Published online Mar 16, 2022. doi: 10.4253/wjge.v14.i3.163
Peer-review started: June 30, 2021
First decision: September 29, 2021
Revised: October 8, 2021
Accepted: February 10, 2022
Article in press: February 10, 2022
Published online: March 16, 2022
Non-variceal acute gastrointestinal bleeding (NVAGIB) accounts for approximately one fifth of the bleeding episodes in cirrhotic patients and can lead to catastrophic consequences with high morbidity and mortality. Available data and trials addressing the efficacy of endoscopic modalities used to treat NVAGIB are very limited.
Variceal bleeding is a well-known cause of decompensation in cirrhotic patients and endoscopic treatment and outcomes after such an episode have been well studied. Whether NVAGIB is related to decompensation and if it indicates worse prognosis in the natural history of cirrhotics still needs to be clarified. Knowledge of endoscopic treatment efficacy and outcomes is a prerequisite in answering these challenging questions. Addressing these issues can lead to future changes in treatment and follow up of these patients.
To analyse the different causes of NVAGIB and their frequency as well as the endoscopic modalities used to achieve haemostasis. To investigate if NVAGIB denotes worse prognosis in the natural history of cirrhotic patients, if endoscopic treatment is efficient and what are the rebleeding and failure rates of endotherapy. Data on these issues may stimulate future research, and assist clinicians in choosing the best endoscopic modality to treat NVAGIB in cirrhotics.
A systematic review using the PRISMA statement for reporting systematic reviews and meta-analyses was conducted. The MEDLINE was searched through PubMed by two authors ( Demetriou G, Augoustaki A) independently for relevant studies from 01/01/1980 until 01/01/2021 using the following query: “Liver Cirrhosis” AND “Gastrointestinal Hemorrhage/therapy”. After applying exclusion/inclusion criteria 23 studies out of 2002 were chosen to be analyzed.
A total of 23 studies (15 retrospective and 8 prospective) included a total of 1288 patients with liver cirrhosis and NVAGIB of whom 958 underwent endoscopic treatment. Causes of NVAGIB in a decreasing frequency order were as follows; peptic ulcers, 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 NVAGIB accounted for 3.5% of cirrhotic patients who underwent endoscopic therapy while rebleeding and mortality rates varied among studies (2%-25% and 3%-40% respectively). Endoscopic treatment related complications were rare (n = 1).
NVAGIB is an important cause of morbidity and mortality in patients with cirrhosis and prompt diagnosis and endoscopic management affect prognosis. Despite limited data it seems that endoscopic management for upper-and lower-NVAGIB is safe and efficacious. The relatively high rebleeding and mortality rates are probably due to study heterogeneity but firm conclusions may not be drawn.
The assumption that NVAGIB may be related to decompensation of liver cirrhosis and poor prognosis still need to be addressed. Expectantly this review will motivate further research on this subject and assist in administering optimal endoscopic therapy to patients with liver cirrhosis.