|
1
|
Driever EG, Cannegieter SC, Gregory S, Kane P, Zen Y, Lisman T, Bernal W. Portal vein intimal thickening in patients with cirrhosis is associated with indicators of portal hypertension. J Thromb Haemost 2025; 23:1551-1561. [PMID: 39914498 DOI: 10.1016/j.jtha.2025.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 01/16/2025] [Accepted: 01/16/2025] [Indexed: 05/02/2025]
Abstract
BACKGROUND The exact pathophysiology of portal vein thrombosis (PVT), a common complication of cirrhosis, remains largely unknown. We previously found that cirrhotic PVT consists of fibrotic intimal thickening of the portal vein wall rather than of true fibrin-rich thrombus. We hypothesized that this intimal thickening of portal vein is secondary to portal hypertension and/or to local inflammatory responses. OBJECTIVES To investigate the portal vein intimal thickness in cirrhotic patients, and its relationship with clinical and laboratory parameters associated with portal hypertension and inflammation. METHODS The intimal thickness of right and left portal branches was measured in hilar liver samples from 232 cirrhotic patients without PVT who underwent liver transplantation. The relation between intimal thickness and pretransplant clinical variables was studied with linear regression. Computed tomography scans of 25 patients prior to liver transplantation were reanalyzed for portal vein and portal hypertension related characteristics. RESULTS Median right intimal thickness was 129 (1-300 [IQR]) μm; median left intimal thickness was 112 (1-230) μm, and there was a correlation between the intimal thickness of the right and left branches in individual patients (r = 0.30, P < .001). Intimal thickness of the portal vein was associated with a history of variceal bleeding, hepatic encephalopathy or ascites, etiology of disease, and statin use. Other factors, including duration of liver disease, presence of infection, or radiological characteristics were not significantly associated with intimal thickness. CONCLUSION Intrahepatic portal vein intimal thickness is highly variable in patients with cirrhosis, but relatively consistent between right and left portal branches. The association between intimal thickness and history of variceal bleeding suggests that portal hypertension may contribute to initiation of intimal thickening, and consequently to the development of PVT.
Collapse
Affiliation(s)
- Ellen G Driever
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Internal Medicine, Section of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Stephen Gregory
- Department of Radiology, King's College Hospital, London, UK
| | - Pauline Kane
- Department of Radiology, King's College Hospital, London, UK
| | - Yoh Zen
- Department of Pathology, Institute of Liver Studies, King's College Hospital, London, UK
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - William Bernal
- Liver Intensive Care Unit, Institute of Liver Studies, King's College Hospital, London, UK; Institute of Liver Studies, King's College Hospital, London, UK
| |
Collapse
|
|
2
|
Praktiknjo M, Dollinger M, Braden B, Laleman W, Trebicka J. [Endo-Hepatology: New Endoscopic Solutions for Old Hepatological Problems]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2025. [PMID: 40306648 DOI: 10.1055/a-2590-9998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2025]
Abstract
With the rapid development of endoscopic ultrasound (EUS), diagnostic and therapeutic platforms have emerged that are applicable in hepatology. New tools such as EUS-guided portal pressure measurement (in combination with EUS-guided liver biopsy) or EUS-guided variceal obliteration using coils and glue present attractive procedures that can potentially overcome the limitations of current gold standards. In this review article, we provide an overview of these new 'endo-hepatology' techniques and highlight their current role in the treatment of liver diseases.
Collapse
Affiliation(s)
| | - Matthias Dollinger
- Medizinische Klinik I Gastroenterologie, Nephrologie und Diabetologie, Klinikum Landshut gGmbH, Landshut, Germany
- Innere Medizin I, University Hospital Ulm, Ulm, Germany
| | - Barbara Braden
- Medizinische Klinik B, Universitätsklinikum Münster, Munster, Germany
| | - Wim Laleman
- Medizinische Klinik B, Universitätsklinikum Münster, Munster, Germany
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, Leuven, Belgium
| | - Jonel Trebicka
- Medizinische Klinik B, Universitätsklinikum Münster, Munster, Germany
| |
Collapse
|
|
3
|
Chen R, Liu Y, Ma L, Zhang W, Zhou Y, Yang M, Yu J, Yan Z, Ma J, Luo J. Correlation and consistency analysis between various indirect portal pressure gradients and actual portal pressure gradient. BMC Gastroenterol 2025; 25:241. [PMID: 40211120 PMCID: PMC11987172 DOI: 10.1186/s12876-025-03816-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2024] [Accepted: 03/24/2025] [Indexed: 04/12/2025] Open
Abstract
OBJECTIVE To evaluate the correlation and consistency between hepatic venous pressure gradient(F-HVPG) calculated as the wedged hepatic venous pressure (WHVP) minus free hepatic venous pressure (FHVP), I-HVPG calculated as WHVP minus inferior vena cava pressure (IVCP) in the hepatic segment, and portal pressure gradient (PPG). METHODS Data were collected from 112 patients with portal hypertension undergoing transjugular intrahepatic portosystemic shunt (TIPS) along with HVPG measurement. FHVP, IVCP, WHVP, and portal venous pressure (PVP) were collected intraoperatively. Pearson's correlation and Bland-Altman method were used to assess correlation and consistency. RESULTS A total of 112 patients were retrospectively collected. The correlation coefficient (r) values (p < 0.001) between FHVP and IVCP, WHVP and PVP, F-HVPG and I-HVPG, F-HVPG and PPG, I-HVPG and PPG were 0.835, 0.717, 0.946, 0.667 and 0.698, respectively; the determination coefficient (R2) values were 0.697, 0.514, 0.895, 0.445 and 0.487, respectively. Bland-Altman plots showed that F-HVPG and I-HVPG had the narrowest 95% limits of agreement. Among patients with FHVP-IVCP > 2 mmHg, the (r) values (p < 0.05) between F-HVPG and I-HVPG, F-HVPG and PPG, I-HVPG and PPG were 0.907, 0.648 and 0.807, respectively; the (R2) values were 0.822, 0.420 and 0.651, respectively. Bland-Altman plots showed that I-HVPG had the narrower 95% limits of agreement with PPG. CONCLUSION F-HVPG and I-HVPG demonstrated high correlation and consistency. I-HVPG consistently correlates more closely with PPG than F-HVPG, both in the overall cohort and in patients with FHVP-IVCP > 2 mmHg. These results suggest that I-HVPG may serve as a more reliable alternative. Due to the significant underestimation of the PPG, HVPG measurement should not be used to exclude patients from a TIPS intervention.
Collapse
Affiliation(s)
- Rufeng Chen
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yaozu Liu
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li Ma
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen Zhang
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yongjie Zhou
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Minjie Yang
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiaze Yu
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhiping Yan
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jingqin Ma
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jianjun Luo
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China.
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China.
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China.
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.
| |
Collapse
|
|
4
|
Zhang W, Kang N, Wang Y, Zhang F, Xue J, Linghu E. Endoscopic treatment for gastroesophageal varices in patients with cirrhosis: a survey comparing between developed and developing countries. BMC Gastroenterol 2025; 25:176. [PMID: 40089662 PMCID: PMC11910852 DOI: 10.1186/s12876-025-03758-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Accepted: 03/04/2025] [Indexed: 03/17/2025] Open
Abstract
BACKGROUND In this survey, we compared endoscopists' approach to treatment of gastroesophageal varices (GOV) in patients with cirrhosis between developed and developing countries. The objective of this study was to undertake a comparative analysis of the approaches employed by endoscopists in developed and developing countries with regard to the treatment of GOV in patients with cirrhosis. METHODS Between Jan 2019 to Aug 2019, we administered a questionnaire-based online survey internationally via e-mail. A total of 148 endoscopists from five countries were invited to participate in the survey, and 93 responses were received (response rate: 62.8%). The questionnaire covered several aspects: characteristics of the respondents, primary prophylactics, endoscopic therapy, and secondary prophylactics for acute variceal bleeding (AVB). The answers were compared between developed and developing countries using the chi-square test. For all tests, a P value of < 0.05 was considered significant. RESULTS There was a significant difference between developed and developing countries in practice settings (P = 0.001), the years of independent gastroenterology or endoscopic practice (P = 0.036), treating non-hemorrhagic large gastric varices with medicine (P = 0.019), and selection of preferred initial endoscopic therapy for active gastric fundic variceal bleeding (P = 0.015). Notably, developed and developing countries did not significantly differ in terms of treatment of non-hemorrhagic esophageal varices (P = 0.076), initial endoscopic therapy for active gastric cardia variceal bleeding (P = 0.272), timing of secondary prophylaxis (P = 0.104), timing of endoscopy (P = 0.073), measures for secondary prophylaxis (P = 0.166), and basis for the selection of management preferences (P = 0.278). CONCLUSION There were some differences in the practice of endoscopists for GOV in patients with cirrhosis between developing and developed countries. We speculate that these differences may affect the costs, management of primary bleeding, and chances of rebleeding in GOV. Furthermore, the equipment and technical conditions of different hospitals may also significantly influence the endoscopist's choice of treatment modality. We hope that future studies will place greater emphasis on this aspect as continuing education of and providing updated equipment to endoscopists are of paramount importance.
Collapse
Affiliation(s)
- Wenhui Zhang
- Department of Gastroenterology, Beijing Daxing District People's Hospital, 26 Huangcun West Road, Daxing district, Beijing, 102699, China
- Endoscopy Center, The Fifth Medical Center of Chinese PLA General Hospital, 100 Xisihuan middle road, Fengtai district, Beijing, 100039, China
| | - Ning Kang
- Institute of Portal Hypertension, The First Hospital of Lanzhou University, 1 Donggangxi road, Chengguan district, Lanzhou, 730099, Gansu, China
| | - Yanling Wang
- Endoscopy Center, The Fifth Medical Center of Chinese PLA General Hospital, 100 Xisihuan middle road, Fengtai district, Beijing, 100039, China
| | - Fulong Zhang
- Department of Gastroenterology, Hangzhou Xixi Hospital, Hangzhou, 310023, China
| | - Jianbo Xue
- Department of Gastroenterology, Beijing Daxing District People's Hospital, 26 Huangcun West Road, Daxing district, Beijing, 102699, China
| | - Enqiang Linghu
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, 28 Fuxing road, Haidian district, Beijing, 100853, China.
| |
Collapse
|
|
5
|
Gao Z, Gao Y, Ma S, Zhang T, Wu J, Guo S, Mei X. A survey of emergency medicine physicians' knowledge, attitude, and practice towards esophagogastric variceal bleeding. Int J Emerg Med 2025; 18:54. [PMID: 40082795 PMCID: PMC11905617 DOI: 10.1186/s12245-025-00849-9] [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: 10/25/2024] [Accepted: 02/25/2025] [Indexed: 03/16/2025] Open
Abstract
BACKGROUND Esophageal-gastric variceal bleeding (EVB) is one of the leading causes of mortality in patients with cirrhotic portal hypertension. Rapid, accurate, and effective emergency care is crucial for successful patient outcomes. AIMS This study aims to evaluate the knowledge, attitudes, and practices of Chinese emergency physicians regarding EVB, with the goal of improving the diagnosis and treatment of gastrointestinal bleeding in emergency settings. METHODS A self-designed questionnaire based on clinical guidelines was developed to assess EVB knowledge, attitudes, and practices of Chinese emergency physicians in treating EVB. An online survey was conducted among emergency physicians nationwide. Data were analyzed using descriptive statistics and correlation analysis. RESULTS The knowledge score for EVB was 11.2 ± 3.5 (total score was 22), indicating a relatively low level of understanding. Statistically significant differences in knowledge scores were observed across hospital grades, educational backgrounds, years of experience, professional titles, and participation in relevant training programs (P < 0.05). The mean attitude score for EVB was above 4 (total score was 5), reflecting a generally positive attitude among physicians. In terms of practices, the score for treatment behavior of EVB was 2.7 ± 1.2, and behavior was positively correlated with knowledge and attitude (P < 0.05). CONCLUSION Chinese emergency physicians demonstrate a low level of knowledge about EVB treatment, although their attitudes remain positive. Their clinical practices in EVB management are also insufficient. Enhancing education on EVB and standardizing treatment protocols are necessary to improve patient outcomes.
