|
1
|
Ponte SB, Oliveira J, Rei A, Salgueiro P. Treatment of Hemorrhoidal Disease in Patients with Liver Cirrhosis: A Systematic Review. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2025; 32:95-108. [PMID: 40171091 PMCID: PMC11961092 DOI: 10.1159/000540702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 07/30/2024] [Indexed: 04/03/2025]
Abstract
Introduction The incidence of hemorrhoidal disease (HD) in cirrhotic patients is similar to that of general population, varying between 21% and 79%. Managing this clinical condition in these patients is challenging, due to the need to differentiate between bleeding originating from hemorrhoids or anorectal varices, and the unique hemostatic balance of each patient, which can lead to a decompensation of liver function and subsequently increase the anesthetic risk. To date, there are no systematic reviews specifically addressing this topic. Methods This was a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were retrieved from three electronic databases. Efficacy (symptomatic improvement, patient satisfaction, quality of life improvement, disease recurrence/need for surgery and/or hemorrhoidal prolapse reduction in anoscopy) and safety (reported adverse events) outcomes were evaluated. Data from each study were initially described individually, followed by a comparative analysis for procedures applied in multiple studies. Results Six studies were included - 1 randomized clinical trial (RCT), 2 prospective cohort studies, 1 retrospective cohort study, and 2 case series. The considered techniques encompassed rubber band ligation (RBL), injection sclerotherapy (IS) using 3 agents - aluminum potassium sulfate and tannic acid (ALTA), ethanolamine oleate 5% (EAO), or N-butyl-cyanoacrylate, hemorrhoidopexy, and emborrhoid technique. RBL showed great symptomatic improvement and patient satisfaction in 63% and 73% of patients, respectively, and in 90% was associated with one-grade prolapse reduction after only one session. The most frequently reported adverse events included pain (16%) and ulceration/fissure (1-17%). Concerning IS, symptomatic improvement was observed in all patients. Recurrence rates varied with the agent used (EAO: 13% at 12 months; N-butyl-cyanoacrylate: 40% at 12 months; ALTA: 18% at 5 years), and 86.7% of patients exhibited more than one-grade reduction after the initial session. The most frequent adverse event was pain (EAO: 63%; N-butyl-cyanoacrylate: 60%). Stapled hemorrhoidopexy resulted in symptomatic improvement in all patients, although associated with a recurrence rate of 25% within 4 months. With an emborrhoid technique, 80% of the patients showed clinical improvement at a 3-month follow-up, without significant adverse events, at the cost of a 40% recurrence rate. Conclusions All the treatment methods assessed in the included studies appear to be effective and safe in cirrhotic patients. This assumption challenges previous concerns regarding significant bleeding after office-based procedures like RBL in this population. Future research should prioritize RCT to thoroughly assess the management of HD in these patients, particularly addressing polidocanol foam sclerotherapy, a minimally invasive technique that has previously been shown to be more effective than RBL in the general population and in patients with bleeding disorders.
Collapse
Affiliation(s)
- Sofia Bizarro Ponte
- Department of Gastroenterology, Unidade Local de Saúde de Santo António, Porto, Portugal
| | - Joana Oliveira
- Instituto de Ciências Biomédicas Abel Salazar da Universidade do Porto, Porto, Portugal
| | - Andreia Rei
- Department of Gastroenterology, Unidade Local de Saúde de Santo António, Porto, Portugal
| | - Paulo Salgueiro
- Department of Gastroenterology, Unidade Local de Saúde de Santo António, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar da Universidade do Porto, Porto, Portugal
| |
Collapse
|
|
2
|
Daðadóttir SM, Ingason AB, Hreinsson JP, Björnsson ES. Comparison of gastrointestinal bleeding in patients with and without liver cirrhosis. Scand J Gastroenterol 2024; 59:1081-1086. [PMID: 39105571 DOI: 10.1080/00365521.2024.2386451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2024] [Revised: 07/15/2024] [Accepted: 07/26/2024] [Indexed: 08/07/2024]
Abstract
OBJECTIVES Upper gastrointestinal bleeding (GIB) in patients has been well-characterized in liver cirrhosis but studies on lower GIB are limited. The clinical characteristics, management and outcomes in patients with and without liver cirrhosis was compared to determine the overall features of GIB in patients with liver cirrhosis compared with non-cirrhotics. METHODS A retrospective study on cirrhotics hospitalized for GIB 2010-2021, matched with control group of non-cirrhotics (1:4) for upper vs. lower GIB. Patients with overt bleeding leading to hospitalization were included. RESULTS Overall, 396 patients had cirrhosis, 267 (67%) men, median age 62, alcoholic etiology 177/396 (45%), median MELD 12 (range 6-32). Overall 102 cirrhotics had GIB, matched with 391 non-cirrhotics. Overall 87 (85%) cirrhotic patients had upper and 15% lower GIB. Compared to non-cirrhotics, the cause of GIB was more commonly acute variceal bleeding (AVB) (42% vs. 1%), hemorrhoids 40% vs. 6% (p = 0.002), less commonly gastric ulcer 13% vs. 31% (p < 0.001), duodenal ulcer 9% vs. 29% (p < 0.001), 5% of cirrhotics used NSAIDs vs. 26% of controls (p < 0.001). Rebleeding occurred in 14% of cirrhotics vs. 3% in controls (p < 0.001). Only one cirrhotic patient (1%) died from GIB vs. 0.8% of controls within 45 days. Overall mortality 45 days after hospitalization was 10% in cirrhotics vs. 5% in controls (p < 0.001). CONCLUSIONS Bleeding from gastric and duodenal ulcers were less common in cirrhotics than in controls. Bleeding from hemorrhoids was more common in cirrhotics. Mortality due to GIB was low in both groups but overall mortality was significantly higher in cirrhotics.
Collapse
Affiliation(s)
| | | | - Johann Pall Hreinsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Einar Stefan Björnsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Division of Gastroenterology, Landspitali University, Reykjavik, Iceland
| |
Collapse
|
|
3
|
Afzal A, Kesavan P, Suhong L, Gage BF, Korenblat K, Schoen M, Sanfilippo K. Predictors of Non-Variceal Hemorrhage in a National Cohort of Patients With Chronic Liver Disease. J Hematol 2024; 13:71-78. [PMID: 38993731 PMCID: PMC11236355 DOI: 10.14740/jh1214] [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: 01/25/2024] [Accepted: 05/04/2024] [Indexed: 07/13/2024] Open
Abstract
Background Non-variceal hemorrhage in patients with chronic liver disease (CLD) increases morbidity, mortality, and healthcare costs. There are limited data on risk factors for non-variceal hemorrhage in the CLD population. The aim of this study was to assess the predictive value of various clinical and laboratory parameters for non-variceal hemorrhage in CLD patients. Methods We conducted a retrospective cohort study of US veterans diagnosed with CLD between 2002 and 2018 within the Veterans Health Administration database. We derived candidate variables from existing risk prediction models for hemorrhage, risk calculators for severity of liver disease, Charlson index of prognostic comorbidities, and prior literature. We used a competing risk analysis to study the relationship between putative risk factors and incidence of non-variceal hemorrhage in patients with CLD. Results Of 15,183 CLD patients with no history of cancer or anticoagulation use, 674 experienced non-variceal hemorrhage within 1 year of CLD diagnosis. In multivariable analysis, 11 of the 26 candidate variables independently predicted non-variceal hemorrhage: race, international normalized ratio (INR) > 1.5, bilirubin ≥ 2 mg/dL, albumin ≤ 3.5 g/dL, anemia, alcohol abuse, antiplatelet therapy, chronic kidney disease, dementia, proton pump inhibitor prescription, and recent infection. Conclusions In this study of almost 15,000 veterans, risk factors for non-variceal bleeding within the first year after diagnosis of CLD included non-Caucasian race, laboratory parameters indicating severe liver disease and recent infection in addition to the risk factors for bleeding observed in a general non-CLD population.
Collapse
Affiliation(s)
- Amber Afzal
- Division of Hematology, Department of Medicine, Washington University in St Louis, MO, USA
- These authors contributed equally to the study
| | - Preethi Kesavan
- Department of Medicine, Washington University in St. Louis, MO, USA
- These authors contributed equally to the study
| | - Luo Suhong
- Division of Oncology, Department of Medicine, John Cochran VA Medical Center, St. Louis, MO, USA
| | - Brian F Gage
- Department of Medicine, Washington University in St. Louis, MO, USA
| | - Kevin Korenblat
- Division of Gastroenterology, Department of Medicine, Washington University in St. Louis, MO, USA
| | - Martin Schoen
- Division of Oncology, Department of Medicine, John Cochran VA Medical Center, St. Louis, MO, USA
| | - Kristen Sanfilippo
- Division of Hematology, Department of Medicine, Washington University in St Louis, MO, USA
- Division of Oncology, Department of Medicine, John Cochran VA Medical Center, St. Louis, MO, USA
| |
Collapse
|
|
4
|
Kim JH, Kim SE, Song DS, Kim HY, Yoon EL, Kang SH, Jung YK, Kwon JH, Lee SW, Han SK, Chang Y, Jeong SW, Yoo JJ, Jin YJ, Cheon GJ, Kim BS, Seo YS, Kim H, Park JW, Kim TH, Sinn DH, Chung WJ, Kim HY, Lee HA, Nam SW, Kim IH, Kim JH, Chae HB, Sohn JH, Cho JY, Park JG, Cho HC, Kim YJ, Yang JM, Suk KT, Kim MY, Kim SG, Yim HJ, Kim W, Jang JY, Kim DJ. The Clinical Courses and Prognosis of Cirrhotic Patients after First Acute Decompensation: Prospective Cohort Study. Diagnostics (Basel) 2023; 14:14. [PMID: 38201324 PMCID: PMC10795755 DOI: 10.3390/diagnostics14010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/15/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND The European Foundation for the Study of Chronic Liver Failure (EF-CLIF) consortium suggested that the clinical courses after acute decompensation (AD) stratify the long-term prognosis: stable decompensated cirrhosis (SDC), unstable decompensated cirrhosis (UDC), pre acute-on-chronic liver failure (pre ACLF), and ACLF. However, previous studies included patients with a history of previous AD and had limitations associated with identifying the clinical factors related to prognosis after the first AD. METHOD The prospective Korean Acute-on-Chronic Liver Failure (KACLiF) cohort included cirrhotic patients who were hospitalised with first AD between July 2015 and August 2018. We analysed the factors associated with readmission after the first AD and compared the characteristics and prognosis among each subgroup to evaluate the risk factors for the occurrence of pre ACLF after AD. RESULT A total of 746 cirrhotic patients who were hospitalised with first AD were enrolled. The subgroups consisted of SDC (n = 565), UDC (n = 29), pre ACLF (n = 28), and ACLF (n = 124). Of note, pre ACLF showed a poorer prognosis than ACLF. The risk factors associated with readmission within 3 months of first AD were non-variceal gastrointestinal (GI) bleeding, hepatic encephalopathy (HE), and high MELD score. Viral aetiology was associated with the occurrence of pre ACLF compared with alcohol aetiology regardless of baseline liver function status. CONCLUSION Cirrhotic patients with first AD who present as non-variceal GI bleeding and HE can easily relapse. Interestingly, the occurrence of AD with organ failure within 3 months of first AD (pre ACLF) has worse prognosis compared with the occurrence of organ failure at first AD (ACLF). In particular, cirrhotic patients with viral hepatitis with/without alcohol consumption showed poor prognosis compared to other aetiologies. Therefore, patients with ACLF after AD within 3 months should be treated more carefully and definitive treatment through LT should be considered.
