of esophageal varices consists of primary prevention, treatment for bleeding varices, and secondary prevention, which are provided by pharmacological, endoscopic, interventional and surgical treatments. Optimal management of esophageal varices requires a clear understanding of the pathophysiology and natural history. In this paper, we outline the current knowledge and future prospect in the pathophysiology of esophageal varices and portal hypertension.
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Primary prophylaxis of variceal hemorrhage in children with portal hypertension: a framework for future research. J Pediatr Gastroenterol Nutr 2011; 52:254-61. [PMID: 21336158 PMCID: PMC3728696 DOI: 10.1097/mpg.0b013e318205993a] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Nonselective β-blocker therapy and endoscopic variceal ligation reduce the incidence of variceal hemorrhage in cirrhotic adults, but their use in children is controversial. There are no evidence-based recommendations for the prophylactic management of children at risk of variceal hemorrhage due to the lack of appropriate randomized controlled trials. In a recent gathering of experts at the American Association for the Study of Liver Diseases annual meeting, significant challenges were identified in attempting to design and implement a clinical trial of primary prophylaxis in children using either of these therapies. These challenges render such a trial unfeasible, primarily due to the large sample size required, inadequate knowledge of appropriate dosing of β-blockers, and difficulty in recruiting to a trial of endoscopic variceal ligation. Pediatric research should focus on addressing questions of natural history and diagnosis of varices, prediction of variceal bleeding, optimal approaches to β-blocker and ligation therapy, and alternative study designs to explore therapeutic efficacy in children.
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Gluud LL, Langholz E, Krag A. Meta-analysis: isosorbide-mononitrate alone or with either beta-blockers or endoscopic therapy for the management of oesophageal varices. Aliment Pharmacol Ther 2010; 32:859-71. [PMID: 20839387 DOI: 10.1111/j.1365-2036.2010.04418.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The evidence concerning the use of isosorbide-mononitrate (IsMn) for oesophageal varices is equivocal. AIM To assess the effects of IsMn for patients with oesophageal varices and no previous bleeding (primary prevention) or previous variceal bleeding (secondary prevention). METHODS Systematic review with meta-analyses of randomized trials on IsMn alone or with beta-blockers or endoscopic therapy for oesophageal varices. Electronic and manual searches were combined. Randomized trials on primary and secondary prevention were included. The primary outcome measure was mortality. Intention-to-treat random effects meta-analyses were performed. The robustness of the results was assessed in trial sequential analyses. RESULTS Ten randomized trials on primary and 17 on secondary prevention were included. Evidence of bias was identified. No apparent effect of IsMn on mortality compared with placebo or beta-blockers or IsMn plus beta-blockers vs. beta-blockers was identified. Compared with endoscopic therapy, IsMn plus beta-blockers had no apparent effect on bleeding, but did seem to reduce mortality in secondary prevention (RR 0.73, 95% CI 0.59-0.89), but not in primary prevention. The effect of IsMn plus beta-blockers on mortality in secondary prevention was not confirmed in trial sequential analysis. CONCLUSIONS Isosorbide-mononitrate used alone or in combination with beta blockers does not seem to offer any reduction in bleeding in the primary or secondary prevention of oesophageal varices. Compared with endoscopic therapy, there may be a survival advantage in using IsMn and beta-blockers, but additional large multicentre trials are needed to verify this finding.
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Affiliation(s)
- L L Gluud
- Department of Internal Medicine, Copenhagen University Hospital, Gentofte, Denmark.
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Moodley J, Lopez R, Carey W. Compliance with practice guidelines and risk of a first esophageal variceal hemorrhage in patients with cirrhosis. Clin Gastroenterol Hepatol 2010; 8:703-8. [PMID: 20226879 DOI: 10.1016/j.cgh.2010.02.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Revised: 02/22/2010] [Accepted: 02/27/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Esophageal variceal hemorrhage (EVH) is a serious complication of cirrhosis, with 20% mortality per episode. The 2007 American Association for the Study of Liver Disease and American College of Gastroenterology practice guidelines regarding esophageal varices in patients with cirrhosis recommend screening and intervention to prevent EVH. We assessed practice guideline compliance and its impact on the rate of first EVH. METHODS An institutional review board-approved retrospective chart review was conducted on a random sample of adult patients newly evaluated for cirrhosis at the Cleveland Clinic from 2003 to 2006 (n = 179). Exclusion criteria were a previous diagnosis of esophageal varices or EVH and/or treatment with beta-adrenergic antagonists. Patients were followed for 23 months (range, 9-38 months). Conformity with practice guidelines and subsequent bleeding rates were determined. Observed bleeding rates were compared to the North Italian Endoscopy Club (NIEC) model. RESULTS Of the patients, 94% had a screening endoscopy, 80% within 6 months of the initial visit. Varices were present in 50% of the patients; 68% of all patients screened and 91% with large varices received a practice guideline-recommended treatment. Twelve patients (7%) had an episode of EVH; 82% of subjects without bleeding had their screening endoscopy within 6 months versus 50% of those with bleeding (P = .016). Actuarial likelihood of bleeding at 2 years was 13% versus 27% predicted by the NIEC model (P < .05). CONCLUSION Compliance with practice guideline recommendations is associated with reduction in first EVH in the first 2 years.
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Affiliation(s)
- Jayavani Moodley
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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