Collapse
Affiliation(s)
- Zhenzhen Gao
- Emergency Medicine Clinical Research Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yusong Gao
- Department of Emergency, Peking university first hospital, Beijing, China
| | - Shuai Ma
- Emergency Medicine Clinical Research Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Tianpeng Zhang
- Department of Emergency, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Junyuan Wu
- Emergency Medicine Clinical Research Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Shubin Guo
- Emergency Medicine Clinical Research Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xue Mei
- Emergency Medicine Clinical Research Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China.
| |
Collapse
|
|
6
|
Kuroda H, Abe T, Kamiyama N, Oguri T, Ito A, Nakaya I, Watanabe T, Abe H, Yusa K, Fujiwara Y, Sato H, Suzuki A, Endo K, Yoshida Y, Oikawa T, Kakisaka K, Sawara K, Miyasaka A, Matsumoto T. Novel subharmonic-aided pressure estimation for identifying high-risk esophagogastric varices. J Gastroenterol 2025; 60:187-196. [PMID: 39470783 PMCID: PMC11794364 DOI: 10.1007/s00535-024-02161-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 10/10/2024] [Indexed: 11/01/2024]
Abstract
BACKGROUND Subharmonic-aided pressure estimation (SHAPE) is a technique for determining changes in ambient pressure. We aimed to analyze a novel SHAPE integrated into ultrasound diagnostic equipment to predict patients with liver cirrhosis at high risk of esophagogastric varices (EV). METHODS This prospective study included 111 patients with liver cirrhosis diagnosed between 2020 and 2023. We obtained liver stiffness measurements (LSM) and spleen stiffness measurements (SSM) using shear wave elastography and hepatic vein-portal vein (HV-PV) gradient using the SHAPE method. The EV risk was determined either as null, low, or high by esophagoscopy and Child-Pugh stage. RESULTS HV-PV gradient increased concordantly with the increase in EV risk (- 7.0 dB in null-risk, - 4.4 dB in low-risk, and - 2.0 dB in high-risk) with statistically significant difference among any two groups. The most appropriate cut-off value of the HV-PV gradient was - 3.5 dB, and sensitivity, specificity, and positive and negative predictive values were 80.0%, 89.0%, 80.0%, and 88.0%, respectively. The areas under the curve values for predicting the high-risk EV were 0.920, 0.843, and 0.824 for the HV-PV gradient, LSM, and SSM, respectively. CONCLUSIONS The novel SHAPE system demonstrated high accuracy in identifying patients with liver cirrhosis at a high risk of EV.
Collapse
Affiliation(s)
- Hidekatsu Kuroda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, Iwate Medical University School of Medicine, Nishitokuta 2-1-1, Yahaba-Cho, Shiwa-Gun, Yahaba, Iwate, 028-3694, Japan.
| | - Tamami Abe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, Iwate Medical University School of Medicine, Nishitokuta 2-1-1, Yahaba-Cho, Shiwa-Gun, Yahaba, Iwate, 028-3694, Japan
| | - Naohisa Kamiyama
- Ultrasound General Imaging, GE HealthCare Japan, Hino-Shi, Japan
| | - Takuma Oguri
- Ultrasound General Imaging, GE HealthCare Japan, Hino-Shi, Japan
| | - Asami Ito
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, Iwate Medical University School of Medicine, Nishitokuta 2-1-1, Yahaba-Cho, Shiwa-Gun, Yahaba, Iwate, 028-3694, Japan
| | - Ippeki Nakaya
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, Iwate Medical University School of Medicine, Nishitokuta 2-1-1, Yahaba-Cho, Shiwa-Gun, Yahaba, Iwate, 028-3694, Japan
| | - Takuya Watanabe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, Iwate Medical University School of Medicine, Nishitokuta 2-1-1, Yahaba-Cho, Shiwa-Gun, Yahaba, Iwate, 028-3694, Japan
| | - Hiroaki Abe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, Iwate Medical University School of Medicine, Nishitokuta 2-1-1, Yahaba-Cho, Shiwa-Gun, Yahaba, Iwate, 028-3694, Japan
| | - Kenji Yusa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, Iwate Medical University School of Medicine, Nishitokuta 2-1-1, Yahaba-Cho, Shiwa-Gun, Yahaba, Iwate, 028-3694, Japan
| | - Yudai Fujiwara
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, Iwate Medical University School of Medicine, Nishitokuta 2-1-1, Yahaba-Cho, Shiwa-Gun, Yahaba, Iwate, 028-3694, Japan
| | - Hiroki Sato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, Iwate Medical University School of Medicine, Nishitokuta 2-1-1, Yahaba-Cho, Shiwa-Gun, Yahaba, Iwate, 028-3694, Japan
| | - Akiko Suzuki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, Iwate Medical University School of Medicine, Nishitokuta 2-1-1, Yahaba-Cho, Shiwa-Gun, Yahaba, Iwate, 028-3694, Japan
| | - Kei Endo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, Iwate Medical University School of Medicine, Nishitokuta 2-1-1, Yahaba-Cho, Shiwa-Gun, Yahaba, Iwate, 028-3694, Japan
| | - Yuichi Yoshida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, Iwate Medical University School of Medicine, Nishitokuta 2-1-1, Yahaba-Cho, Shiwa-Gun, Yahaba, Iwate, 028-3694, Japan
| | - Takayoshi Oikawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, Iwate Medical University School of Medicine, Nishitokuta 2-1-1, Yahaba-Cho, Shiwa-Gun, Yahaba, Iwate, 028-3694, Japan
| | - Keisuke Kakisaka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, Iwate Medical University School of Medicine, Nishitokuta 2-1-1, Yahaba-Cho, Shiwa-Gun, Yahaba, Iwate, 028-3694, Japan
| | - Kei Sawara
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, Iwate Medical University School of Medicine, Nishitokuta 2-1-1, Yahaba-Cho, Shiwa-Gun, Yahaba, Iwate, 028-3694, Japan
| | - Akio Miyasaka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, Iwate Medical University School of Medicine, Nishitokuta 2-1-1, Yahaba-Cho, Shiwa-Gun, Yahaba, Iwate, 028-3694, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, Iwate Medical University School of Medicine, Nishitokuta 2-1-1, Yahaba-Cho, Shiwa-Gun, Yahaba, Iwate, 028-3694, Japan
| |
Collapse
|
|
7
|
Magaz M, Giudicelli-Lett H, Abraldes JG, Nicoară-Farcău O, Turon F, Rajoriya N, Goel A, Raymenants K, Hillaire S, Téllez L, Elkrief L, Procopet B, Orts L, Nery F, Shukla A, Larrue H, Degroote H, Aguilera V, Llop E, Turco L, Indulti F, Gioia S, Tosetti G, Bitto N, Becchetti C, Alvarado E, Roig C, Diaz R, Praktiknjo M, Konicek AL, Olivas P, Fortea JI, Masnou H, Puente Á, Ardèvol A, Navascués CA, Romero-Gutiérrez M, Scheiner B, Semmler G, Mandorfer M, Damião F, Baiges A, Ojeda A, Simón-Talero M, González-Alayón C, Díaz A, García-Criado Á, De Gottardi A, Hernández-Guerra M, Genescà J, Drilhon N, Noronha Ferreira C, Reiberger T, Rodríguez M, Morillas RM, Crespo J, Trebicka J, Bañares R, Villanueva C, Berzigotti A, Primignani M, La Mura V, Riggio O, Schepis F, Verhelst X, Calleja JL, Bureau C, Albillos A, Nevens F, Hernández-Gea V, Tripathi D, Rautou PE, García-Pagán JC. Porto-sinusoidal vascular liver disorder with portal hypertension: Natural history and long-term outcome. J Hepatol 2025; 82:72-83. [PMID: 39181213 DOI: 10.1016/j.jhep.2024.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 07/24/2024] [Accepted: 07/30/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND & AIMS Current knowledge of the natural history of patients with porto-sinusoidal vascular disorder (PSVD) is derived from small studies. The aim of the present study was to determine the natural history of PSVD and prognostic factors in a large multicenter cohort of patients. METHODS We performed a retrospective study on patients with PSVD and signs of portal hypertension (PH) prospectively registered in 27 centers. RESULTS A total of 587 patients were included, median age of 47 years and 38% were women. Four-hundred and one patients had an associated condition, which was graded as severe in 157. Median follow-up was 68 months. At diagnosis, 64% of patients were asymptomatic while 36% had a PH-related complication: PH-related bleeding in 112 patients, ascites in 117, and hepatic encephalopathy in 11. In those not presenting with bleeding, the incidence of first bleeding was 15% at 5 years, with a 5-year rebleeding rate of 18%. The 5-year cumulative incidence of new or worsening ascites was 18% and of developing portal vein thrombosis was 16%. Fifty (8.5%) patients received a liver transplantation and 109 (19%) died, including 55 non-liver-related deaths. Transplant-free survival was 97% and 83% at 1 and 5 years, respectively. Variables independently associated with transplant-free survival were age, ascites, serum bilirubin, albumin and creatinine levels at diagnosis and severe associated conditions. This allowed for the creation of a nomogram that accurately predicted prognosis. CONCLUSIONS The prognosis of PSVD is strongly determined by the severity of the associated underlying conditions and parameters of liver and renal function. IMPACT AND IMPLICATIONS Porto-sinusoidal vascular liver disorder (PSVD) is a rare entity that usually affects young people, frequently causes severe complications of portal hypertension, and may reduce life expectancy. To date, there is scarce information regarding its clinical manifestations, natural history and prognostic factors. The present study, including the largest number of patients with PSVD reported so far, shows that overall, when managed at centers of expertise, the prognosis of patients with PSVD is good, with LT-free survival rates of 83% and 72% at 5 and 10 years, respectively. Presence and severity of an underlying associated condition, presence of ascites, age and bilirubin, albumin and creatinine levels were associated with poor prognosis. These results are important to know for hepatologists. A final model combining these parameters enabled development of a nomogram that predicts prognosis with good discrimination and calibration capacity and can be easily applied in clinical practice.