Collapse
Affiliation(s)
- Jung Hee Kim
- Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea; (J.H.K.); (H.K.); (K.T.S.); (D.J.K.)
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon 24252, Republic of Korea
| | - Sung-Eun Kim
- Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea; (J.H.K.); (H.K.); (K.T.S.); (D.J.K.)
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon 24252, Republic of Korea
| | - Do Seon Song
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (D.S.S.); (H.Y.K.); (J.H.K.); (S.W.L.); (J.M.Y.)
| | - Hee Yeon Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (D.S.S.); (H.Y.K.); (J.H.K.); (S.W.L.); (J.M.Y.)
| | - Eileen L. Yoon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul 04763, Republic of Korea; (E.L.Y.); (J.H.S.)
| | - Seong Hee Kang
- Department of Internal Medicine, Korea University Medical Center, Seoul 02841, Republic of Korea; (S.H.K.); (Y.S.S.); (J.H.K.); (H.J.Y.)
| | - Young-Kul Jung
- Department of Internal Medicine, Korea University Medical Center, Seoul 02841, Republic of Korea; (S.H.K.); (Y.S.S.); (J.H.K.); (H.J.Y.)
| | - Jung Hyun Kwon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (D.S.S.); (H.Y.K.); (J.H.K.); (S.W.L.); (J.M.Y.)
| | - Sung Won Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (D.S.S.); (H.Y.K.); (J.H.K.); (S.W.L.); (J.M.Y.)
| | - Seul Ki Han
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea; (S.K.H.); (M.Y.K.)
| | - Young Chang
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul 04401, Republic of Korea; (Y.C.); (S.W.J.); (J.-Y.J.)
| | - Soung Won Jeong
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul 04401, Republic of Korea; (Y.C.); (S.W.J.); (J.-Y.J.)
| | - Jeong Ju Yoo
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon 14584, Republic of Korea; (J.J.Y.); (S.G.K.)
| | - Young-Joo Jin
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon 22212, Republic of Korea;
| | - Gab Jin Cheon
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung 25440, Republic of Korea;
| | - Byung Seok Kim
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu 42472, Republic of Korea;
| | - Yeon Seok Seo
- Department of Internal Medicine, Korea University Medical Center, Seoul 02841, Republic of Korea; (S.H.K.); (Y.S.S.); (J.H.K.); (H.J.Y.)
| | - Hyoungsu Kim
- Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea; (J.H.K.); (H.K.); (K.T.S.); (D.J.K.)
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon 24252, Republic of Korea
| | - Ji Won Park
- Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea; (J.H.K.); (H.K.); (K.T.S.); (D.J.K.)
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon 24252, Republic of Korea
| | - Tae Hyung Kim
- Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea; (J.H.K.); (H.K.); (K.T.S.); (D.J.K.)
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon 24252, Republic of Korea
| | - Dong Hyun Sinn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06531, Republic of Korea;
| | - Woo Jin Chung
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu 42601, Republic of Korea;
| | - Hwi Young Kim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul 07804, Republic of Korea (H.A.L.)
| | - Han Ah Lee
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul 07804, Republic of Korea (H.A.L.)
| | - Seung Woo Nam
- Department of Internal Medicine, National Medical Center, Seoul 04564, Republic of Korea;
| | - In Hee Kim
- Department of Internal Medicine, Chonbuk National University Hospital, Chonbuk National University Medical School, Jeonju 54896, Republic of Korea;
| | - Ji Hoon Kim
- Department of Internal Medicine, Korea University Medical Center, Seoul 02841, Republic of Korea; (S.H.K.); (Y.S.S.); (J.H.K.); (H.J.Y.)
| | - Hee Bok Chae
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju 28644, Republic of Korea;
| | - Joo Hyun Sohn
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul 04763, Republic of Korea; (E.L.Y.); (J.H.S.)
| | - Ju Yeon Cho
- Department of Internal Medicine, College of Medicine, Chosun University, Gwangju 61452, Republic of Korea;
| | - Jung Gil Park
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu 42415, Republic of Korea;
| | - Hyun Chin Cho
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju 52727, Republic of Korea;
| | - Yoon Jun Kim
- Department of Internal Medicine, Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Jin Mo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (D.S.S.); (H.Y.K.); (J.H.K.); (S.W.L.); (J.M.Y.)
| | - Ki Tae Suk
- Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea; (J.H.K.); (H.K.); (K.T.S.); (D.J.K.)
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon 24252, Republic of Korea
| | - Moon Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea; (S.K.H.); (M.Y.K.)
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon 14584, Republic of Korea; (J.J.Y.); (S.G.K.)
| | - Hyung Joon Yim
- Department of Internal Medicine, Korea University Medical Center, Seoul 02841, Republic of Korea; (S.H.K.); (Y.S.S.); (J.H.K.); (H.J.Y.)
| | - Won Kim
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea;
| | - Jae-Young Jang
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul 04401, Republic of Korea; (Y.C.); (S.W.J.); (J.-Y.J.)
| | - Dong Joon Kim
- Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea; (J.H.K.); (H.K.); (K.T.S.); (D.J.K.)
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon 24252, Republic of Korea
| |
Collapse
|
|
5
|
Kruger AJ, Abougergi MS, Jalil S, Sobotka LA, Wellner MR, Porter KM, Conteh LF, Kelly SG, Mumtaz K. Outcomes of Nonvariceal Upper Gastrointestinal Bleeding in Patients With Cirrhosis: A National Analysis. J Clin Gastroenterol 2023; 57:848-853. [PMID: 35960536 DOI: 10.1097/mcg.0000000000001746] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 06/26/2022] [Indexed: 12/10/2022]
Abstract
GOALS We sought to evaluate hospital outcomes of cirrhosis patients with nonvariceal upper gastrointestinal bleeding (NVUGIB). BACKGROUND NVUGIB is common in patients with cirrhosis. However, national outcome studies of these patients are lacking. STUDY We utilized the 2014 Nationwide Readmission Database to evaluate NVUGIB in patients with cirrhosis, further stratified as no cirrhosis (NC), compensated cirrhosis (CC), or decompensated cirrhosis (DC). Validated International Classification of Diseases, Ninth Revision, Clinical Modification codes captured diagnoses and interventions. Outcomes included 30-day readmission rates, index admission mortality rates, health care utilization, and predictors of readmission and mortality using multivariable regression analysis. RESULTS Overall, 13,701 patients with cirrhosis were admitted with NVUGIB. The 30-day readmission rate was 20.8%. Patients with CC were more likely to undergo an esophagogastroduodenoscopy (EGD) within 1 calendar day of admission (74.1%) than patients with DC (67.9%) or NC (69.4%). Patients with DC had longer hospitalizations (4.1 d) and higher costs of care ($11,834). The index admission mortality rate was higher in patients with DC (6.2%) than in patients with CC (1.7%, P <0.001) or NC (1.4%, P <0.001). Predictors of 30-day readmission included performing an EGD >1 calendar day from admission (OR: 1.21; 95% CI, 1.00 to 1.46) and DC (OR: 1.78; 95% CI, 1.54 to 2.06). DC was a predictor of index admission mortality (OR: 3.68; 95% CI, 2.67 to 5.05). CONCLUSIONS NVUGIB among patients with DC is associated with higher readmission rates, mortality rates, and health care utilization compared with patients with CC and NC. Early EGD is a modifiable variable associated with reduced readmission rates. Early identification of high-risk patients and adherence to guidelines may improve clinical outcomes.
Collapse
Affiliation(s)
| | - Marwan S Abougergi
- Division of Gastroenterology, Department of Internal Medicine, University of South Carolina School of Medicine, Columbia, SC
| | - Sajid Jalil
- Division of Gastroenterology, Hepatology, and Nutrition
| | | | | | - Kyle M Porter
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Sean G Kelly
- Division of Gastroenterology, Hepatology, and Nutrition
| | - Khalid Mumtaz
- Division of Gastroenterology, Hepatology, and Nutrition
| |
Collapse
|
|
6
|
Marginean CM, Pirscoveanu D, Popescu M, Docea AO, Radu A, Popescu AIS, Vasile CM, Mitrut R, Marginean IC, Iacob GA, Firu DM, Mitrut P. Diagnostic Approach and Pathophysiological Mechanisms of Anemia in Chronic Liver Disease—An Overview. GASTROENTEROLOGY INSIGHTS 2023; 14:327-341. [DOI: 10.3390/gastroent14030024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2025] Open
Abstract
Hematological abnormalities are frequently linked to chronic liver disease of any etiology. About 75% of patients with advanced chronic liver disease experience anemia. The causes of anemia are complex and multifactorial, particularly in cirrhotic patients. Acute and long-term blood loss from the upper gastrointestinal tract, malnutrition, an enlarged spleen brought on by portal hypertension, hemolysis, and coagulation issues are the main causes of anemia. Alcohol, a common cause of chronic liver disease, determines anemia through direct toxicity on the bone marrow, with the suppression of hematopoiesis, through vitamin B6, B12, and folate deficiency due to low intake and malabsorption. In patients with chronic hepatitis C virus infection, antiviral drugs such as pegylated interferon and ribavirin can also cause significant anemia. The use of interferon has been linked to bone marrow toxicity, and hemolytic anemia brought on by ribavirin is a well-known dose-dependent side effect. Within six months of the infection with hepatitis B, hepatitis C, and Epstein–Barr viruses, aplastic anemia associated with hepatitis is seen. This anemia is characterized by pancytopenia brought on by hypocellular bone marrow. Esophageal varices, portal hypertensive gastropathy, and gastric antral vascular ectasia can all cause acute and chronic blood loss. These conditions can progress to iron deficiency anemia, microcytic anemia, and hypochromic anemia. Another common hematologic abnormality in liver cirrhosis is macrocytosis, with multifactorial causes. Vitamin B12 and folate deficiency are frequent in liver cirrhosis, especially of alcoholic etiology, due to increased intestinal permeability, dysbiosis, and malnutrition. Many chronic liver diseases, like viral and autoimmune hepatitis, have a chronic inflammatory substrate. Proinflammatory cytokines, including tumor necrosis factor and interleukin 1, 6, and 10, are the main factors that diminish iron availability in progenitor erythrocytes and subsequent erythropoiesis, leading to the development of chronic inflammatory, normochromic, normocytic anemia.
Collapse
Affiliation(s)
- Cristina Maria Marginean
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Denisa Pirscoveanu
- Department of Neurology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Mihaela Popescu
- Department of Endocrinology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Anca Oana Docea
- Department of Toxicology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Antonia Radu
- Department of Pharmaceutical Botany, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | | | - Corina Maria Vasile
- Department of Pediatric and Adult Congenital Cardiology, Bordeaux University Hospital, 33600 Pessac, France
| | - Radu Mitrut
- Department of Cardiology, University and Emergency Hospital, 050098 Bucharest, Romania
| | | | - George Alexandru Iacob
- Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Dan Mihai Firu
- Department of Medical Semiology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Paul Mitrut
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| |
Collapse
|
|
7
|
Abstract
Patients with cirrhosis frequently require admission to the intensive care unit (ICU). Common indications for admission to ICU include one or more reasons of sepsis, shock due to any cause, acute gastrointestinal bleeding, and altered mentation either due to hepatic encephalopathy, alcohol withdrawal/intoxication, or metabolic encephalopathy. The appropriate critical care of an individual can determine the outcomes of these sick patients. The Airway, Breathing, Circulation, Disability (ABCD) approach to a patient admitted to ICU includes airway, breathing, circulation, and disability management. In this review, the authors discuss the common indications for ICU admission in a patient with cirrhosis and also their management.
Collapse
Affiliation(s)
- Mahathi Avadhanam
- Department of Emergency Medicine, Queen Elizabeth hospital, London, UK
| | - Anand V Kulkarni
- Department of Hepatology, AIG Hospitals, Gachibowli, Hyderabad, India-500032.
| |
Collapse
|
|
8
|
Ungureanu BS, Gheonea DI, Florescu DN, Iordache S, Cazacu SM, Iovanescu VF, Rogoveanu I, Turcu-Stiolica A. Predicting mortality in patients with nonvariceal upper gastrointestinal bleeding using machine-learning. Front Med (Lausanne) 2023; 10:1134835. [PMID: 36873879 PMCID: PMC9982090 DOI: 10.3389/fmed.2023.1134835] [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: 12/30/2022] [Accepted: 02/06/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Non-endoscopic risk scores, Glasgow Blatchford (GBS) and admission Rockall (Rock), are limited by poor specificity. The aim of this study was to develop an Artificial Neural Network (ANN) for the non-endoscopic triage of nonvariceal upper gastrointestinal bleeding (NVUGIB), with mortality as a primary outcome. METHODS Four machine learning algorithms, namely, Linear Discriminant Analysis (LDA), Quadratic Discriminant Analysis (QDA), logistic regression (LR), K-Nearest Neighbor (K-NN), were performed with GBS, Rock, Beylor Bleeding score (BBS), AIM65, and T-score. RESULTS A total of 1,096 NVUGIB hospitalized in the Gastroenterology Department of the County Clinical Emergency Hospital of Craiova, Romania, randomly divided into training and testing groups, were included retrospectively in our study. The machine learning models were more accurate at identifying patients who met the endpoint of mortality than any of the existing risk scores. AIM65 was the most important score in the detection of whether a NVUGIB would die or not, whereas BBS had no influence on this. Also, the greater AIM65 and GBS, and the lower Rock and T-score, the higher mortality will be. CONCLUSION The best accuracy was obtained by the hyperparameter-tuned K-NN classifier (98%), giving the highest precision and recall on the training and testing datasets among all developed models, showing that machine learning can accurately predict mortality in patients with NVUGIB.
Collapse
Affiliation(s)
- Bogdan Silviu Ungureanu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Dan Ionut Gheonea
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Dan Nicolae Florescu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Sevastita Iordache
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Sergiu Marian Cazacu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Vlad Florin Iovanescu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Ion Rogoveanu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Adina Turcu-Stiolica
- Department of Pharmacoeconomics, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| |
Collapse
|
|
9
|
Afzal A, Gage BF, Suhong L, Schoen MW, Korenblat K, Sanfilippo KM. Different risks of hemorrhage in patients with elevated international normalized ratio from chronic liver disease versus warfarin therapy, a population-based retrospective cohort study. J Thromb Haemost 2022; 20:1610-1617. [PMID: 35491428 PMCID: PMC9247029 DOI: 10.1111/jth.15743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/19/2022] [Accepted: 04/19/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with chronic liver disease (CLD) often present with an elevated international normalized ratio (INR). Although elevated INR reflects a higher risk of hemorrhage among warfarin users, its clinical significance in CLD patients is less clear. OBJECTIVES We used Veterans Health Administration data to quantify the association between INR and (non-variceal) hemorrhage in patients with CLD compared to warfarin users. METHODS We performed a multivariate competing risk analysis to study the association between INR and hemorrhage in the two cohorts. We used an interaction term between INR and cohort (CLD/warfarin users) to test if INR had different effects on hemorrhage in the two cohorts. RESULTS Data from 80 134 patients (14, 412 with CLD and 65, 722 taking warfarin) were analyzed. The effect of INR on the risk of hemorrhage differed between CLD patients and warfarin users (interaction P < .001). As INR increased above 1.5, the adjusted hazard ratio (aHR) for hemorrhage in CLD patients increased to 2.25 but remained fairly constant with further elevation of INR values. In contrast, the risk of hemorrhage in patients taking warfarin remained low with INR in the subtherapeutic (INR <2.0) and therapeutic ranges (INR 2.0-3.0), and increased exponentially with INR in the supratherapeutic range (aHR 1.64 with INR >3.0-3.5, and 4.70 with INR >3.5). CONCLUSIONS The relationship between INR and risk of hemorrhage in CLD patients is different from that in warfarin users. Caution should be exercised extrapolating data from warfarin users to make clinical decisions in CLD patients.
Collapse
Affiliation(s)
- Amber Afzal
- Department of Medicine, Division of Hematology, Washington University in St Louis, MO
| | - Brian F Gage
- Department of Medicine, Division of General Medical Sciences, Washington University in St Louis, MO
| | - Luo Suhong
- Research Service, St. Louis Veterans Affairs Medical Center, St Louis, MO
| | - Martin W Schoen
- Department of Medicine, St. Louis Veterans Affairs Medical Center, St Louis, MO
| | - Kevin Korenblat
- Department of Medicine, Division of Gastroenterology, Washington University in St Louis, MO, USA
| | - Kristen M Sanfilippo
- Department of Medicine, Division of Hematology, Washington University in St Louis, MO
- Department of Medicine, St. Louis Veterans Affairs Medical Center, St Louis, MO
| |
Collapse
|
|
10
|
Demetiou G, Augoustaki A, Kalaitzakis E. Endoscopic management and outcome of non-variceal bleeding in patients with liver cirrhosis: A systematic review. World J Gastrointest Endosc 2022. [DOI: 10.4253/wjge.v14.i3.164] [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: 02/06/2023] Open
|
|
11
|
Demetriou G, Augoustaki A, Kalaitzakis E. Endoscopic management and outcome of non-variceal bleeding in patients with liver cirrhosis: A systematic review. World J Gastrointest Endosc 2022; 14:163-175. [PMID: 35432740 PMCID: PMC8984531 DOI: 10.4253/wjge.v14.i3.163] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/08/2021] [Accepted: 02/10/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute non-variceal bleeding accounts for approximately 20% of all-cause bleeding episodes in patients with liver cirrhosis. It is associated with high morbidity and mortality therefore prompt diagnosis and endoscopic management are crucial.
AIM To evaluate available data on the efficacy of endoscopic treatment modalities used to control acute non-variceal gastrointestinal bleeding (GIB) in cirrhotic patients as well as to assess treatment outcomes.
METHODS Employing PRISMA methodology, the MEDLINE was searched through PubMed using appropriate MeSH terms. Data are reported in a summative manner and separately for each major non-variceal cause of bleeding.
RESULTS Overall, 23 studies were identified with a total of 1288 cirrhotic patients of whom 958/1288 underwent endoscopic therapy for acute non-variceal GIB. Peptic ulcer bleeding was the most common cause of acute non-variceal bleeding, followed by portal hypertensive gastropathy, gastric antral vascular ectasia, Mallory-Weiss syndrome, Dieaulafoy lesions, portal hypertensive colopathy, and hemorrhoids. Failure to control bleeding from all-causes of non-variceal GIB accounted for less than 3.5% of cirrhotic patients. Rebleeding (range 2%-25%) and mortality (range 3%-40%) rates varied, presumably due to study heterogeneity. Rebleeding was usually managed endoscopically and salvage therapy using arterial embolisation or surgery was undertaken in very few cases. Mortality was usually associated with liver function deterioration and other organ failure or infections rather than uncontrolled bleeding. Endoscopic treatment-related complications were extremely rare. Lower acute non-variceal bleeding was examined in two studies (197/1288 patients) achieving initial hemostasis in all patients using argon plasma coagulation for portal hypertensive colopathy and endoscopic band ligation or sclerotherapy for bleeding hemorrhoids (rebleeding range 10%-13%). Data on the efficacy of endoscopic therapy of cirrhotic patients vs non-cirrhotic controls with acute GIB are very scarce.
CONCLUSION Endotherapy seems to be efficient as a means to control non-variceal hemorrhage in cirrhosis, although published data are very limited, particularly those comparing cirrhotics with non-cirrhotics and those regarding acute bleeding from the lower gastrointestinal tract. Rebleeding and mortality rates appear to be relatively high, although firm conclusions may not be drawn due to study heterogeneity. Hopefully this review may stimulate further research on this subject and help clinicians administer optimal endoscopic therapy for cirrhotic patients.