Collapse
Affiliation(s)
- Marta Magaz
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Departament de Medicina i Ciències de la Salut. Universitat de Barcelona, Barcelona, Spain
| | - Heloïse Giudicelli-Lett
- Université de Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France; AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Juan G Abraldes
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Oana Nicoară-Farcău
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Departament de Medicina i Ciències de la Salut. Universitat de Barcelona, Barcelona, Spain
| | - Fanny Turon
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Departament de Medicina i Ciències de la Salut. Universitat de Barcelona, Barcelona, Spain
| | - Neil Rajoriya
- The Liver Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ashish Goel
- The Liver Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karlien Raymenants
- Department of Gastroenterology and Hepatology, University Hospital KU Leuven, Leuven, Belgium
| | - Sophie Hillaire
- Université de Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France; AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Luis Téllez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, CIBERehd, Universidad de Alcalá, Madrid, Spain
| | - Laure Elkrief
- Université de Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France; Service d'Hépato-Gastroentérologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland; Service d'Hépato-Gastroentérologie, CHU de Tours, France
| | - Bogdan Procopet
- Regional Institute of Gastroenterology and Hepatology "Octavian Fodor", Hepatology Department and "Iuliu Hatieganu" University of Medicine and Pharmacy, 3rd Medical Clinic, Cluj-Napoca, Romania
| | - Lara Orts
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Departament de Medicina i Ciències de la Salut. Universitat de Barcelona, Barcelona, Spain
| | - Filipe Nery
- Immuno-Physiology and Pharmacology Department, School of Medicine and Biomedical Sciences, University of Porto, Portugal
| | - Akash Shukla
- Seth GS Medical College and KEM Hospital, Sion, Mumbai, India
| | - Hélène Larrue
- Department of Hepatology, Rangueil Hospital, CHU Toulouse, University Paul Sabatier of Toulouse, France
| | - Helena Degroote
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Victoria Aguilera
- Liver Transplantation and Hepatology Unit, Hospital Universitari i Politécnic La Fe, Valencia, Spain. CIBERehd (Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Valencia Spain), Instituto de Salud Carlos III, Spain
| | - Elba Llop
- Liver Unit, Hospital U, Puerta de Hierro. Universidad Autònoma de Madrid, CIBEREHD, IDIPHISA, Madrid, Spain
| | - Laura Turco
- Department of Gastroenterology and Hepatology, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Italy
| | - Federica Indulti
- Department of Gastroenterology and Hepatology, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Italy
| | - Stefania Gioia
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Giulia Tosetti
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine -Hemostasis and Thrombosis, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Niccolò Bitto
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine -Hemostasis and Thrombosis, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Chiara Becchetti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Edilmar Alvarado
- Liver Unit, Department of Gastroenterology Hospital Sant Pau, Barcelona, Autonomous University, Barcelona, Spain. Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Cristina Roig
- Liver Unit, Department of Gastroenterology Hospital Sant Pau, Barcelona, Autonomous University, Barcelona, Spain. Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Raquel Diaz
- Department of Gastroenterology and Hepatology, University Gregorio Marañón Hospital, liSGM, CIBERehd, Barcelona, Spain; Facultad de Medicina. Universidad Complutense de Madrid, Madrid, Spain
| | - Michael Praktiknjo
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Anna-Lena Konicek
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Pol Olivas
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Departament de Medicina i Ciències de la Salut. Universitat de Barcelona, Barcelona, Spain
| | - José Ignacio Fortea
- Liver Unit, Digestive Disease Department, Marqués de Valdecilla University Hospital, Santander, Cantabria University, Spain
| | - Helena Masnou
- Liver Unit, University Hospital Germans Trias i Pujol, Badalona, Spain. Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Spain
| | - Ángela Puente
- Liver Unit, Digestive Disease Department, Marqués de Valdecilla University Hospital, Santander, Cantabria University, Spain
| | - Alba Ardèvol
- Liver Unit, University Hospital Germans Trias i Pujol, Badalona, Spain. Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Spain
| | - Carmen A Navascués
- Liver Unit, Department of Gastroenterology and Hepatology, Hospital Universitario Central de Asturias, University of Oviedo, Oviedo, Spain
| | - Marta Romero-Gutiérrez
- Liver Unit, Department of Gastroenterology and Hepatology, Complejo Hospitalario Universitario de Toledo, Spain
| | - Bernhard Scheiner
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Georg Semmler
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Filipe Damião
- Department of Gastroenterology and Hepatology, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Anna Baiges
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Departament de Medicina i Ciències de la Salut. Universitat de Barcelona, Barcelona, Spain
| | - Asunción Ojeda
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Departament de Medicina i Ciències de la Salut. Universitat de Barcelona, Barcelona, Spain
| | - Macarena Simón-Talero
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebrón, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBERehd, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carlos González-Alayón
- Liver Unit, Department of Gastroenterology and Hepatology, Hospital Universitario de Canarias. Tenerife, Spain
| | - Alba Díaz
- Department of Histopathology, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | | | - Andrea De Gottardi
- Dept. of Gastroenterology and Hepatology, Cantonal Hospital Lucerne, University of Lucerne, Switzerland
| | - Manuel Hernández-Guerra
- Liver Unit, Department of Gastroenterology and Hepatology, Hospital Universitario de Canarias. Tenerife, Spain
| | - Joan Genescà
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebrón, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBERehd, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Nicolas Drilhon
- Université de Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France; AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Carlos Noronha Ferreira
- Department of Gastroenterology and Hepatology, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Thomas Reiberger
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Manuel Rodríguez
- Liver Unit, Department of Gastroenterology and Hepatology, Hospital Universitario Central de Asturias, University of Oviedo, Oviedo, Spain
| | - Rosa María Morillas
- Liver Unit, University Hospital Germans Trias i Pujol, Badalona, Spain. Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Spain
| | - Javier Crespo
- Liver Unit, Digestive Disease Department, Marqués de Valdecilla University Hospital, Santander, Cantabria University, Spain
| | - Jonel Trebicka
- Hepatology, Department of Internal Medicine I, Goethe University Frankfurt, Frankfurt, Germany; European Foundation for Study of Chronic Liver Failure, Barcelona, Spain
| | - Rafael Bañares
- Department of Gastroenterology and Hepatology, University Gregorio Marañón Hospital, liSGM, CIBERehd, Barcelona, Spain
| | - Càndid Villanueva
- Liver Unit, Department of Gastroenterology Hospital Sant Pau, Barcelona, Autonomous University, Barcelona, Spain. Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Massimo Primignani
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine -Hemostasis and Thrombosis, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Vincenzo La Mura
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine -Hemostasis and Thrombosis, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Oliviero Riggio
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Filippo Schepis
- Department of Gastroenterology and Hepatology, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Italy
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - José Luis Calleja
- Liver Unit, Hospital U, Puerta de Hierro. Universidad Autònoma de Madrid, CIBEREHD, IDIPHISA, Madrid, Spain
| | - Christophe Bureau
- Department of Hepatology, Rangueil Hospital, CHU Toulouse, University Paul Sabatier of Toulouse, France
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, CIBERehd, Universidad de Alcalá, Madrid, Spain
| | - Frederik Nevens
- Department of Gastroenterology and Hepatology, University Hospital KU Leuven, Leuven, Belgium
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Departament de Medicina i Ciències de la Salut. Universitat de Barcelona, Barcelona, Spain
| | - Dhiraj Tripathi
- The Liver Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Pierre-Emmanuel Rautou
- Université de Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France; AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Departament de Medicina i Ciències de la Salut. Universitat de Barcelona, Barcelona, Spain.
| |
Collapse
|
|
8
|
Tao K, Shan X, He B, Zeng Q, Wu M, Jie L, Yuan W, Dan H, Tao Z. Sequential endoscopic treatment for esophageal and gastric variceal bleeding significantly reduces patient mortality and rebleeding rates. Therap Adv Gastroenterol 2024; 17:17562848241299743. [PMID: 39553446 PMCID: PMC11565611 DOI: 10.1177/17562848241299743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 10/28/2024] [Indexed: 11/19/2024] Open
Abstract
Background Esophageal-gastric variceal bleeding (EGVB) is a serious complication in patients with liver cirrhosis, characterized by high mortality and rebleeding rates. The effect of sequential endoscopic therapy on patient mortality and rebleeding rates remains unclear. Objectives This study aimed to evaluate the effects of sequential endoscopic therapy on mortality and rebleeding rates in patients with EGVB. Design In this single-center retrospective study, 373 hospitalized cases of EGVB caused by liver cirrhosis, collected between November 2019 and November 2023, were divided into four groups according to different treatment methods: a sequential endoscopy group, emergency endoscopy group, emergency endoscopy plus transjugular intrahepatic portosystemic shunt (TIPS) group and control group. Methods Mortality and rebleeding rates were compared among the four groups using statistical analyses. Results The mortality and rebleeding rates of the sequential endoscopy group (3.7% and 19%, respectively) were significantly lower than those of the emergency endoscopy (22% and 36%, respectively), emergency endoscopy plus TIPS (33% and 28%, respectively), and control groups (33% and 51%, respectively) (p = 0.013 and p = 0.013, respectively). Conclusion Sequential endoscopic therapy may significantly reduce the mortality and rebleeding rates of patients with EGVB compared to other conventional treatment strategies. The findings of the study could help develop approaches benefiting EGVB treatment.
Collapse
Affiliation(s)
- Kong Tao
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Renmin South Road, Shunqing District, Nanchong City, Sichuan 637000, China
| | - Xu Shan
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Binbo He
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Qingyu Zeng
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Meirong Wu
- Nanchong Hospital of Traditional Chinese Medicine, Nanchong, China
| | - Liu Jie
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Wenfeng Yuan
- Department of Gastroenterology, Yingshan County Hospital of Traditional Chinese Medicine, Nanchong, China
| | - Hu Dan
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | | |
Collapse
|
|
9
|
Chen S, Geng Q, Lin Y, Ye Y, Yang Q. Gastroscopic treatment of acute gastric variceal rupture through the right lateral position. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024. [PMID: 39364714 DOI: 10.17235/reed.2024.10797/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2024]
Abstract
Acute variceal bleeding is a life-threatening condition and a common cause of cirrhosis-related death, severe acute bleeding is difficult to treat and has a high mortality rate, drug treatment is often ineffective. We encountered a patient with cirrhosis with ruptured and bleeding gastroscopic varices requiring emergency endoscopic surgical treatment. However, in the routine left lateral position the treatment was interfered with by a fresh blood clot obscuring the gastric fundus. We were able to expose the gastric fundus by turning the patient to the right lateral position and eventually successfully treated the patient. This provides a new idea for the endoscopic treatment of acute gastric varices and may improve the success rate of treatment.
Collapse
Affiliation(s)
- Shubei Chen
- Gastroenterology, The Second People's Hospital of Neijiang
| | - Qiang Geng
- Oncology, The Second People's Hospital of Neijiang
| | - Ying Lin
- Gastroenterology, The Second People's Hospital of Neijiang
| | - Yong Ye
- Gastroenterology, The Second People's Hospital of Neijiang
| | - Qing Yang
- Gastroenterology , The Second People's Hospital of Neijiang,
| |
Collapse
|
|
10
|
Shalaby S, Nicoară-Farcău O, Perez-Campuzano V, Olivas P, Torres S, García-Pagán JC, Hernández-Gea V. Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Treatment of Bleeding from Cardiofundal and Ectopic Varices in Cirrhosis. J Clin Med 2024; 13:5681. [PMID: 39407741 PMCID: PMC11476950 DOI: 10.3390/jcm13195681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 07/26/2024] [Accepted: 09/21/2024] [Indexed: 10/20/2024] Open
Abstract
Acute variceal bleeding in cirrhosis represents a critical clinical event that significantly impacts patient prognosis, with mortality rates increasing further after a second episode. This underscores the need for immediate intervention and optimal prophylaxis. The creation of a transjugular intrahepatic portosystemic shunt (TIPS) has been proven to be highly effective for managing esophageal variceal bleeding. However, the use of TIPS for managing cardiofundal gastric varices and ectopic varices remains debated due to their unique vascular anatomy and the limited data available. These varices, although less prevalent than esophageal varices, are complex and heterogeneous vascular shunts between the splanchnic venous system and the systemic veins. Indeed, while endoscopic therapy with tissue adhesives is widely endorsed for achieving hemostasis in active hemorrhage, there is no consensus regarding the optimal approach for secondary prophylaxis. Recent research emphasizes the efficacy of endovascular techniques over endoscopic treatments, such as TIPS and endovascular variceal embolization techniques. This review examines the use of TIPS in managing acute variceal bleeding in patients with cirrhosis, focusing specifically on cardiofundal gastric varices and ectopic varices, discussing optimal patient care based on the latest evidence, aiming to improve outcomes for this challenging subset of patients.