Collapse
Affiliation(s)
- Georgios Demetriou
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion 71500, Greece
| | - Aikaterini Augoustaki
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion 71500, Greece
| | - Evangelos Kalaitzakis
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion 71500, Greece
| |
Collapse
|
|
12
|
Zullo A, Soncini M, Bucci C, Marmo R. Clinical outcomes in cirrhotics with variceal or nonvariceal gastrointestinal bleeding: A prospective, multicenter cohort study. J Gastroenterol Hepatol 2021; 36:3219-3223. [PMID: 34189770 DOI: 10.1111/jgh.15601] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/14/2021] [Accepted: 06/26/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Upper gastrointestinal bleeding (UGIB) is associated with a distinct mortality in cirrhotics. We evaluated whether the rate of mortality and other outcomes differs between variceal and nonvariceal UGIB. METHODS This was a prospective, multicenter, cohort study on UGIB cirrhotics observed in 50 hospitals. Variceal or nonvariceal UGIB were diagnosed at endoscopy. The 6-week mortality rate, need of blood transfusion, intensive care unit (ICU) admission, radiologic or surgical intervention, rebleeding rate, and length of stay in hospital were the main clinical outcomes compared. Data were analyzed at univariate and multivariate analysis, and odds ratio (OR) with their 95% confidence interval (CI) was calculated. RESULTS The study enrolled 706 cirrhotics, including 516 (73%) variceal and 190 (27%) nonvariceal UGIB. There were 78 (11%; 95% CI = 8.7-13.4) deceases, without any difference between variceal (11.0%) and nonvariceal (11.0%) groups. Child-Pugh score C (OR: 6.99; 95% CI = 2.58-18.95), and development of either hepatorenal syndrome (OR: 16.5; 95% CI = 7.02-38.9) or hepatic encephalopathy (OR: 2.38; 95% CI = 1.25-4.5) were independent predictors of mortality. Transfusions and onset of hepatic encephalopathy were significantly more frequent in variceal, whereas ICU admission rate was higher in nonvariceal bleedings. Overall, antibiotic prophylaxis was eventually administered in only 392 (55.5%) patients. CONCLUSIONS Data found that the overall mortality rate in cirrhotics with UGIB seems to be reducing and that the value did not differ between variceal and nonvariceal types. Prevention of both hepatorenal syndrome and hepatic encephalopathy and implementation of antibiotic prophylaxis could improve survival in these patients.
Collapse
Affiliation(s)
- Angelo Zullo
- Gastroenterology Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Marco Soncini
- Department of Internal Medicine, "A. Manzoni" Hospital, Lecco, Italy
| | - Cristina Bucci
- Gastroenterology Unit, L. Curto Hospital, Polla, Salerno, Italy
| | - Riccardo Marmo
- Gastroenterology Unit, L. Curto Hospital, Polla, Salerno, Italy
| | | |
Collapse
|
|
13
|
Hegazy S, Elsabaawy M, Eltabakh M, Hammad R, Bedair H. CD62P (P-selectin) expression as a platelet activation marker in patients with liver cirrhosis with and without cholestasis. Clin Exp Hepatol 2021; 7:231-240. [PMID: 34295992 PMCID: PMC8284161 DOI: 10.5114/ceh.2021.107566] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/24/2021] [Indexed: 11/25/2022] Open
Abstract
AIM OF THE STUDY P-selectin (CD62P) is a platelet activation marker that was claimed to mediate the accumulation of platelets induced by cholestasis. The nature of platelet dysfunction and hemostasis abnormalities in cholestatic liver disease needs to be more explored. The aim of this study was to assess platelet CD62P expression in cirrhotic patients with and without cholestasis, and to evaluate its relationship with a bleeding tendency. MATERIAL AND METHODS 150 patients were included in this case-control study. Participants were divided into 84 patients with liver cirrhosis (group I), 44 of whom had cholestasis (Group Ia) and 40 patients were without cholestasis (group Ib); 36 patients who were cholestatic without liver cirrhosis (group II); and 30 healthy subjects who formed the control group (group III). Platelet CD62P expression was assessed by a flow cytometer. RESULTS Platelets expressing CD62P were significantly increased in all patient groups compared to controls (p < 0.001). Platelets expressing CD62P were significantly increased in gastrointestinal (GIT) bleeders compared to non-bleeders in cirrhotic and cholestatic groups (p < 0.001 each). Among group I patients at cut-off > 12.4, up-regulation of platelet CD62P yielded 72% sensitivity and 44.1% specificity to discriminate bleeders from non-bleeders (p = 0.01), while among group II at cut-off > 12.9, it yielded 90% sensitivity and 80.8% specificity (p < 0.001). In cirrhotic patients, platelet CD62P expression was significantly increased in patients with an advanced Child-Pugh class (p < 0.001). Platelet expressing CD62P was shown as an independent risk factor for bleeding among cirrhotic cases with an odds ratio of 1.07 and CI 0.99-1.15. CONCLUSIONS Up-regulation of platelet CD62P expression can serve as a GIT bleeding predictor in liver cirrhosis.
Collapse
|
|
14
|
High Rate of Gastrointestinal Bleeding in Patients with Secondary Sclerosing Cholangitis in Critically Ill Patients (SC-CIP). J Clin Med 2021; 10:jcm10091925. [PMID: 33946877 PMCID: PMC8125451 DOI: 10.3390/jcm10091925] [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: 03/12/2021] [Revised: 04/21/2021] [Accepted: 04/27/2021] [Indexed: 11/26/2022] Open
Abstract
Secondary sclerosing cholangitis in critically ill patients (SC-CIP) is a rare cholestatic liver disease triggered by long-term intensive care treatment. The aim of this study was to evaluate the frequency and characteristics of gastrointestinal bleeding in SC-CIP. Patients with diagnosed SC-CIP were retrospectively identified and compared to a control group of patients with cardiac surgery and intensive care treatment but without the development of SC-CIP. Fifty-three patients with SC-CIP and 19 controls were included in the study. The frequency of gastrointestinal bleeding was 30% in SC-CIP (16 patients) and 5% in the control group (1 patient) (p = 0.03). Bleeding occured in the mean 13 months after admission to an intensive care unit in SC-CIP, three patients (19%) suffered bleeding during intensive care treatment. Three SC-CIP patients (19%) had cirrhosis at the time of bleeding, five (31%) had splenomegaly, and four (25%) received oral anticoagulation. In SC-CIP, 13 bleedings were identified in the upper gastrointestinal tract, two in the lower, and one remained unknown. The most common reasons for bleeding were gastroduodenal ulcers. In total, 80% of patients needed blood units, and one death due to bleeding occurred in SC-CIP. In conclusion, gastrointestinal bleeding is a frequent complication in patients with SC-CIP. Whether the liver disease itself or cofactors cause the susceptibility for bleeding remains unclear.
Collapse
|
|
15
|
Thrombocytopenia and Hemostatic Changes in Acute and Chronic Liver Disease: Pathophysiology, Clinical and Laboratory Features, and Management. J Clin Med 2021; 10:jcm10071530. [PMID: 33917431 PMCID: PMC8038677 DOI: 10.3390/jcm10071530] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/22/2021] [Accepted: 03/24/2021] [Indexed: 12/12/2022] Open
Abstract
Thrombocytopenia, defined as a platelet count <150,000/μL, is the most common complication of advanced liver disease or cirrhosis with an incidence of up to 75%. A decrease in platelet count can be the first presenting sign and tends to be proportionally related to the severity of hepatic failure. The pathophysiology of thrombocytopenia in liver disease is multifactorial, including (i) splenomegaly and subsequently increased splenic sequestration of circulating platelets, (ii) reduced hepatic synthesis of thrombopoietin with missing stimulation both of megakaryocytopoiesis and thrombocytopoiesis, resulting in diminished platelet production and release from the bone marrow, and (iii) increased platelet destruction or consumption. Among these pathologies, the decrease in thrombopoietin synthesis has been identified as a central mechanism. Two newly licensed oral thrombopoietin mimetics/receptor agonists, avatrombopag and lusutrombopag, are now available for targeted treatment of thrombocytopenia in patients with advanced liver disease, who are undergoing invasive procedures. This review summarizes recent advances in the understanding of defective but at low level rebalanced hemostasis in stable cirrhosis, discusses clinical consequences and persistent controversial issues related to the inherent bleeding risk, and is focused on a risk-adapted management of thrombocytopenia in patients with chronic liver disease, including a restrictive transfusion regimen.
Collapse
|
|
16
|
Roberts LN, Bernal W. Incidence of Bleeding and Thrombosis in Patients with Liver Disease. Semin Thromb Hemost 2020; 46:656-664. [PMID: 32757184 DOI: 10.1055/s-0040-1714205] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Historically, liver disease has been associated with a bleeding tendency. Global hemostatic assays have demonstrated that hemostasis is overall rebalanced, in both acute liver failure and chronic liver disease. It is now recognized that many bleeding events in chronic liver disease are mediated by portal hypertension rather than an underlying hemostatic defect. This is acknowledged in recent guidelines, which recommend against coagulation testing prior to low risk procedures in this patient group, with avoidance also of attempts at correction of prolonged coagulation times. Over time, the incidence of bleeding events has decreased in both chronic liver disease and acute liver failure, with improved supportive care, targeted treatments for underlying cause of liver disease, and the advent of liver transplantation. Concurrently, there has been increased recognition of the risk of thrombosis in chronic liver disease, with a predilection for the splanchnic vasculature. This review describes the incidence of bleeding and thrombosis in chronic liver disease and acute liver failure, including the periprocedural and liver transplantation setting.
Collapse
Affiliation(s)
- Lara N Roberts
- Department of Haematological Medicine, King's Thrombosis Centre, London, United Kingdom
| | - William Bernal
- Liver Intensive Therapy Unit, Institute of Liver Studies, King's College Hospital, London, United Kingdom
| |
Collapse
|
|
17
|
Spur cell anemia related to alcoholic liver cirrhosis managed without liver transplantation: a case report and literature review. Clin J Gastroenterol 2020; 13:882-890. [PMID: 32472376 PMCID: PMC7259740 DOI: 10.1007/s12328-020-01142-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 05/20/2020] [Indexed: 11/13/2022]
Abstract
Spur cell anemia is an acquired hemolytic anemia associated with liver cirrhosis and is characterized by the presence of increased large red blood cells, which are covered with spike-like projections that vary in width, length, and distribution. A 26-year-old man was referred to our hospital presenting with jaundice, lower limb edema, and dyspnea. The patient was subsequently diagnosed with spur cell anemia related to alcoholic liver cirrhosis. Spur cell anemia is an independent predictor of mortality in liver cirrhosis and has been associated with extremely poor prognosis. The most effective treatment for spur cell anemia is liver transplantation. As seen in the literature, the treatment of spur cell anemia without liver transplantation is quite challenging. This report highlights the importance of management and treatment strategies, including control of fluid retention, blood transfusion, plasma diafiltration, and administration of diuretics. Our treatment strategies might be useful in patients who are not candidate of liver transplantation or patients waiting for liver transplantation.