Collapse
Affiliation(s)
- Sarah Shalaby
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Oana Nicoară-Farcău
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Hepatology Department, Regional Institute of Gastroenterology and Hepatology “Octavian Fodor”, “Iuliu Hatieganu” University of Medicine and Pharmacy, 3rd Medical Clinic, 400394 Cluj-Napoca, Romania
| | - Valeria Perez-Campuzano
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Pol Olivas
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Sonia Torres
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
- Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, 08036 Barcelona, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
- Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, 08036 Barcelona, Spain
| |
Collapse
|
|
11
|
Wang D, Chen X, Lv L, Yang T, Huang B, Cao Y, Zhang Y, Lu J, Yin J. The learning curve of laparoscopic splenectomy and esophagogastric devascularization for portal hypertension with 10-year follow-up. Surg Endosc 2024; 38:5228-5238. [PMID: 39046495 PMCID: PMC11362247 DOI: 10.1007/s00464-024-11017-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 06/30/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION AND OBJECTIVES Laparoscopic splenectomy and esophagogastric devascularization (LSED) are minimally invasive, effective, and safe in treating esophageal-fundic variceal bleeding with portal hypertension (PHT). The study aimed to assess the learning curve of LSED by cumulative summation (CUSUM) analysis. The 10-year follow-up data for LSED and open surgery were also examined. PATIENTS AND METHODS Five hundred and ninety-four patients were retrospectively analyzed. Operation time, intraoperative blood loss, open operation conversion, and postoperative complications were selected as the evaluation indicators of surgical ability. The learning curve of LESD was assessed by the CUSUM approach. Patient features, perioperative indices, and 10-year follow-up data were examined. RESULTS Totally 236 patients underwent open surgery, and 358 underwent LSED. Patient characteristics were similar between groups. The LSED patients experienced less intraoperative blood loss, fewer complications, and faster recovery compared to the open surgery cohort. The learning curve of LESD was maximal for a case number of 50. Preoperative general characteristics were comparable for both stages. But the skilled stage had decreased operation time, reduced blood loss, less postoperative complications, and better recovery compared to the learning stage. The LSED group had higher recurrent hemorrhage-free survival rate and increased overall survival in comparison with cases administered open surgery in the 10-year follow-up. Free-liver cancer rates were similar between two groups. CONCLUSIONS About 50 cases are needed to master the LSED procedure. Compared to open surgery, LSED is a safer, feasible, and safe procedure for PHT patients, correlating with decreased rebleeding rate and better overall survival.
Collapse
Affiliation(s)
- Dong Wang
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, 569 Xin Si Road, Xi'an, 710038, China
| | - Xiao Chen
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, 569 Xin Si Road, Xi'an, 710038, China
| | - Ling Lv
- Department of Disease Prevention and Health Care, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China
| | - Tao Yang
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, 569 Xin Si Road, Xi'an, 710038, China
| | - Bo Huang
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, 569 Xin Si Road, Xi'an, 710038, China
| | - Yanlong Cao
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, 569 Xin Si Road, Xi'an, 710038, China
| | - Yong Zhang
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, 569 Xin Si Road, Xi'an, 710038, China
| | - Jianguo Lu
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, 569 Xin Si Road, Xi'an, 710038, China
| | - Jikai Yin
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, 569 Xin Si Road, Xi'an, 710038, China.
| |
Collapse
|
|
12
|
Vanderschueren E, Armandi A, Kwanten W, Cassiman D, Francque S, Schattenberg JM, Laleman W. Spleen Stiffness-Based Algorithms Are Superior to Baveno VI Criteria to Rule Out Varices Needing Treatment in Patients With Advanced Chronic Liver Disease. Am J Gastroenterol 2024; 119:1515-1524. [PMID: 38502095 DOI: 10.14309/ajg.0000000000002708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 01/23/2024] [Indexed: 03/20/2024]
Abstract
INTRODUCTION The Baveno VI criteria have set the stage for noninvasive assessment of compensated advanced chronic liver disease (ACLD). The algorithm combining liver stiffness measurement (LSM, <20 kPa) and platelet count (>150,000/μL) safely avoids screening endoscopy for varices needing treatment (VNT) but identifies only a relatively low number of patients. We aimed to evaluate the value of spleen stiffness measurement (SSM) using spleen-dedicated elastography in ruling out VNT. METHODS In this real-life multicenter retrospective derivation-validation cohort, all consecutive patients with ACLD (defined by LSM ≥10 kPa) with available upper endoscopy, laboratory results, spleen diameter, LSM, and SSM measured with spleen-dedicated transient elastography were included. VNT were defined as medium-to-large varices or small varices with red spots. RESULTS In the derivation cohort (n = 201, 11.9% VNT), SSM demonstrated excellent capability at identifying VNT (area under the receiver operating characteristic curve [AUROC] 0.88), outperforming LSM (AUROC 0.77, P = 0.03) and platelets (AUROC 0.73, P = 0.002). In comparison with Baveno VI criteria (33.8% spared endoscopies), the sequential Baveno VI plus SSM and a novel spleen size and stiffness model were able to increase the number of patients avoiding endoscopy (66.2% and 71.1%, respectively) without missing more than 5% of VNT. These findings were confirmed in an external validation cohort of patients with more advanced liver disease (n = 176, 34.7% VNT) in which the number of spared endoscopies tripled (27.3% and 31.3% for SSM-based algorithms) compared with Baveno VI criteria (8.5%). DISCUSSION Spleen stiffness-based algorithms are superior to Baveno VI criteria in ruling out VNT in patients with ACLD and double the number of patients avoiding screening endoscopy.
Collapse
Affiliation(s)
- Emma Vanderschueren
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Catholic University of Leuven, Leuven, Belgium
| | - Angelo Armandi
- Metabolic Liver Disease Research Program, I Department of Internal Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Division of Gastroenterology and Hepatology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Wilhelmus Kwanten
- Laboratory of Experimental Medicine and Paediatrics (LEMP), University of Antwerp (UA), Antwerp, Belgium
- Department of Gastroenterology & Hepatology, University Hospital Antwerp, Antwerp, Belgium
| | - David Cassiman
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Catholic University of Leuven, Leuven, Belgium
| | - Sven Francque
- Laboratory of Experimental Medicine and Paediatrics (LEMP), University of Antwerp (UA), Antwerp, Belgium
- Department of Gastroenterology & Hepatology, University Hospital Antwerp, Antwerp, Belgium
| | - Jörn M Schattenberg
- Department of Internal Medicine, Saarland University Medical Center, Homburg, Germany
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Catholic University of Leuven, Leuven, Belgium
| |
Collapse
|
|
13
|
Yan H, Xiang Z, Zhao C, Luo S, Liu H, Li M, Huang M. 6-mm shunt transjugular intrahepatic portosystemic shunt in patients with severe liver atrophy and variceal bleeding. Eur Radiol 2024; 34:4697-4707. [PMID: 38006453 DOI: 10.1007/s00330-023-10346-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 08/19/2023] [Accepted: 08/23/2023] [Indexed: 11/27/2023]
Abstract
OBJECTIVES We proposed a strategy for the creation of a 6-mm transjugular intrahepatic portosystemic shunt (TIPS) and to assess its effectiveness compared to a conventional 8-mm shunt for TIPS-induced hepatic encephalopathy (HE). METHODS Patients were reviewed retrospectively using propensity score matching (1:1) and divided into 6-mm and 8-mm shunt groups based on shunt diameter. The stent patency, HE incidence, and rebleeding rate between the two groups were then compared. RESULTS From January 2018 to June 2021, both 6-mm shunt group and 8-mm shunt group included 58 patients. The 6-mm shunt group had significantly smaller liver volumes (879.3 ± 237.1 vs. 1008.8 ± 293.0; p = 0.010), and the median stent patency times were 30.7 and 33.8 months in the 6-mm and 8-mm groups, respectively (p = 0.124). No statistically significant difference was found between the two groups in the 1-year (8.6% vs. 3.4%; p = 0.242) and 2-year (17.2% vs. 12.1%; p = 0.242) rebleeding rates. The 1-year cumulative incidences of overt HE were 12.1% and 27.6% in the 6-mm and 8-mm groups, respectively (p = 0.040), and the 2-year cumulative overt HE incidences in these groups were 19.0% and 36.2%, respectively (p = 0.038). Notably, patients with a 6-mm shunt also experienced less hepatic impairment. CONCLUSIONS For patients with variceal bleeding and a small liver volume, the 6-mm shunt significantly reduced the incidence of overt HE, protected perioperative liver function, and did not affect stent patency or rebleeding rate. CLINICAL RELEVANCE STATEMENT For patients with variceal bleeding with small liver volume, the 6-mm transjugular intrahepatic portosystemic shunt (TIPS) significantly reduced the incidence of overt hepatic encephalopathy after TIPS, protected perioperative liver function, and did not affect stent patency and rebleeding rate. KEY POINTS • A strategy for the creation of a 6-mm transjugular intrahepatic portosystemic shunt for patients with variceal bleeding and a small liver volume was proposed. • The 6-mm transjugular intrahepatic portosystemic shunt significantly reduced the incidence of overt hepatic encephalopathy. • The 6-mm transjugular intrahepatic portosystemic shunt did not affect stent patency or rebleeding rate.
Collapse
Affiliation(s)
- Huzheng Yan
- Department of Interventional Radiology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhanwang Xiang
- Department of Interventional Radiology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Chenghao Zhao
- Department of Interventional Radiology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Shuyang Luo
- Department of Interventional Radiology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Huan Liu
- Department of Interventional Radiology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Mingan Li
- Department of Interventional Radiology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
| | - Mingsheng Huang
- Department of Interventional Radiology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
| |
Collapse
|
|
14
|
Glückert K, Decker A, Meier JA, Nowak S, Sanoubara F, Gödiker J, Reinartz Groba SN, Kimmann M, Luetkens JA, Chang J, Sprinkart AM, Praktiknjo M. 3D-Volumetric Shunt Measurement for Detection of High-Risk Esophageal Varices in Liver Cirrhosis. J Clin Med 2024; 13:2678. [PMID: 38731206 PMCID: PMC11084829 DOI: 10.3390/jcm13092678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/28/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024] Open
Abstract
Background and Objectives: Esophageal varices (EV) and variceal hemorrhages are major causes of mortality in liver cirrhosis patients. Detecting EVs early is crucial for effective management. Computed tomography (CT) scans, commonly performed for various liver-related indications, provide an opportunity for non-invasive EV assessment. However, previous CT studies focused on variceal diameter, neglecting the three-dimensional (3D) nature of varices and shunt vessels. This study aims to evaluate the potential of 3D volumetric shunt-vessel measurements from routine CT scans for detecting high-risk esophageal varices in portal hypertension. Methods: 3D volumetric measurements of esophageal varices were conducted using routine CT scans and compared to endoscopic variceal grading. Receiver operating characteristic (ROC) analyses were performed to determine the optimal cutoff value for identifying high-risk varices based on shunt volume. The study included 142 patients who underwent both esophagogastroduodenoscopy (EGD) and contrast-enhanced CT within six months. Results: The study established a cutoff value for identifying high-risk varices. The CT measurements exhibited a significant correlation with endoscopic EV grading (correlation coefficient r = 0.417, p < 0.001). A CT cutoff value of 2060 mm3 for variceal volume showed a sensitivity of 72.1% and a specificity of 65.5% for detecting high-risk varices during endoscopy. Conclusions: This study demonstrates the feasibility of opportunistically measuring variceal volumes from routine CT scans. CT volumetry for assessing EVs may have prognostic value, especially in cirrhosis patients who are not suitable candidates for endoscopy.