Collapse
|
|
18
|
Khalifa A, Rockey DC. Lower Gastrointestinal Bleeding in Patients With Cirrhosis-Etiology and Outcomes. Am J Med Sci 2020; 359:206-211. [PMID: 32087941 PMCID: PMC7416553 DOI: 10.1016/j.amjms.2020.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/06/2019] [Accepted: 01/10/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Lower gastrointestinal bleeding (LGIB) is a common clinical problem, and may be more prevalent among patients with cirrhosis, especially in the setting of portal hypertension and coagulopathy. However, there is extremely little data available on the subject of LGIB in patients with cirrhosis. Therefore, the primary objective of this study was to better understand the etiology and outcomes of cirrhotic patients hospitalized with LGIB. MATERIALS AND METHODS We analyzed 3,735 cirrhotic patients admitted to the Medical University of South Carolina between January 2011 and September 2018, and identified patients admitted with a primary diagnosis of hematochezia or bright red blood per rectum. RESULTS Thirty patients with cirrhosis and LGIB were included in the cohort. The mean age was 56 ± 13 years, with 30% women. The mean model of end stage liver disease score was 22, and Child-Pugh (CP) scores were C: 41%, B: 33% and A: 26%. The mean Charlson Comorbidity Index was 5.6. Twenty-four (80%) patients had a clinical decompensating event (hepatic encephalopathy, ascites, esophageal varices); the mean hepatic venous pressure gradient was 14.1 mm Hg (n = 8). In 33% of patients, LGIB was considered significant bleeding that necessitated blood transfusion. The most common cause of LGIB was hemorrhoids (11 patients, 37%), followed by portal hypertensive enteropathy or colopathy (7 patients, 23%). Hemoglobin levels on admission were lower in patients with CP B/C cirrhosis than in those with CP A (P < 0.001). The length of stay was 9 ± 10 days, and 5 patients died (mortality, 17%). CONCLUSIONS Despite being uncommon, LGIB in cirrhotic patients is associated with a high mortality rate.
Collapse
Affiliation(s)
- Ali Khalifa
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Don C Rockey
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina.
| |
Collapse
|
|
19
|
Biolato M, Tarli C, Marrone G, Barbaro B, Liguori A, Gasbarrini A, Grieco A. Gallbladder perforation without cholecystitis in a patient awaiting liver transplantation: a peculiar case report of anaemia in cirrhosis. BMC Gastroenterol 2019; 19:112. [PMID: 31248359 PMCID: PMC6598236 DOI: 10.1186/s12876-019-1018-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 06/07/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Acute anaemia in decompensated liver cirrhosis is commonly caused due to gastrointestinal bleeding; however, sometimes, detecting the site of blood loss is challenging. A patient on waitlist for orthotopic liver transplantation because of decompensated liver cirrhosis was admitted with acute anaemia and recurrence of ascites. Their abdomen CT showed migration of gallbladder stones in the pelvis while paracentesis documented hemoperitoneum. A diagnosis of gallbladder perforation was performed. CONCLUSION Challenging choice of a "wait and see" strategy with conservative therapy, avoiding high-risk cholecystectomy, resulted in a successful liver transplant.
Collapse
Affiliation(s)
- Marco Biolato
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Claudia Tarli
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Giuseppe Marrone
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Brunella Barbaro
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Antonio Liguori
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Antonio Gasbarrini
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Antonio Grieco
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| |
Collapse
|
|
20
|
Comparison of various prognostic scores in variceal and non-variceal upper gastrointestinal bleeding: A prospective cohort study. Indian J Gastroenterol 2019; 38:158-166. [PMID: 30830583 DOI: 10.1007/s12664-018-0928-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 12/19/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Various prognostic scores like Glasgow-Blatchford bleeding score (GBS), modified Glasgow-Blatchford bleeding score (mGBS), full Rockall score (FRS) including endoscopic findings, clinical Rockall score (CRS), and albumin, international normalized ratio (INR), mental status, systolic blood pressure, age >65 (AIMS65) are used for risk stratification in patients with upper gastrointestinal bleeding (UGIB). The utility of these scores in variceal UGIB (VUGIB) is not well defined. In this prospective study, we aimed to assess the performance of these scores in patients with non-variceal (NVUGIB) and VUGIB. METHODS We included 1011 patients (during March 2017 and August 2018) including 439 with NVUGIB and 572 VUGIB. Performance of GBS, mGBS, FRS, CRS, and AIMS65 for various outcome measures was analyzed using the area under receiver operator characteristic curve (AUROC). RESULTS The accuracy of prognostic scores in predicting the composite outcome including the need of hospital-based intervention and 42-day mortality was higher in NVUGIB as compared with VUGIB, AUROC: CRS: 0.641 vs. 0.537; FRS: 0.669 vs. 0.625; GBS: 0.719 vs. 0.587; mGBS: 0.711 vs. 0.594; AIMS65: 0.567 vs. 0.548. GBS and mGBS at a cut-off score of 1 had the highest negative predictive value, 91.7% and 91.3%, respectively, for predicting composite outcome in NVUGIB. Similarly, these scores had better accuracy for predicting 42-day rebleeding in NVUGIB as compared to VUGIB, AUROC: CRS: 0.680 vs. 0.537; FRS: 0.698 vs. 0.565; GBS: 0.661 vs. 0.543; mGBS: 0.627 vs. 0.540; AIMS65: 0.695 vs. 0.606. CONCLUSION The prognostic scores such as CRS, FRS, GBS, mGBS, and AIMS65 predict the need for hospital-based management, rebleeding, and mortality better among patients with NVUGIB than VUGIB.
Collapse
|
|
21
|
Lenti MV, Pasina L, Cococcia S, Cortesi L, Miceli E, Caccia Dominioni C, Pisati M, Mengoli C, Perticone F, Nobili A, Di Sabatino A, Corazza GR. Mortality rate and risk factors for gastrointestinal bleeding in elderly patients. Eur J Intern Med 2019; 61:54-61. [PMID: 30522789 DOI: 10.1016/j.ejim.2018.11.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) is burdened by high mortality rate that increases with aging. Elderly patients may be exposed to multiple risk factors for GIB. We aimed at defining the impact of GIB in elderly patients. METHODS Since 2008, samples of elderly patients (age ≥ 65 years) with multimorbidity admitted to 101 internal medicine wards across Italy have been prospectively enrolled and followed-up (REPOSI registry). Diagnoses of GIB, length of stay (LOS), mortality rate, and possible risk factors, including drugs, index of comorbidity (Cumulative Illness Rating Scale [CIRS]), polypharmacy, and chronic diseases were assessed. Adjusted multivariate logistic regression models were computed. RESULTS 3872 patients were included (mean age 79 ± 7.5 years, F:M ratio 1.1:1). GIB was reported in 120 patients (mean age 79.6 ± 7.3 years, F:M 0.9:1), with a crude prevalence of 3.1%. Upper GIB occurred in 72 patients (mean age 79.3 ± 7.6 years, F:M 0.8:1), lower GIB in 51 patients (mean age 79.4 ± 7.1 years, F:M 0.9:1), and both upper/lower GIB in 3 patients. Hemorrhagic gastritis/duodenitis and colonic diverticular disease were the most common causes. The LOS of patients with GIB was 11.7 ± 8.1 days, with a 3.3% in-hospital and a 9.4% 3-month mortality rates. Liver cirrhosis (OR 5.64; CI 2.51-12.65), non-ASA antiplatelet agents (OR 2.70; CI 1.23-5.90), and CIRS index of comorbidity >3 (OR 2.41; CI 1.16-4.98) were associated with GIB (p < 0.05). CONCLUSIONS A high index of comorbidity is associated with high odds of GIB in elderly patients. The use of non-ASA antiplatelet agents should be discussed in patients with multimorbidity.
Collapse
Affiliation(s)
- Marco Vincenzo Lenti
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy.
| | - Luca Pasina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Sara Cococcia
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Laura Cortesi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Emanuela Miceli
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Costanza Caccia Dominioni
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Martina Pisati
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Caterina Mengoli
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Francesco Perticone
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | | | - Antonio Di Sabatino
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Gino Roberto Corazza
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| |
Collapse
|
|
22
|
Nam SJ, Kim JH, Park SC. The Usefulness of New-Generation Capsule Endoscopy in Patients with Portal Hypertensive Enteropathy. Clin Endosc 2018; 51:505-507. [PMID: 30449077 PMCID: PMC6283760 DOI: 10.5946/ce.2018.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 10/31/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Seung-Joo Nam
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Ji Hyun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Sung Chul Park
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| |
Collapse
|
|
23
|
Abstract
BACKGROUND Despite the advantages of stapled hemorrhoidopexy reported in the literature in terms of postoperative pain, hospital stay, and duration of convalescence, it was described to have a higher recurrence rate compared with conventional hemorrhoidectomy. OBJECTIVE The aim of this study was to evaluate clinical outcomes and patient satisfaction after stapled hemorrhoidopexy at 10-year follow-up. DESIGN This was a retrospective cohort analysis conducted on prospectively collected data. SETTINGS The study was conducted at a single tertiary care center. PATIENTS Eighty-six consecutive patients treated with stapled hemorrhoidopexy for grade 3 hemorrhoidal prolapse between January and December 2006 were included. MAIN OUTCOME MEASURES Patients satisfaction and recurrence rates were measured. RESULTS Eighty-six patients (45 men and 41 women; median age, 49 y (range, 31-74 y)) underwent stapled hemorrhoidopexy. Eight patients had urinary retention during the immediate postoperative period, and 2 patients required a reoperation for suture line bleeding. The median hospital stay was 12 hours (range, 12-96 h). No suture line dehiscence, rectovaginal fistula, pelvic sepsis, anal abscess, or anal stenosis was recorded during the follow-up. Seventy-seven patients (90%) completed the expected follow-up, with a median duration of 119.0 months (range 115.4-121.8 mo). Among them, 30 patients (39%) experienced a recurrent hemorrhoidal prolapse, 8 of whom needed a reoperation. Thirty-four patients (44%) reported urge to defecate with a median visual analog scale of 1 (range, 1-7). Six patients (8%) reported gas leakage at the last follow-up visit, whereas no liquid or solid stool leakage was recorded. Satisfaction rate at 10-year follow-up was 68%. LIMITATIONS The study was limited by its small sample size and lack of a control group. CONCLUSIONS The high recurrence rate and low patient satisfaction rate showed that stapled hemorrhoidopexy reduces its efficacy in the long-term. See Video Abstract at http://links.lww.com/DCR/A510.
Collapse
Affiliation(s)
- Gabriele Bellio
- Colorectal and Pelvic Floor Diseases Center, Department of General Surgery, S. Maria dei Battuti Hospital, Conegliano Veneto, Italy
| | | | | |
Collapse
|
|
24
|
Basili S, Raparelli V, Napoleone L, Talerico G, Corazza GR, Perticone F, Sacerdoti D, Andriulli A, Licata A, Pietrangelo A, Picardi A, Raimondo G, Violi F. Platelet Count Does Not Predict Bleeding in Cirrhotic Patients: Results from the PRO-LIVER Study. Am J Gastroenterol 2018; 113:368-375. [PMID: 29257146 DOI: 10.1038/ajg.2017.457] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 11/06/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Thrombocytopenia is a hallmark for patients with cirrhosis and it is perceived as a risk factor for bleeding events. However, the relationship between platelet count and bleeding is still unclear. METHODS We investigated the relationship between platelet count and major or clinical relevant nonmajor bleedings during a follow-up of ∼4 years. RESULTS A total of 280 cirrhotic patients with different degrees of liver disease (67% males; age 64±37 years; 47% Child-Pugh B and C) were followed up for a median of 1,129 (interquartile range: 800-1,498) days yielding 953.12 patient-year of observation. The annual rate of any significant bleeding was 5.45%/year (3.57%/year and 1.89%/year for major and minor bleeding, respectively). Fifty-two (18.6%) patients experienced a major (n=34) or minor (n=18) bleeding event, predominantly from gastrointestinal origin. Platelet counts progressively decreased with the worsening of liver disease and were similar in patients with or without major or minor bleeding: a platelet count ≤50 × 103/μl was detected in 3 (6%) patients with and in 20 (9%) patients without any bleeding event. Conversely, prothrombin time-international normalized ratio was slightly higher in patients with overall or major bleeding. On Cox proportional hazard analysis, only a previous gastrointestinal bleeding (hazard ratio (HR): 1.96; 95% confidence interval: 1.11-3.47; P=0.020) and encephalopathy (HR: 2.05; 95% confidence interval: 1.16-3.62; P=0.013) independently predicted overall bleeding events. CONCLUSIONS Platelet count does not predict unprovoked major or minor bleeding in cirrhotic patients.
Collapse
Affiliation(s)
- S Basili
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - V Raparelli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - L Napoleone
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - G Talerico
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - G R Corazza
- Clinica Medica I, Department of Internal Medicine S. Matteo, University Hospital Pavia, Pavia, Italy
| | - F Perticone
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - D Sacerdoti
- Department of Medicine, University of Padova, Padova, Italy
| | - A Andriulli
- Division of Gastroenterology, Casa Sollievo Sofferenza Hospital, IRCCS, San Giovanni Rotondo, Italy
| | - A Licata
- Department of Internal Medicine and Specialities, DIBIMIS, University of Palermo, Palermo, Italy
| | - A Pietrangelo
- Unit of Internal Medicine 2, Department of Medical and Surgical Science for Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - A Picardi
- Internal Medicine and Hepatology Unit, University Campus Bio-Medico, Rome, Italy
| | - G Raimondo
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - F Violi
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| |
Collapse
|
|
25
|
Austrian consensus guidelines on the management and treatment of portal hypertension (Billroth III). Wien Klin Wochenschr 2017; 129:135-158. [PMID: 29063233 PMCID: PMC5674135 DOI: 10.1007/s00508-017-1262-3] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/22/2017] [Indexed: 12/14/2022]
Abstract
The Billroth III guidelines were developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on 18 February 2017 in Vienna. Based on international guidelines and considering recent landmark studies, the Billroth III recommendations aim to help physicians in guiding diagnostic and therapeutic strategies in patients with portal hypertension.
Collapse
|
|
26
|
Gastrointestinal Hemorrhage after Spontaneous Subarachnoid Hemorrhage: A Single-Center Cohort Study. Sci Rep 2017; 7:13557. [PMID: 29051548 PMCID: PMC5648848 DOI: 10.1038/s41598-017-13707-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 09/27/2017] [Indexed: 12/18/2022] Open
Abstract
Spontaneous subarachnoid hemorrhage (SAH) is a devastating disease, and gastrointestinal hemorrhage is one of several potential complications of acute strokes. We aim to analyze its prevalence, risk factors, and association with in-hospital prognosis following SAH. A total of 1047 adult patients with a primary diagnosis of spontaneous SAH were retrospectively enrolled. We retrieved medical information from the administrative database utilizing diagnostic and procedure codes of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Patients with SAH included 418 men and 629 women, and their mean age was 57.2 (standard deviation 14.6) years (range, 18–93 years). Gastrointestinal hemorrhage occurred in 30 of the 1047 patients, accounting for 2.9%. In a multivariate logistic regression model, the independent risk factors for gastrointestinal hemorrhage were liver disease and hydrocephalus. The in-hospital mortality rates were 43.3% and 29.3% in patients with and without gastrointestinal hemorrhage, respectively, but the difference was not statistically significant. In conclusion, the prevalence of gastrointestinal hemorrhage was 2.9% in patients hospitalized for spontaneous SAH. Underlying liver disease and the presence of hydrocephalus were both independent risk factors for this complication, which is a reminder to clinicians to pay increased attention in such cases.
Collapse
|
|
27
|
Williams MJ, Hayes P. Improving the management of gastrointestinal bleeding in patients with cirrhosis. Expert Rev Gastroenterol Hepatol 2016; 10:505-15. [PMID: 26581713 DOI: 10.1586/17474124.2016.1122523] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Gastrointestinal bleeding remains a major cause of mortality in patients with cirrhosis. The most common source of bleeding is from gastroesophageal varices but non-variceal bleeding from peptic ulcer disease also carries a significant risk in patients with liver disease. The prognosis is related to the severity of the underlying liver disease, and deaths often occur due to liver failure, infection or renal failure. Optimal management should therefore not only achieve haemostasis but address these complications as well. The management of gastrointestinal bleeding in patients with cirrhosis includes a range of medical, endoscopic and radiological interventions. This article updates the recent developments in this area and highlights topics where further research is still required.
Collapse
Affiliation(s)
- Michael J Williams
- a Centre for Liver and Digestive Diseases , Royal Infirmary of Edinburgh , Edinburgh , UK
| | - Peter Hayes
- a Centre for Liver and Digestive Diseases , Royal Infirmary of Edinburgh , Edinburgh , UK
| |
Collapse
|
|
28
|
Licinio R, Losurdo G, Carparelli S, Iannone A, Giorgio F, Barone M, Principi M, Ierardi E, Di Leo A. Helicobacter pylori, liver cirrhosis, and portal hypertension: an updated appraisal. Immunopharmacol Immunotoxicol 2016; 38:408-413. [PMID: 27788611 DOI: 10.1080/08923973.2016.1247855] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 10/06/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Helicobacter pylori (H. pylori) is the most common cause of gastritis and peptic ulcer. However, H. pylori is even involved in extragastric diseases, and it has been hypothesized that H. pylori could be a risk factor for several hepatic diseases. For instance, a direct involvement of H. pylori in the development of portal hypertension (PH) in cirrhotic patients has been postulated. METHODS We performed a literature search in major databases to elucidate the relationship between H. pylori, portal hypertension, and liver cirrhosis. RESULTS The effect of H. pylori on PH may be multifactorial. Endothelial dysfunction, alterations in the vasodilating dynamics, and neoangiogenesis are the most appealing theories about this issue, but the proofs come mainly from experimental studies, therefore a solid pathophysiological basis is still to be demonstrated. Congestive gastropathy (CG) and gastric antral vascular ectasia (GAVE) are two common endoscopic entities responsible for acute/chronic upper gastrointestinal bleeding, and a link with H. pylori has been hypothesized: the gastric mucosa, exposed to H. pylori, could develop both inflammatory microcirculatory alterations and thrombi, resembling the histologic pattern of GAVE. CONCLUSIONS Despite clues for an association between H. pylori and PH have been shown, these evidences are mostly experimental, therefore, in the absence of a direct proof on human beings, the role of H. pylori in the development of PH is uncertain. However, since this germ may be a cause of peptic ulcer, it should be found and eradicated in cirrhotic patients to reduce the risk of blood loss anemia.
Collapse
Affiliation(s)
- Raffaele Licinio
- a Department of Emergency and Organ Transplantation , Section of Gastroenterology, AOU Policlinico , Bari , Italy
| | - Giuseppe Losurdo
- a Department of Emergency and Organ Transplantation , Section of Gastroenterology, AOU Policlinico , Bari , Italy
| | - Sonia Carparelli
- a Department of Emergency and Organ Transplantation , Section of Gastroenterology, AOU Policlinico , Bari , Italy
| | - Andrea Iannone
- a Department of Emergency and Organ Transplantation , Section of Gastroenterology, AOU Policlinico , Bari , Italy
| | - Floriana Giorgio
- a Department of Emergency and Organ Transplantation , Section of Gastroenterology, AOU Policlinico , Bari , Italy
| | - Michele Barone
- a Department of Emergency and Organ Transplantation , Section of Gastroenterology, AOU Policlinico , Bari , Italy
| | - Mariabeatrice Principi
- a Department of Emergency and Organ Transplantation , Section of Gastroenterology, AOU Policlinico , Bari , Italy
| | - Enzo Ierardi
- a Department of Emergency and Organ Transplantation , Section of Gastroenterology, AOU Policlinico , Bari , Italy
| | - Alfredo Di Leo
- a Department of Emergency and Organ Transplantation , Section of Gastroenterology, AOU Policlinico , Bari , Italy
| |
Collapse
|
|
29
|
Gupta A, Anand AC. Should patients presenting with peptic ulcer bleed be screened to rule out cirrhosis of the liver? Indian J Gastroenterol 2016; 35:495-496. [PMID: 27774571 DOI: 10.1007/s12664-016-0702-8] [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]
Affiliation(s)
- Ansul Gupta
- Department of Hepatology and Gastroenterology, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, 110 076, India
| | - Anil C Anand
- Department of Hepatology and Gastroenterology, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, 110 076, India.