Collapse
Affiliation(s)
- Kathleen Glückert
- Department of Internal Medicine I, University Hospital Bonn, 53127 Bonn, Germany
| | - Alexandra Decker
- Department of Internal Medicine I, University Hospital Bonn, 53127 Bonn, Germany
| | - Jörn Arne Meier
- Department of Internal Medicine B, University Hospital Münster, 48149 Münster, Germany
| | - Sebastian Nowak
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, 53127 Bonn, Germany
| | - Feras Sanoubara
- Department of Internal Medicine B, University Hospital Münster, 48149 Münster, Germany
| | - Juliana Gödiker
- Department of Internal Medicine B, University Hospital Münster, 48149 Münster, Germany
| | | | - Markus Kimmann
- Department of Internal Medicine B, University Hospital Münster, 48149 Münster, Germany
| | - Julian A. Luetkens
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, 53127 Bonn, Germany
| | - Johannes Chang
- Department of Internal Medicine I, University Hospital Bonn, 53127 Bonn, Germany
| | - Alois M. Sprinkart
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, 53127 Bonn, Germany
| | - Michael Praktiknjo
- Department of Internal Medicine I, University Hospital Bonn, 53127 Bonn, Germany
- Department of Internal Medicine B, University Hospital Münster, 48149 Münster, Germany
| |
Collapse
|
|
15
|
Patel VC, McPhail MJ, Uddin R, Jafari H, Lawrence V, Le Boutillier C, Shearer J, Yaziji N, Cape A, Ahmed H, Ward C, Walsh P, Besly K, Zamalloa A, Kelly J, Carter B. Beta-blockers or Placebo for Primary Prophylaxis (BOPPP) of oesophageal varices: study protocol for a randomised controlled trial. Trials 2024; 25:265. [PMID: 38627804 PMCID: PMC11022376 DOI: 10.1186/s13063-024-08063-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/18/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Liver disease is within the top five causes of premature death in adults. Deaths caused by complications of cirrhosis continue to rise, whilst deaths related to other non-liver disease areas are declining. Portal hypertension is the primary sequelae of cirrhosis and is associated with the development of variceal haemorrhage, ascites, hepatic encephalopathy and infection, collectively termed hepatic decompensation, which leads to hospitalisation and mortality. It remains uncertain whether administering a non-selective beta-blocker (NSBB), specifically carvedilol, at an earlier stage, i.e. when oesophageal varices are small, can prevent VH and reduce all-cause decompensation (ACD). METHODS/DESIGN The BOPPP trial is a pragmatic, multicentre, placebo-controlled, triple-blinded, randomised controlled trial (RCT) in England, Scotland, Wales and Northern Ireland. Patients aged 18 years or older with cirrhosis and small oesophageal varices that have never bled will be recruited, subject to exclusion criteria. The trial aims to enrol 740 patients across 55 hospitals in the UK. Patients are allocated randomly on a 1:1 ratio to receive either carvedilol 6.25 mg (a NSBB) or a matched placebo, once or twice daily, for 36 months, to attain adequate power to determine the effectiveness of carvedilol in preventing or reducing ACD. The primary outcome is the time to first decompensating event. It is a composite primary outcome made up of variceal haemorrhage (VH, new or worsening ascites, new or worsening hepatic encephalopathy (HE), spontaneous bacterial peritonitis (SBP), hepatorenal syndrome, an increase in Child-Pugh grade by 1 grade or MELD score by 5 points, and liver-related mortality. Secondary outcomes include progression to medium or large oesophageal varices, development of gastric, duodenal, or ectopic varices, participant quality of life, healthcare costs and transplant-free survival. DISCUSSION The BOPPP trial aims to investigate the clinical and cost-effectiveness of carvedilol in patients with cirrhosis and small oesophageal varices to determine whether this non-selective beta-blocker can prevent or reduce hepatic decompensation. There is clinical equipoise on whether intervening in cirrhosis, at an earlier stage of portal hypertension, with NSBB therapy is beneficial. Should the trial yield a positive result, we anticipate that the administration and use of carvedilol will become widespread with pathways developed to standardise the administration of the medication in primary care. ETHICS AND DISSEMINATION The trial has been approved by the National Health Service (NHS) Research Ethics Committee (REC) (reference number: 19/YH/0015). The results of the trial will be submitted for publication in a peer-reviewed scientific journal. Participants will be informed of the results via the BOPPP website ( www.boppp-trial.org ) and partners in the British Liver Trust (BLT) organisation. TRIAL REGISTRATION EUDRACT reference number: 2018-002509-78. ISRCTN reference number: ISRCTN10324656. Registered on April 24 2019.
Collapse
Affiliation(s)
- Vishal C Patel
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK.
- Institute of Liver Studies, Faculty of Life Sciences and Medicine, School of Immunology and Microbial Sciences, King's College London, London, UK.
- The Roger Williams Institute of Hepatology, Foundation for Liver Research, 111 Coldharbour Lane, London, SE5 9NT, UK.
| | - Mark J McPhail
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
- Institute of Liver Studies, Faculty of Life Sciences and Medicine, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Ruhama Uddin
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Hassan Jafari
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- King's Clinical Trials Unit, Institute of Psychiatry, Psychology & Neuroscience,, King's College London, London, UK
| | - Vanessa Lawrence
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Clair Le Boutillier
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Division of Methodologies, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - James Shearer
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Nahel Yaziji
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Angela Cape
- King's Clinical Trials Unit, Institute of Psychiatry, Psychology & Neuroscience,, King's College London, London, UK
| | - Haroon Ahmed
- Cardiff University, Division of Population Medicine, Cardiff, UK
| | | | - Peter Walsh
- British Liver Trust, Venta Court, Winchester, UK
| | - Kevin Besly
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Ane Zamalloa
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Joanna Kelly
- King's Clinical Trials Unit, Institute of Psychiatry, Psychology & Neuroscience,, King's College London, London, UK
| | - Ben Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- King's Clinical Trials Unit, Institute of Psychiatry, Psychology & Neuroscience,, King's College London, London, UK
| |
Collapse
|
|
16
|
Wang B, Zhou J, Wu X, Sun Y, Li L, Li P, Li M, Jiang W, Xu M, Feng B, Xu X, Cheng J, Xie W, Han T, Wang X, Li H, Piao H, Zhao X, Chen S, Meng T, Guan Q, Meng F, Kong Y, Ou X, Jia J, You H. Carvedilol Plus NUC for Patients With HBV-Compensated Cirrhosis Under Virological Suppression: A Randomized Open-Label Trial. Am J Gastroenterol 2024; 119:700-711. [PMID: 37929952 DOI: 10.14309/ajg.0000000000002569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/16/2023] [Indexed: 11/07/2023]
Abstract
INTRODUCTION Portal hypertension progression can be relieved after controlling the etiology of liver cirrhosis. Whether beta-blockers could additionally enhance the effects during treatment, particularly for small esophageal varices (EV), was unclear. This study aims to assess the efficacy of add-on carvedilol to delay EV progression during anti-hepatitis B virus (HBV) treatment in HBV-related cirrhosis. METHODS This randomized controlled trial enrolled patients with virologically suppressed HBV-compensated cirrhosis and small/medium EV. The participants were randomly assigned to receive nucleos(t)ide analog (NUC) or carvedilol 12.5 mg plus NUC (1:1 allocation ratio). The primary end point was the progression rate of EV at 2 years of follow-up. RESULTS A total of 238 patients (small EV, 77.3%) were randomized into 119 NUC and 119 carvedilol plus NUC (carvedilol [CARV] combination group). Among them, 205 patients (86.1%) completed paired endoscopies. EV progression rate was 15.5% (16/103) in the NUC group and 12.7% (13/102) in the CARV combination group (relative risk = 0.79, 95% confidence interval 0.36-1.75, P = 0.567). Subgroup analysis on medium EV showed the CARV combination group had a more favorable effect in promoting EV regression (43.5% vs 13.1%, P = 0.022) than NUC alone, but not in small cases ( P = 0.534). The incidence of liver-related events (decompensation, hepatocellular carcinoma, or death/liver transplantation) within 2 years was similar between the 2 groups (11.2% vs 10.4%, P = 0.881). DISCUSSION The overall results did not show statistically significant differences between the added carvedilol strategy and NUC monotherapy in preventing EV progression in patients with virologically suppressed HBV-compensated cirrhosis. However, the carvedilol-added approach might offer improved outcomes specifically for patients with medium EV (NCT03736265).
Collapse
Affiliation(s)
- Bingqiong Wang
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Jialing Zhou
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Xiaoning Wu
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Yameng Sun
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Lei Li
- Department of Gastroenterology and Hepatology, Beijing Youan Hospital, Capital Medical University, Beijing, China
- Department of Gastroenterology and Hepatology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Ping Li
- Department of Hepatology, Tianjin Second People's Hospital, Tianjin, China
| | - Minghui Li
- Liver Disease Center, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Wei Jiang
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Mingyi Xu
- Department of Gastroenterology and Hepatology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Gastroenterology and Hepatology, Shanghai East Hospital, Shanghai, China
| | - Bo Feng
- Hepatology Institute, Peking University People's Hospital, Beijing, China
| | - Xiaoyuan Xu
- Department of Infectious Disease, Peking University First Hospital, Beijing, China
| | - Jilin Cheng
- Department of Gastroenterology, Shanghai Public Health Clinical Center, Shanghai, China
| | - Wen Xie
- Liver Disease Center, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Tao Han
- Department of Hepatology, Tianjin Third Central Hospital, Tianjin Medical University, Tianjin, China
- Department of Gastroenterology and Hepatology, Tianjin Union Medical Center Affiliated to Nankai University, Tianjin, China
| | - Xiaozhong Wang
- Department of Hepatology, Xinjiang Uygur Autonomous Region Traditional Chinese Medicine Hospital, Urumqi, Xinjiang, China
| | - Hai Li
- Department of Gastroenterology, Tianjin Xiqing Hospital, Tianjin, China
| | - Hongxin Piao
- Department of Infectious Diseases, Affiliated Hospital of Yanbian University, Yanji, China
| | - Xinyu Zhao
- Department of Clinical Epidemiology and EBM Unit, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Shuyan Chen
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Tongtong Meng
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Qiushuang Guan
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Fandong Meng
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Yuanyuan Kong
- Department of Clinical Epidemiology and EBM Unit, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Xiaojuan Ou
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Jidong Jia
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Hong You
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis, National Clinical Research Center for Digestive Diseases, Beijing, China
| |
Collapse
|
|
17
|
Chen B, Wang J, Sheng W, Ma B, Xu P, Cheng X, Cheng W, Cai C, Wang G, Pan W, Wan C, Zheng C, Cheng P, Zhang J. Prognosis of LSPD versus TIPS for the treatment of esophagogastric variceal bleeding in cirrhosis. Surg Endosc 2024; 38:2106-2115. [PMID: 38438672 PMCID: PMC10978701 DOI: 10.1007/s00464-024-10729-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 01/28/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND This study aimed to compare postoperative complications in patients with esophagogastric variceal bleeding (EVB) who underwent laparoscopic splenectomy combined with pericardial devascularization (LSPD) versus transjugular intrahepatic portosystemic shunt (TIPS) procedures. METHODS A retrospective collection of medical records was conducted from January 2014 to May 2020 at Union Hospital, Tongji Medical College, Huazhong University of Science and Technology. The study included patients from the departments of trauma surgery, interventional radiology, and general surgery who were diagnosed with EVB caused by portal hypertension and treated with LSPD or TIPS. Follow-up data were obtained to assess the occurrence of postoperative complications in both groups. RESULTS A total of 201 patients were included in the study, with 104 cases in the LSPD group and 97 cases in the TIPS group. There was no significant difference in the 1-year and 3-year post-surgery survival rates between the TIPS and LSPD groups (P = 0.669, 0.066). The 3-year survival rate of Child-Pugh B patients in the LSPD group was higher than TIPS group (P = 0.041). The LSPD group also had a significantly higher rate of freedom from rebleeding at 3-year post-surgery compared to the TIPS group (P = 0.038). Stratified analysis showed no statistically significant difference in the rebleeding rate between the two groups. Furthermore, the LSPD group had a higher rate of freedom from overt hepatic encephalopathy at 1-year and 3-year post-surgery compared to the TIPS group (P = 0.007, < 0.001). The LSPD group also had a lower rate of severe complications at 3-year post-surgery compared to the TIPS group (P = 0.020). CONCLUSION Compared to TIPS, LSPD does not increase the risk of mortality and rebleeding, while demonstrating fewer complications. In patients classified as Child-Pugh A and B, the use of LSPD for treating EVB is both safe and effective.
Collapse
Affiliation(s)
- Biao Chen
- Department of Emergency Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Jingxuan Wang
- Wisdom Lake Academy of Pharmacy, Xi'an Jiaotong-Liverpool University, Suzhou, 215123, Jiangsu, China
| | - Weiyong Sheng
- Department of Cardiac Surgery, Wannan Medical College, Yijishan Hospital, Wuhu, 241000, Anhui, China
| | - Bingqing Ma
- Department of Emergency Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Peng Xu
- Department of Emergency Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Xing Cheng
- Health Management Center, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Weiyi Cheng
- Department of Emergency Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Chengjun Cai
- Department of Emergency Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Guoliang Wang
- Department of Hepatobiliary Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Wenming Pan
- Department of Emergency Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Chidan Wan
- Department of Hepatobiliary Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Chuansheng Zheng
- Department of Interventional Radiology, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Ping Cheng
- Department of Emergency Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Jinxiang Zhang
- Department of Emergency Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China.
| |
Collapse
|
|
18
|
Lu H, Li T, Xia Y, Shao L, Yu S, Xu L. Management of an Esophago-pleural Fistula after Emergent Endoscopic Variceal Injectional Sclerotherapy: A Case Report And Literature Review. Intern Med 2024; 63:937-941. [PMID: 37587038 PMCID: PMC11045370 DOI: 10.2169/internalmedicine.1961-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/05/2023] [Indexed: 08/18/2023] Open
Abstract
A 48-year-old man developed sudden-onset haematemesis and melena after decompensated posthepatitic cirrhosis. Endoscopic variceal injectional sclerotherapy was emergently performed. However, the patient developed esophago-pleural fistula, empyema, and liver failure. He thus received symptomatic treatments and nasojejunal feedings, which failed to restore the nutrition as the gastroesophageal reflux exacerbated the hydrothorax. Percutaneous endoscopic gastro-jejunal (PEG-J) was therefore carefully performed for enteral nutrition support. The patient had recovered from the fistula at a six-month follow-up, which allowed the resumption of an oral diet. Our literature review revealed that PEG-J is a feasible approach to treating esophago-pleural fistula, a rare but lethal complication of endoscopic sclerotherapy.
Collapse
Affiliation(s)
- Hongpeng Lu
- Department of Gastroenterology, The First Affiliated Hospital of Ningbo University, China
| | - Tongyu Li
- Department of Hematology, The First Affiliated Hospital of Ningbo University, China
| | - Ying Xia
- Department of Gastroenterology, The First Affiliated Hospital of Ningbo University, China
| | - Lihong Shao
- Department of Gastroenterology, The First Affiliated Hospital of Ningbo University, China
| | - Siyi Yu
- Department of Gastroenterology, The First Affiliated Hospital of Ningbo University, China
| | - Lei Xu
- Department of Gastroenterology, The First Affiliated Hospital of Ningbo University, China
| |
Collapse
|
|
19
|
Jiang JJ, Gao C, Mao JF, Yang GY, Huang J, Yu XH, Tan Y, Zhang JC, Zheng XF. Effect of endoscopic therapy and drug therapy on prognosis and rebleeding in patients with esophagogastric variceal bleeding. Sci Rep 2024; 14:7364. [PMID: 38548903 PMCID: PMC10978843 DOI: 10.1038/s41598-024-57791-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 03/21/2024] [Indexed: 04/01/2024] Open
Abstract
Esophagogastric variceal bleeding (EVB) is one of the common digestive system emergencies with poor prognosis and high rate of rebleeding after treatment. To explore the effects of endoscopic therapy and drug therapy on the prognosis and rebleeding of patients with EVB, and then select better treatment methods to effectively improve the prognosis. From January 2013 to December 2022, 965 patients with EVB who were hospitalized in gastroenterology Department of the 940 Hospital of Joint Logistic Support Forces of PLA were retrospectively analyzed. Patients were divided into endoscopic treatment group (ET, n = 586) and drug treatment group (DT, n = 379). Propensity score matching (PSM) analysis was performed in both groups, and the general information, efficacy and length of hospital stay were recorded. The patients were followed up for 3 months after bleeding control to determine whether rebleeding occurred. There were 286 cases in each group after PSM. Compared with DT group, ET had higher treatment success rate (P < 0.001), lower rebleeding rate (P < 0.001), lower mortality rate within 3 months, and no significant difference in total hospital stay (P > 0.05). Compared with drug therapy, endoscopic treatment of EVB has short-term efficacy advantages, and can effectively reduce the incidence of rebleeding and mortality within 3 months.
Collapse
Affiliation(s)
- Jing-Jing Jiang
- Department of Gastroenterology, The 940 Hospital of Joint Logistic Support Forces of PLA, Qilihe District, 333Rd Binhenan Road, Lanzhou, 730050, Gansu, China
- The First School of Clinical Medical, Gansu University of Chinese Medicine, Lanzhou, 730000, Gansu, China
| | - Chun Gao
- Department of Gastroenterology, The 940 Hospital of Joint Logistic Support Forces of PLA, Qilihe District, 333Rd Binhenan Road, Lanzhou, 730050, Gansu, China
- The First School of Clinical Medical, Gansu University of Chinese Medicine, Lanzhou, 730000, Gansu, China
| | - Jun-Feng Mao
- Department of Nuclear Medicine, The 940 Hospital of Joint Logistic Support Forces of PLA, Lanzhou, 730050, Gansu, China
| | - Guo-Yuan Yang
- The First School of Clinical Medical, Gansu University of Chinese Medicine, Lanzhou, 730000, Gansu, China
| | - Jun Huang
- Department of Gastroenterology, The 940 Hospital of Joint Logistic Support Forces of PLA, Qilihe District, 333Rd Binhenan Road, Lanzhou, 730050, Gansu, China
- The First School of Clinical Medical, Gansu University of Chinese Medicine, Lanzhou, 730000, Gansu, China
| | - Xiao-Hui Yu
- Department of Gastroenterology, The 940 Hospital of Joint Logistic Support Forces of PLA, Qilihe District, 333Rd Binhenan Road, Lanzhou, 730050, Gansu, China
| | - Yong Tan
- Department of Gastroenterology, The 940 Hospital of Joint Logistic Support Forces of PLA, Qilihe District, 333Rd Binhenan Road, Lanzhou, 730050, Gansu, China
| | - Jiu-Cong Zhang
- Department of Gastroenterology, The 940 Hospital of Joint Logistic Support Forces of PLA, Qilihe District, 333Rd Binhenan Road, Lanzhou, 730050, Gansu, China.
| | - Xiao-Feng Zheng
- Department of Gastroenterology, The Second Hospital of Lanzhou University, Lanzhou, 730030, Gansu, China.
| |
Collapse
|
|
20
|
Zhang YH, Hu B. Future directions of noninvasive prediction of esophageal variceal bleeding: No worry about the present computed tomography inefficiency. World J Gastrointest Endosc 2024; 16:108-111. [PMID: 38577650 PMCID: PMC10989247 DOI: 10.4253/wjge.v16.i3.108] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/16/2024] [Accepted: 02/06/2024] [Indexed: 03/14/2024] Open
Abstract
In this editorial, we comment on the minireview by Martino A, published in the recent issue of World Journal of Gastrointestinal Endoscopy 2023; 15 (12): 681-689. We focused mainly on the possibility of replacing the hepatic venous pressure gradient (HVPG) and endoscopy with noninvasive methods for predicting esophageal variceal bleeding. The risk factors for bleeding were the size of the varices, the red sign and the Child-Pugh score. The intrinsic core factor that drove these changes was the HVPG. Therefore, the present studies investigating noninvasive methods, including computed tomography, magnetic resonance imaging, elastography, and laboratory tests, are working on correlating imaging or serum marker data with intravenous pressure and clinical outcomes, such as bleeding. A single parameter is usually not enough to construct an efficient model. Therefore, multiple factors were used in most of the studies to construct predictive models. Encouraging results have been obtained, in which bleeding prediction was partly reached. However, these methods are not satisfactory enough to replace invasive methods, due to the many drawbacks of different studies. There is still plenty of room for future improvement. Prediction of the precise timing of bleeding using various models, and extracting the texture of variceal walls using high-definition imaging modalities to predict the red sign are interesting directions to lay investment on.
Collapse
Affiliation(s)
- Yu-Hang Zhang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Bing Hu
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| |
Collapse
|
|
21
|
Juneja D. Artificial intelligence: Applications in critical care gastroenterology. Artif Intell Gastrointest Endosc 2024; 5:89138. [DOI: 10.37126/aige.v5.i1.89138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/07/2023] [Accepted: 12/26/2023] [Indexed: 02/20/2024] Open
Abstract
Gastrointestinal (GI) complications frequently necessitate intensive care unit (ICU) admission. Additionally, critically ill patients also develop GI complications requiring further diagnostic and therapeutic interventions. However, these patients form a vulnerable group, who are at risk for developing side effects and complications. Every effort must be made to reduce invasiveness and ensure safety of interventions in ICU patients. Artificial intelligence (AI) is a rapidly evolving technology with several potential applications in healthcare settings. ICUs produce a large amount of data, which may be employed for creation of AI algorithms, and provide a lucrative opportunity for application of AI. However, the current role of AI in these patients remains limited due to lack of large-scale trials comparing the efficacy of AI with the accepted standards of care.
Collapse
Affiliation(s)
- Deven Juneja
- Department of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
| |
Collapse
|
|
22
|
Gralnek IM, Garcia-Pagan JC, Hernández-Gea V. Challenges in the Management of Esophagogastric Varices and Variceal Hemorrhage in Cirrhosis - A Narrative Review. Am J Med 2024; 137:210-217. [PMID: 38128860 DOI: 10.1016/j.amjmed.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 12/02/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
Over the past decade, significant advancements in pharmacological, endoscopic, and radiographic treatments have emerged in the management of patients with cirrhosis and esophagogastric varices or variceal hemorrhage. These advances have been in several areas, including the role of screening and primary prophylaxis (preventing an initial variceal bleed), evaluation and management of acute esophagogastric variceal hemorrhage, and in preventing variceal rebleeding. Therefore, we believe there is a need for an updated, evidence-based "narrative review" on this important clinical topic that will be relevant for internists, hospitalists, intensive care unit physicians, and those in training. We believe the guidance presented in this narrative review will enhance daily medical practice of health care professionals and has the potential to improve quality of care for these complex patients.
Collapse
Affiliation(s)
- Ian M Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel; Rappaport Faculty of Medicine Technion Israel Institute of Technology, Haifa, Israel.