| |
Collapse
|
|
30
|
Uchino K, Tateishi R, Fujiwara N, Minami T, Sato M, Enooku K, Nakagawa H, Asaoka Y, Kondo Y, Yoshida H, Moriya K, Shiina S, Omata M, Koike K. Impact of serum ferritin level on hepatocarcinogenesis in chronic hepatitis C patients. Hepatol Res 2016; 46:259-68. [PMID: 25788045 DOI: 10.1111/hepr.12517] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 03/07/2015] [Accepted: 03/13/2015] [Indexed: 02/08/2023]
Abstract
AIM To elucidate the impact of the serum ferritin level, a surrogate indicator of hepatic iron accumulation, on hepatocarcinogenesis in chronic hepatitis C patients. METHODS Serum ferritin was measured in 487 chronic hepatitis C patients without history of hepatocellular carcinoma (HCC) after excluding patients in phlebotomy, those with overt chronic gastrointestinal bleeding and those who achieved sustained virological response before enrollment. Patients were divided into four groups (G1-G4) by quartile points of serum ferritin, with sexes separated. RESULTS The serum ferritin level was positively correlated with total bilirubin, aspartate aminotransferase, alanine aminotransferase (ALT), γ-glutamyltransferase, hemoglobin and AFP, and inversely correlated with prothrombin activity in both sexes. A significant difference in HCC incidence was observed only in male patients; the incidence was higher in G1 (≤80 ng/mL, n = 54) and G4 (≥323 ng/mL, n = 54) compared with that of G2 (81-160 ng/mL, n = 54) and G3 (161-322 ng/mL, n = 52). The spline curve indicating the relationship between the hazard ratio and serum ferritin level took the form of a J-shape for male patients. In multivariate analysis, G1 and G4 showed higher incidence of HCC among men with a hazard ratio of 2.19 (95% confidence interval, 1.02-4.70; P = 0.045) compared with G2 and G3, together with older age, lower serum albumin and ALT above the normal upper limit. CONCLUSION The serum ferritin level is an independent risk factor for HCC development in male patients with chronic hepatitis C when the level is extremely high or low.
Collapse
Affiliation(s)
- Koji Uchino
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Ryosuke Tateishi
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Naoto Fujiwara
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Tatsuya Minami
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Masaya Sato
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kenichiro Enooku
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Hayato Nakagawa
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yoshinari Asaoka
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yuji Kondo
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Haruhiko Yoshida
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kyoji Moriya
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Shuichiro Shiina
- Department of Gastroenterology, Juntendo University, Tokyo, Japan
| | - Masao Omata
- Yamanashi Prefectural Hospital Organization, Yamanashi, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| |
Collapse
|
|
31
|
Feakins RM. Obesity and metabolic syndrome: pathological effects on the gastrointestinal tract. Histopathology 2016; 68:630-40. [DOI: 10.1111/his.12907] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 11/17/2015] [Indexed: 12/27/2022]
Affiliation(s)
- Roger M Feakins
- Department of Cellular Pathology; Royal London Hospital; London UK
| |
Collapse
|
|
32
|
Nojkov B, Cappell MS. Distinctive aspects of peptic ulcer disease, Dieulafoy's lesion, and Mallory-Weiss syndrome in patients with advanced alcoholic liver disease or cirrhosis. World J Gastroenterol 2016; 22:446-466. [PMID: 26755890 PMCID: PMC4698507 DOI: 10.3748/wjg.v22.i1.446] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/11/2015] [Accepted: 11/24/2015] [Indexed: 02/06/2023] Open
Abstract
AIM To systematically review the data on distinctive aspects of peptic ulcer disease (PUD), Dieulafoy's lesion (DL), and Mallory-Weiss syndrome (MWS) in patients with advanced alcoholic liver disease (aALD), including alcoholic hepatitis or alcoholic cirrhosis. METHODS Computerized literature search performed via PubMed using the following medical subject heading terms and keywords: "alcoholic liver disease", "alcoholic hepatitis"," alcoholic cirrhosis", "cirrhosis", "liver disease", "upper gastrointestinal bleeding", "non-variceal upper gastrointestinal bleeding", "PUD", ''DL'', ''Mallory-Weiss tear", and "MWS''. RESULTS While the majority of acute gastrointestinal (GI) bleeding with aALD is related to portal hypertension, about 30%-40% of acute GI bleeding in patients with aALD is unrelated to portal hypertension. Such bleeding constitutes an important complication of aALD because of its frequency, severity, and associated mortality. Patients with cirrhosis have a markedly increased risk of PUD, which further increases with the progression of cirrhosis. Patients with cirrhosis or aALD and peptic ulcer bleeding (PUB) have worse clinical outcomes than other patients with PUB, including uncontrolled bleeding, rebleeding, and mortality. Alcohol consumption, nonsteroidal anti-inflammatory drug use, and portal hypertension may have a pathogenic role in the development of PUD in patients with aALD. Limited data suggest that Helicobacter pylori does not play a significant role in the pathogenesis of PUD in most cirrhotic patients. The frequency of bleeding from DL appears to be increased in patients with aALD. DL may be associated with an especially high mortality in these patients. MWS is strongly associated with heavy alcohol consumption from binge drinking or chronic alcoholism, and is associated with aALD. Patients with aALD have more severe MWS bleeding and are more likely to rebleed when compared to non-cirrhotics. Pre-endoscopic management of acute GI bleeding in patients with aALD unrelated to portal hypertension is similar to the management of aALD patients with GI bleeding from portal hypertension, because clinical distinction before endoscopy is difficult. Most patients require intensive care unit admission and attention to avoid over-transfusion, to correct electrolyte abnormalities and coagulopathies, and to administer antibiotic prophylaxis. Alcoholics should receive thiamine and be closely monitored for symptoms of alcohol withdrawal. Prompt endoscopy, after initial resuscitation, is essential to diagnose and appropriately treat these patients. Generally, the same endoscopic hemostatic techniques are used in patients bleeding from PUD, DL, or MWS in patients with aALD as in the general population. CONCLUSION Nonvariceal upper GI bleeding in patients with aALD has clinically important differences from that in the general population without aALD, including: more frequent and more severe bleeding from PUD, DL, or MWS.
Collapse
|
|
33
|
Gabr MA, Tawfik MAER, El-Sawy AAA. Non-variceal upper gastrointestinal bleeding in cirrhotic patients in Nile Delta. Indian J Gastroenterol 2016; 35:25-32. [PMID: 26884125 DOI: 10.1007/s12664-016-0622-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 01/20/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND STUDY AIMS Acute upper gastrointestinal bleeding (AUGIB) in cirrhotic patients occurs mainly from esophageal and gastric varices; however, quite a large number of cirrhotic patients bleed from other sources as well. The aim of the present work is to determine the prevalence of non-variceal UGIB as well as its different causes among the cirrhotic portal hypertensive patients in Nile Delta. METHODS Emergency upper gastrointestinal (UGI) endoscopy for AUGIB was done in 650 patients. Out of these patients, 550 (84.6%) patients who were proved to have cirrhosis were the subject of the present study. RESULTS From all cirrhotic portal hypertensive patients, 415 (75.5%) bled from variceal sources (esophageal and gastric) while 135 (24.5%) of them bled from non-variceal sources. Among variceal sources of bleeding, esophageal varices were much more common than gastric varices. Peptic ulcer was the most common non-variceal source of bleeding. CONCLUSIONS Non-variceal bleeding in cirrhosis was not frequent, and sources included peptic ulcer, portal hypertensive gastropathy, and erosive disease of the stomach and duodenum.
Collapse
Affiliation(s)
- Mamdouh Ahmed Gabr
- Hepatogastroenterology and Endoscopy Unit, Internal Medicine Department, Tanta University Hospital, Tanta, Egypt
| | - Mohamed Abd El-Raouf Tawfik
- Hepatogastroenterology and Endoscopy Unit, Internal Medicine Department, Tanta University Hospital, Tanta, Egypt.
| | - Abd Allah Ahmed El-Sawy
- Hepatogastroenterology and Endoscopy Unit, Internal Medicine Department, Tanta University Hospital, Tanta, Egypt
| |
Collapse
|
|
34
|
Capsule Endoscopy for Portal Hypertensive Enteropathy. Gastroenterol Res Pract 2015; 2016:8501394. [PMID: 26819613 PMCID: PMC4706926 DOI: 10.1155/2016/8501394] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 07/15/2015] [Indexed: 02/08/2023] Open
Abstract
Portal hypertensive enteropathy (PHE) is a mucosal abnormality of the small bowel that is observed in patients with portal hypertension (PH) and can lead to gastrointestinal bleeding and anemia. The pathogenesis is still not completely understood. The introduction of new endoscopic methods, including capsule endoscopy (CE) or balloon-assisted enteroscopy, has increased the detection of these abnormalities. CE can also serve as a road map for deciding subsequent interventions and evaluating the treatment effect. The prevalence of PHE is reportedly 40-70% in patients with PH. Endoscopic findings can be roughly divided into vascular and nonvascular lesions such as inflammatory-like lesions. Traditionally, PHE-associated factors include large esophageal varices, portal hypertensive gastropathy or colopathy, Child-Turcotte-Pugh class B or C, a history of variceal treatment, and acute gastrointestinal bleeding. More recently, on using scoring systems, a high computed tomography or transient elastography score was reportedly PHE-related factors. However, the prevalence of PHE and its related associated factors remain controversial. The management of PHE has not yet been standardized. It should be individualized according to each patient's situation, the availability of therapy, and each institutional expertise.