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, Universitat de Barcelona University of Barcelona, Barcelona, CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, Universitat de Barcelona University of Barcelona, Barcelona, CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
| |
Collapse
|
|
23
|
Balcar L, Mandorfer M, Hernández-Gea V, Procopet B, Meyer EL, Giráldez Á, Amitrano L, Villanueva C, Thabut D, Samaniego LI, Silva-Junior G, Martinez J, Genescà J, Bureau C, Trebicka J, Herrera EL, Laleman W, Palazón Azorín JM, Alonso JC, Gluud LL, Ferreira CN, Cañete N, Rodríguez M, Ferlitsch A, Mundi JL, Grønbæk H, Hernandez Guerra MN, Sassatelli R, Dell'Era A, Senzolo M, Abraldes JG, Romero-Gómez M, Zipprich A, Casas M, Masnou H, Primignani M, Krag A, Nevens F, Calleja JL, Jansen C, Catalina MV, Albillos A, Rudler M, Tapias EA, Guardascione MA, Tantau M, Schwarzer R, Reiberger T, Laursen SB, Lopez-Gomez M, Cachero A, Ferrarese A, Ripoll C, La Mura V, Bosch J, García-Pagán JC. Predicting survival in patients with 'non-high-risk' acute variceal bleeding receiving β-blockers+ligation to prevent re-bleeding. J Hepatol 2024; 80:73-81. [PMID: 37852414 DOI: 10.1016/j.jhep.2023.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 10/03/2023] [Accepted: 10/09/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND & AIMS Pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) is the treatment of choice for high-risk acute variceal bleeding (AVB; i.e., Child-Turcotte-Pugh [CTP] B8-9+active bleeding/C10-13). Nevertheless, some 'non-high-risk' patients have poor outcomes despite the combination of non-selective beta-blockers and endoscopic variceal ligation for secondary prophylaxis. We investigated prognostic factors for re-bleeding and mortality in 'non-high-risk' AVB to identify subgroups who may benefit from more potent treatments (i.e., TIPS) to prevent further decompensation and mortality. METHODS A total of 2,225 adults with cirrhosis and variceal bleeding were prospectively recruited at 34 centres between 2011-2015; for the purpose of this study, case definitions and information on prognostic indicators at index AVB and on day 5 were further refined in low-risk patients, of whom 581 (without failure to control bleeding or contraindications to TIPS) who were managed by non-selective beta-blockers/endoscopic variceal ligation, were finally included. Patients were followed for 1 year. RESULTS Overall, 90 patients (15%) re-bled and 70 (12%) patients died during follow-up. Using clinical routine data, no meaningful predictors of re-bleeding were identified. However, re-bleeding (included as a time-dependent co-variable) increased mortality, even after accounting for differences in patient characteristics (adjusted cause-specific hazard ratio: 2.57; 95% CI 1.43-4.62; p = 0.002). A nomogram including CTP, creatinine, and sodium measured at baseline accurately (concordance: 0.752) stratified the risk of death. CONCLUSION The majority of 'non-high-risk' patients with AVB have an excellent prognosis, if treated according to current recommendations. However, about one-fifth of patients, i.e. those with CTP ≥8 and/or high creatinine levels or hyponatremia, have a considerable risk of death within 1 year of the index bleed. Future clinical trials should investigate whether elective TIPS placement reduces mortality in these patients. IMPACT AND IMPLICATIONS Pre-emptive transjugular intrahepatic portosystemic shunt placement improves outcomes in high-risk acute variceal bleeding; nevertheless, some 'non-high-risk' patients have poor outcomes despite the combination of non-selective beta-blockers and endoscopic variceal ligation. This is the first large-scale study investigating prognostic factors for re-bleeding and mortality in 'non-high-risk' acute variceal bleeding. While no clinically meaningful predictors were identified for re-bleeding, we developed a nomogram integrating baseline Child-Turcotte-Pugh score, creatinine, and sodium to stratify mortality risk. Our study paves the way for future clinical trials evaluating whether elective transjugular intrahepatic portosystemic shunt placement improves outcomes in presumably 'non-high-risk' patients who are identified as being at increased risk of death.
Collapse
Affiliation(s)
- Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Austria; Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain; Fundació Clinic Recerca Biomèdica-Institut d'Investigacions Biomèdiques August Pi I Sunyer (FCRB-IDIBAPS), Spain; Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain
| | - Bogdan Procopet
- Hepatology Department and 3rd Medical Clinic, Regional Institute of Gastroenterology and Hepatology 'Octavian Fodor' and 'Iuliu Hatieganu' University of Medicine and Pharmacy, Romania
| | - Elias Laurin Meyer
- Section for Medical Statistics, Center for Medical Data Science, Medical University of Vienna, Vienna, Austria; Berry Consultants, Vienna, Austria
| | - Álvaro Giráldez
- Clinical Management Unit of Digestive Diseases, University Hospital Virgen Del Rocio, Spain
| | | | - Candid Villanueva
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Servei De Patologia Digestiva, Hospital De La Santa Creu I Sant Pau, Spain
| | | | - Luis Ibáñez Samaniego
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Servicio De Medicina De Aparato Digestivo Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Lisgm, Spain
| | - Gilberto Silva-Junior
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain
| | - Javier Martinez
- Department of Gastroenterology and Instituto Ramón y Cajal De Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal and University of Alcalá, Spain
| | - Joan Genescà
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Spain
| | - Christophe Bureau
- Department of Hepato-Gastroenterology, Purpan Hospital, University of Toulouse, France
| | - Jonel Trebicka
- Department of Internal Medicine B, University of Münster, Germany; Department of Gastroenterology and Hepatology, Odense University Hospital, Denmark; Department of Internal Medicine I, University of Bonn, Germany
| | - Elba Llop Herrera
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Liver Unit, Hospital Universitario Puerta De Hierro Majadahonda, Universidad Autònoma de Madrid, Spain
| | - Wim Laleman
- Department of Liver and Biliopancreatic Disorders, KU Leuven, Belgium
| | | | - Jose Castellote Alonso
- Gastroenterology Department, Hepatology Unit, Hospital Universitari de Bellvitge, Idibell, Universitat de Barcelona, Spain
| | - Lise Lotte Gluud
- Gastro Unit, Medical Division, Copenhagen University Hospital Hvidovre and Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Carlos Noronha Ferreira
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Portugal
| | - Nuria Cañete
- Liver Section, Gastroenterology Department and Imim (Hospital del Mar Medical Research Institute), Gastroenterology Department, Spain
| | - Manuel Rodríguez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Spain
| | - Arnulf Ferlitsch
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Austria; Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain; Department of Internal Medicine I, Gastroenterology and Nephrology, St. John of God Hospital, Vienna, Austria
| | - Jose Luis Mundi
- Department of Gastroenterology, University Hospital San Cecilio, Spain
| | - Henning Grønbæk
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
| | | | - Romano Sassatelli
- Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria Nuova-IRRCS, Italy
| | - Alessandra Dell'Era
- Gastroenterology Unit, Asst Fatebenefratelli Sacco, Department of Clinical and Biomedical Sciences, Università Degli Studi Di Milano, Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Italy
| | - Juan Gonzalez Abraldes
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), CEGIIR, University of Alberta, Canada
| | - Manuel Romero-Gómez
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Unidad De Hepatología, Hospital Universitario De Valme, Spain
| | - Alexander Zipprich
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Germany
| | - Meritxell Casas
- Hepatology Unit, Digestive Disease Department, Hospital De Sabadell, Universitat Autónoma de Barcelona, Spain
| | - Helena Masnou
- Hospital Universitari Germans Trias I Pujol, Universitat Autònoma Barcelona, Spain
| | - Massimo Primignani
- CRC 'a.M. and a. Migliavacca' Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università Degli Studi Di Milano, Italy
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Denmark
| | - Frederik Nevens
- Department of Liver and Biliopancreatic Disorders, KU Leuven, Belgium
| | - Jose Luis Calleja
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Liver Unit, Hospital Universitario Puerta De Hierro Majadahonda, Universidad Autònoma de Madrid, Spain
| | | | - María Vega Catalina
- Servicio De Medicina De Aparato Digestivo Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Lisgm, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Instituto Ramón y Cajal De Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal and University of Alcalá, Spain
| | - Marika Rudler
- Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, France
| | - Edilmar Alvarado Tapias
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Servei De Patologia Digestiva, Hospital De La Santa Creu I Sant Pau, Spain
| | | | - Marcel Tantau
- Hepatology Department and 3rd Medical Clinic, Regional Institute of Gastroenterology and Hepatology 'Octavian Fodor' and 'Iuliu Hatieganu' University of Medicine and Pharmacy, Romania
| | - Rémy Schwarzer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Austria
| | | | - Marta Lopez-Gomez
- Liver Unit, Hospital Universitario Puerta De Hierro Majadahonda, Universidad Autònoma de Madrid, Spain; Liver Unit, Hospital Universitario Puerta De Hierro Majadahonda, Spain
| | - Alba Cachero
- Gastroenterology Department, Hepatology Unit, Hospital Universitari de Bellvitge, Idibell, Universitat de Barcelona, Spain
| | - Alberto Ferrarese
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Italy
| | - Cristina Ripoll
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Germany; Internal Medicine IV, Universitätsklinikum Jena, Friedrich Schiller University, Jena, Germany
| | - Vincenzo La Mura
- Hospital Universitari Germans Trias I Pujol, Universitat Autònoma Barcelona, Spain; Uoc Medicina Generale - Emostasi e Trombosi, Fondazione IRRCS, Cà Granda, Ospedale Maggiore Policlinico, Italy
| | - Jaime Bosch
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain; Fundació Clinic Recerca Biomèdica-Institut d'Investigacions Biomèdiques August Pi I Sunyer (FCRB-IDIBAPS), Spain; Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain; Fundació Clinic Recerca Biomèdica-Institut d'Investigacions Biomèdiques August Pi I Sunyer (FCRB-IDIBAPS), Spain; Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain.
| |
Collapse
|
|
24
|
Laleman W, Vanderschueren E, Mehdi ZS, Wiest R, Cardenas A, Trebicka J. Endoscopic procedures in hepatology: Current trends and new developments. J Hepatol 2024; 80:124-139. [PMID: 37730125 DOI: 10.1016/j.jhep.2023.08.032] [Citation(s) in RCA: 1] [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: 04/09/2023] [Revised: 08/10/2023] [Accepted: 08/28/2023] [Indexed: 09/22/2023]
Abstract
Gastrointestinal endoscopy has long been a reliable backbone in the diagnosis and management of hepatobilary disorders and their complications. However, with evolving non-invasive testing, personalised medicine has reframed the utility and necessity of endoscopic screening. Conversely, the growing interest and use of endoscopic ultrasound (EUS) and advanced endoscopy within gastrointestinal units has also opened novel diagnostic and therapeutic avenues for patients with various hepatobiliary diseases. The integration of "advanced endoscopy" within the practice of hepatology is nowadays referred to as "endo-hepatology". In essence, endo-hepatology consists of two pillars: one focusing primarily on disorders of the liver parenchyma, vascular disorders, and portal hypertension, which is mainly captured via EUS, while the other targets the hepatobiliary tract via endoscopic retrograde cholangiopancreatography and advanced imaging. Applications under the umbrella of endo-hepatology include, amongst others, EUS-guided liver biopsy, EUS-guided portal pressure gradient measurement, coil and glue embolisation of gastric varices as well as cholangioscopy. As such endo-hepatology could become an attractive concept wherein advanced endoscopy might reinforce the medical management of patients with hepatobiliary disorders and their complications after initial basic work-up. In this review, we discuss current trends and future developments within endo-hepatology and the remaining hurdles to overcome.