Collapse
|
|
35
|
Triantos C, Kalafateli M. Endoscopic treatment of esophageal varices in patients with liver cirrhosis. World J Gastroenterol 2014; 20:13015-13026. [PMID: 25278695 PMCID: PMC4177480 DOI: 10.3748/wjg.v20.i36.13015] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 01/15/2014] [Accepted: 05/26/2014] [Indexed: 02/06/2023] Open
Abstract
Variceal bleeding is a life-threatening complication of portal hypertension with a six-week mortality rate of approximately 20%. Patients with medium- or large-sized varices can be treated for primary prophylaxis of variceal bleeding using two strategies: non-selective beta-blockers (NSBBs) or endoscopic variceal ligation (EVL). Both treatments are equally effective. Patients with acute variceal bleeding are critically ill patients. The available data suggest that vasoactive drugs, combined with endoscopic therapy and antibiotics, are the best treatment strategy with EVL being the endoscopic procedure of choice. In cases of uncontrolled bleeding, transjugular intrahepatic portosystemic shunt (TIPS) with polytetrafluoroethylene (PTFE)-covered stents are recommended. Approximately 60% of the patients experience rebleeding, with a mortality rate of 30%. Secondary prophylaxis should start on day six following the initial bleeding episode. The combination of NSBBs and EVL is the recommended management, whereas TIPS with PTFE-covered stents are the preferred option in patients who fail endoscopic and pharmacologic treatment. Apart from injection sclerotherapy and EVL, other endoscopic procedures, including tissue adhesives, endoloops, endoscopic clipping and argon plasma coagulation, have been used in the management of esophageal varices. However, their efficacy and safety, compared to standard endoscopic treatment, remain to be further elucidated. There are safety issues accompanying endoscopic techniques with aspiration pneumonia occurring at a rate of approximately 2.5%. In conclusion, future research is needed to improve treatment strategies, including novel endoscopic techniques with better efficacy, lower cost, and fewer adverse events.
Collapse
|
|
36
|
Gado A, Ebeid B, Axon A. Prevalence and outcome of peptic ulcer bleeding in patients with liver cirrhosis. ALEXANDRIA JOURNAL OF MEDICINE 2014. [DOI: 10.1016/j.ajme.2014.01.001] [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: 10/25/2022] Open
Affiliation(s)
- Ahmed Gado
- Department of Medicine, Bolak Eldakror Hospital , Giza, Egypt
| | - Basel Ebeid
- Department of Tropical Medicine and Infectious Diseases, Beny Suef University , Beny Suef, Egypt
| | - Anthony Axon
- Department of Gastroenterology, The General Infirmary at Leeds , Leeds, United Kingdom
| |
Collapse
|
|
37
|
Muche M, Somasundaram R. Akute Hepatitis, Leberversagen, akut dekompensierte Leberzirrhose. Notf Rett Med 2014. [DOI: 10.1007/s10049-014-1842-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
|
38
|
Huang W, Qian JR, Chen YX. Valsartan improves portal hypertensive gastropathy in rats possibly via TGF-β1/Smad signaling pathway. Shijie Huaren Xiaohua Zazhi 2014; 22:9-16. [DOI: 10.11569/wcjd.v22.i1.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the efficacy and mechanisms of action of valsartan on portal hypertensive gastropathy in rats with gastric mucosa lesions.
METHODS: Forty-eight SD rats were randomly divided into a sham-operated group, a portal hypertension gastropathy group, a valsartan prevention group, a normal dose valsartan group and a high dose valsartan group. Portal hypertensive gastropathy was induced by the partial portal vein ligation method. Gastric mucosa TGF-beta1 expression and microvessel density (MVD) were detected by immunohistochemical staining method. Gastric mucosa Smad2 and Smad7 protein expression was detected by Western blot. Plasma levels of rennin activity (PRA), angiotensin II (Ang II), alanine aminotransferase (ALT), and albumin (ALB) were determined by ELISA.
RESULTS: Compared with the model group, gastric mucosa TGF-β1 (11.58 ± 2.27, 13.29 ± 2.82, 13.15 ± 3.36 vs 24.25 ± 3.48, all P <0.05) and Smad2 (0.86 ± 0.59, 0.82±0.36, 0.83 ± 0.49 vs 1.60 ± 0.77, P < 0.05) protein expression was significantly decreased in the valsartan prevention group, normal dose valsartan group and high dose valsartan group. Smad7 protein expression in the valsartan prevention group, normal dose valsartan group and high dose valsartan group was significantly higher than that in the model group (1.59 ± 0.72, 1.65 ± 0.80, 1.69 ± 0.85 vs 0.58 ± 0.35, all P < 0.05). Plasma PRA (16.49 ng/mL ± 2.77 ng/mL, 15.92 ng/mL ± 4.30 ng/mL, 16.72 ng/mL ± 5.48 ng/mL vs 11.49 ng/mL ± 2.12 ng/mL, all P <0.05) and Ang II (1664.44 pg/mL ± 285.47 pg/mL, 1686.82 pg/mL ± 499.16 pg/mL, 1734.07 pg/mL ± 326.66 pg/mL vs 1110.38 pg/mL ± 193.85 pg/mL, all P <0.01) were also significantly higher in the valsartan prevention group, normal dose valsartan group and high dose valsartan group than in the model group.
CONCLUSION: Valsartan can improve portal hypertensive gastropathy probably by down-regulating TGF-β1 and Smad2 expression and up-regulating Smad7 expression.
Collapse
|
|
39
|
Taefi A, Cho WK, Nouraie M. Decreasing trend of upper gastrointestinal bleeding mortality risk over three decades. Dig Dis Sci 2013; 58:2940-8. [PMID: 23828142 DOI: 10.1007/s10620-013-2765-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 06/14/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Upper gastrointestinal bleeding (UGIB) causes over $1 billion in medical expenses annually. AIMS The purpose of this study was to examine changes of UGIB mortality risks and trends over the last three decades. METHODS We analyzed the National Hospital Discharge Sample from 1979 to 2009. Patients with primary ICD-9 code representing a diagnosis of UGIB were included. The UGIB mortality risks and trends in each decade by anatomical sites, bleeding causes, comorbidities, and other important variables were analyzed. RESULTS UGIB mortality risk decreased by 35.4 % from 4.8 % in the first decade to 3.1 % in the third decade (P < 0.001). Age and number of hospitalization days were significant risk factors in all decades. Most significant decreases were observed in patients over 65 years and during the first day of admission. Gastric (P < 0.001) and esophageal (P = 0.018) bleedings showed significant decreasing mortality risk trends. Duodenal bleeding mortality risk was stable in three decades. Mortality risk declined significantly among patients with renal failure (from 50.0 to 4.0 %) and heart failure (from 17.9 to 5.2 %; both P < 0.001) while changes in cases with ischemic heart disease, cancer, and liver failure were less significant. CONCLUSION UGIB morality risks, especially of the first hospital day and geriatric patients, significantly decreased over the last three decades, presumably from recent advances in emergency medical care. Mortality risk of gastric, but not duodenal, bleeding had the most significant reduction. Critical care improvements in patients with various comorbidities may explain significant UGIB mortality risk reductions. This study provides invaluable insight into the causes and trends of UGIB mortality risks for future studies.
Collapse
Affiliation(s)
- Amir Taefi
- Department of Medicine, MedStar Washington Hospital Center, 110 Irving St, NW Suite 3A3-A7, Washington, DC, 20010-2975, USA
| | | | | |
Collapse
|
|
40
|
Huang W, Qian JR. Treatment with valsartan reduces TGF-β1 expression and collagen fiber content in the portal vein of rats with portal hypertensive gastropathy. Shijie Huaren Xiaohua Zazhi 2013; 21:2765-2771. [DOI: 10.11569/wcjd.v21.i27.2765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the effect of treatment with valsartan on portal vein lesions in rats with portal hypertensive gastropathy (PHG).
METHODS: Forty-eight SD rats were randomly divided into a sham operation group, a PHG model group, a valsartan prevention group, a normal dose valsartan group, and a double dose valsartan group. Partial portal vein ligation was used to induce PHG. Portal venous pressure (PVP) and heart rate (HR) were measured. Immunohistochemistry was used to detect TGF-β1 protein expression in the portal vein, and Masson's trichrome technique was used to determine the content of collagen fibers.
RESULTS: The PVP decreased significantly in the normal dose valsartan group, double dose valsartan group and prevention group compared with the model group (13.32 cmH2O ± 0.96 cmH2O vs 9.54 cmH2O ± 0.80 cmH2O, 9.04 cmH2O ± 0.96 cmH2O, 8.30 cmH2O ± 0.41 cmH2O, all P < 0.01). TGF-β1 expression and collagen fiber content were significantly higher in the model group than in the sham operation group (8.51 ± 1.42 vs 5.73 ± 0.87, 2.01 ± 1.25 vs 0.82 ± 0.54); however, TGF-β1 expression and collagen fiber content were significantly lower in the valsartan normal dose group, double dose group and prevention group than in the model group (6.54 ± 1.09, 6.45 ± 1.37, 6.42 ± 1.98 vs 8.51 ± 1.42; 0.92 ± 0.53, 1.09 ± 0.40, 1.03 ± 0.36 vs 2.01 ± 1.25, all P < 0.05).
CONCLUSION: TGF-β1 expression and collagen fiber content in the portal vein increase in rats with PHG. Treatment with valsartan can not only reduce portal pressure and TGF-β1 expression in the portal vein but also decrease collagen synthesis.
Collapse
|
|
41
|
Kovács E, Palatka K, Németh A, Pásztor É, Pfliegler G. [Severe anemia caused by haemorrhoids: the casae of a young man with toxic cirrhosis]. Orv Hetil 2013; 154:382-6. [PMID: 23461979 DOI: 10.1556/oh.2013.29561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A 38-year-old alcoholic man with severe iron deficient anaemia, and bloody-mucous stool was found to have haemorrhoidal bleeding. In spite of intravenous iron supplements haemoglobin levels were falling. He was admitted because of deteriorating condition, jaundice, severe anaemia (haemoglobin, 38 g/l) and iron deficiency. Except of toxic (alcohol) agent all other causes of liver disease could be excluded. Sclero-, and medical therapy, and abstinence resulted in a rapid improvement in his condition and subsequently rectal bleeding also disappeared. Bleeding from the upper gastrointestinal tract is a well known and serious complication in liver cirrhosis, however, a voluminous blood loss resulting in a life-threatening anaemia from lower gastrointestinal tract or haemorrhoids, as it was detected in this patient, is quite rare. Sclerotherapy seems to be an effective method with only minor complications when compared with other invasive techniques. However, the patient's compliance even in liver cirrhosis with haemorrhoidal nodes is essential for long-term success.
Collapse
Affiliation(s)
- Erzsébet Kovács
- Debreceni Egyetem, Orvos- és Egészségtudományi Centrum Ritka Betegségek Tanszék, Belgyógyászati Intézet, Debrecen.
| | | | | | | | | |
Collapse
|
|
42
|
Cirrhosis and gastrointestinal bleeding. Dig Dis Sci 2012; 57:3307. [PMID: 23086119 DOI: 10.1007/s10620-012-2442-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Accepted: 09/26/2012] [Indexed: 12/09/2022]
|