Collapse
Affiliation(s)
- Wim Laleman
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU LEUVEN, Leuven, Belgium; Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Münster, Germany.
| | - Emma Vanderschueren
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU LEUVEN, Leuven, Belgium
| | - Zain Seyad Mehdi
- Department of Mechanical Engineering, KU LEUVEN, Leuven, Belgium
| | - Reiner Wiest
- Department of Visceral Surgery and Medicine, University Inselspital, Bern, Switzerland
| | - Andres Cardenas
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigacion Biomedica en Red Enfermedades Hepaticas y Digestivas (CIBERehd), Madrid, Spain; Institute of Digestive Disease and Metabolism, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Jonel Trebicka
- Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Münster, Germany; European Foundation of Chronic Liver Failure, EFCLIF, Barcelona, Spain
| |
Collapse
|
|
25
|
Xu X, Tang C, Linghu E, Ding H, Chinese Society of Hepatology, Chinese Medical Association; Chinese Society of Gastroenterology, Chinese Medical Association; Chinese Society of Digestive Endoscopy, Chinese Medical Association. Guidelines for the Management of Esophagogastric Variceal Bleeding in Cirrhotic Portal Hypertension. J Clin Transl Hepatol 2023; 11:1565-1579. [PMID: 38161497 PMCID: PMC10752807 DOI: 10.14218/jcth.2023.00061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 07/11/2023] [Accepted: 09/07/2023] [Indexed: 01/03/2024] Open
Abstract
To standardize the diagnosis, treatment, and management of esophagogastric variceal bleeding (EVB) in patients with cirrhotic portal hypertension, the Chinese Society of Hepatology, the Chinese Society of Gastroenterology, and the Chinese Society of Digestive Endoscopy of the Chinese Medical Association brought together relevant experts, reviewed the latest national and international progress in clinical research on EVB in cirrhotic portal hypertension, and followed evidence-based medicine to update the Guidelines on the Management of EVB in Cirrhotic Portal Hypertension. The guidelines provide recommendations for the diagnosis, treatment, and management of EVB in cirrhotic portal hypertension and with the aim to improve the level of clinical treatment of EVB in patients with cirrhotic portal hypertension.
Collapse
Affiliation(s)
- Xiaoyuan Xu
- Department of Gastroenterology, Peking University First Hospital, Beijing, China
| | - Chengwei Tang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Enqiang Linghu
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Huiguo Ding
- Department of Gastroenterology and Hepatology, Beijing You’an Hospital Affiliated to Capital Medical University, Beijing, China
| | - Chinese Society of Hepatology, Chinese Medical Association; Chinese Society of Gastroenterology, Chinese Medical Association; Chinese Society of Digestive Endoscopy, Chinese Medical Association
- Department of Gastroenterology, Peking University First Hospital, Beijing, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Gastroenterology and Hepatology, Beijing You’an Hospital Affiliated to Capital Medical University, Beijing, China
| |
Collapse
|
|
26
|
Liu B, Zhang D, Dong C, Yue Z, Wang L, Fan Z, Wu Y, Zhang K, Jiang L, Ding H, Zhang Y, Wang J, Liu F. Correlation between hepatic venous pressure gradient and portal pressure gradient in patients with autoimmune cirrhotic portal hypertension and collateral branches of the hepatic vein. Hepatol Res 2023; 53:1084-1095. [PMID: 37353943 DOI: 10.1111/hepr.13939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 06/25/2023]
Abstract
AIM To assess the correlation and agreement between hepatic venous pressure gradient (HVPG) and portal pressure gradient (PPG) in patients with autoimmune liver diseases (ALD) and portal hypertension, and to investigate the extent to which hepatic vein collateralization affects the accuracy of this assessment. METHODS Ninety-eight patients with ALD between 2017 and 2021 who underwent transjugular intrahepatic portosystemic shunt with conventional and innovative 15 mL pressurized contrast were selected to measure wedged hepatic venous pressure (WHVP) and portal venous pressure and to calculate the HVPG and PPG. Pearson's correlation was used for correlation analysis between the two groups. Bland-Altman plots were plotted to estimate the agreement between paired pressures. RESULTS The r values of PPG and HVPG in the early, middle, late, and portal venous visualization were 0.404, 0.789, 0.807, and 0.830, respectively, and the R2 values were 0.163, 0.622, 0.651, and 0.690, respectively. The p value for the r and R2 values in the early group was 0.015, and the p values in the remaining groups were less than 0.001. Bland-Altman plots showed that patients in the portal venous visualization group had the narrowest 95% limits of agreement. The mean value of the difference was close to the zero-scale line. CONCLUSIONS In patients with ALD, the correlation between the HVPG and PPG was good, and the later the collateral development, the better the correlation. Hepatic vein collateral was an essential factor in underestimating WHVP and HVPG, and the earlier the collateral appeared, the more obvious the underestimation.
Collapse
Affiliation(s)
- Bowen Liu
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Dan Zhang
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Chengbin Dong
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Zhendong Yue
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Lei Wang
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Zhenhua Fan
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Yifan Wu
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Ke Zhang
- Department of General Surgery, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Li Jiang
- Department of General Surgery, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Huiguo Ding
- Department of Gastroenterology, Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | - Yuening Zhang
- Department of Gastroenterology, Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | - Jian Wang
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Peking University, Beijing, China
| | - Fuquan Liu
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
|
27
|
Gao L, Li MB, Li JY, Liu Y, Ren C, Feng DP. Impressive recompensation in transjugular intrahepatic portosystemic shunt-treated individuals with complications of decompensated cirrhosis based on Baveno VII criteria. World J Gastroenterol 2023; 29:5383-5394. [PMID: 37900585 PMCID: PMC10600797 DOI: 10.3748/wjg.v29.i38.5383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/15/2023] [Accepted: 09/20/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is the standard second-line treatment option for individuals with complications of decompensated cirrhosis, such as variceal bleeding and refractory ascites. AIM To investigate whether recompensation existed in TIPS-treated patients with decompensated cirrhosis according to Baveno VII criteria. METHODS This retrospective analysis was performed on 64 patients who received TIPS for variceal bleeding or refractory ascites. The definition of recompensation referred to Baveno VII criteria and previous study. Clinical events, laboratory tests, and radiological examinations were regularly conducted during a preset follow-up period. The recompensation ratio in this cohort was calculated. Beyond that, univariate and multivariate regression models were conducted to identify the predictors of recompensation. RESULTS Of the 64 patients with a 12-mo follow-up, 20 (31%) achieved recompensation. Age [odds ratio (OR): 1.124; 95% confidence interval (CI): 1.034-1.222] and post-TIPS portal pressure gradient < 12 mmHg (OR: 0.119; 95%CI: 0.024-0.584) were identified as independent predictors of recompensation in patients with decompensated cirrhosis after TIPS. CONCLUSION The present study demonstrated that nearly one-third of the TIPS-treated patients achieved recompensation within this cohort. According to our findings, recompensation is more likely to be achieved in younger patients. In addition, postoperative portal pressure gradient reduction below 12 mmHg contributes to the occurrence of recompensation.
Collapse
Affiliation(s)
- Long Gao
- Department of Oncological and Vascular Intervention, First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
- Shanxi Provincial Clinical Research Center for Interventional Medicine, First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Man-Biao Li
- College of Medical Imaging, Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Jin-Yu Li
- Department of Oncological and Vascular Intervention, First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
- Shanxi Provincial Clinical Research Center for Interventional Medicine, First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Yang Liu
- College of Medical Imaging, Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Chao Ren
- College of Medical Imaging, Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Dui-Ping Feng
- Department of Oncological and Vascular Intervention, First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
- Shanxi Provincial Clinical Research Center for Interventional Medicine, First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| |
Collapse
|
|
28
|
Gu W, Zeleke Y, Hortlik H, Schaaf L, Uschner FE, Schulz M, Tischendorf M, Peiffer KH, Brol MJ, Kimmann M, Vogl T, Köhler M, Meyer C, Gerbes A, Rössle M, Laleman W, Zipprich A, Steib C, Praktiknjo M, Trebicka J. Use and outcome of TIPS in hospitalized patients in Germany: A Nationwide study (2007-2018). Hepatol Commun 2023; 7:e0237. [PMID: 37708430 PMCID: PMC10503680 DOI: 10.1097/hc9.0000000000000237] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/14/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND The number of complications in patients admitted for cirrhosis has increased over time. Portal hypertension is the driver of many complications of cirrhosis. TIPS placement is the most effective treatment of portal hypertension. The aim of this study was to analyze the use and impact of TIPS placement in the last decade in a nationwide study in Germany. METHODS We analyzed 14,598 admissions of patients for TIPS insertions in Germany from 2007 to 2018 using the DRG system, 12,877 out of 2,000,765 total admissions of patients with cirrhosis. All diagnoses and procedures were coded according to ICD-10-CM and OPS codes. The data were analyzed, focusing on the number of admissions and in-hospital mortality. RESULTS The number of TIPS placements increased over the last decade. In-hospital mortality of cirrhotic patients with TIPS decreased when it was placed for severe bleeding (15.2% [TIPS] vs. 19.5% [endoscopy treatment]), ascites (8.7% [TIPS] vs. 14.4% [paracentesis]), and hepatorenal syndrome (HRS) (17.1% [TIPS] vs. 43.3% [no-TIPS]). In the case of bleeding, TIPS significantly decreased in-hospital mortality and also in ascites and HRS. During hospitalization, 22.6% admissions of patients with TIPS insertion showed HE. However, in-hospital mortality in patients admitted with HE grades 1 or 2 and TIPS was lower than in patients without TIPS. In the logistic regression, a higher HE grade(3 and 4), infection, and circulatory disease were found to be independently associated with in-hospital mortality in patients with TIPS insertion. CONCLUSION Our nationwide study demonstrates that TIPS insertion is increasingly used in Germany. TIPS improves outcomes, especially in patients with ascites and HRS, regardless of lower HE grades, while higher HE grades, infection, and circulatory diseases seem to be associated with risk of in-hospital mortality.
Collapse
Affiliation(s)
- Wenyi Gu
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Yasmin Zeleke
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Hannah Hortlik
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Louisa Schaaf
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Frank E. Uschner
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Martin Schulz
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Michael Tischendorf
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Kai-Henrik Peiffer
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | | | - Markus Kimmann
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Thomas Vogl
- Institute of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Michael Köhler
- Clinic for Radiology, University Hospital Muenster, Muenster, Germany
| | - Carsten Meyer
- Clinic for Radiology, University Hospital Bonn, Bonn, Germany
| | - Alexander Gerbes
- Department of Medicine II, University Clinic Munich LMU, Munich, Germany
| | - Martin Rössle
- Department of Internal Medicine II, Faculty of Medicine, Medical Centre University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Wim Laleman
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Alexander Zipprich
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Christian Steib
- Department of Medicine II, University Clinic Munich LMU, Munich, Germany
| | - Michael Praktiknjo
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Jonel Trebicka
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
- European Foundation for Study of Chronic Liver Failure, Barcelona, Spain
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| |
Collapse
|
|
29
|
Mattos AAD, Mattos AZD, Sartori GDP, Both GT, Tovo CV. THE ROLE OF ELASTOGRAPHY IN CLINICALLY SIGNIFICANT PORTAL HYPERTENSION. ARQUIVOS DE GASTROENTEROLOGIA 2023; 60:525-535. [PMID: 38018555 DOI: 10.1590/s0004-2803.230402023-64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/08/2023] [Indexed: 11/30/2023]
Abstract
• In compensated cirrhosis, using non-invasive methods would exempt the patient from the need of an endoscopy. • The Baveno VII presented the "rule of 5" for Vibration-Controlled Transient Elastography; liver stiffness measurement ≤15 kPa and platelets >150.000/mm3 exclude clinically significant portal hypertension (CSPH), while when ≥25 kPa is highly suggestive of CSPH. • Spleen stiffness measurement has been proposed as a more specific technique to predict the presence of CSPH. • Elastography has gained prestige in the non-invasive evaluation of patients with advanced chronic liver disease by allowing prophylactic measures to be taken when suggesting the presence of CSPH. This is a narrative review that aims to discuss the importance of elastographic methods in the evaluation of clinically significant portal hypertension (CSPH) in cirrhotic patients, where the authors propose an algorithm for evaluating these patients. In compensated advanced chronic liver disease, the goal is to prevent the development of CSPH and, in those already with CSPH, prevent the appearance of gastroesophageal varices (GEV) and other complications of portal hypertension. In compensated cirrhosis, the prevalence of GEV is 30-40%, of which 10-20% are at risk of bleeding. Therefore, using non-invasive methods would exempt the patient from the need of an endoscopy. Hepatic Elastography is a non-invasive, safe, reproducible method, available through many techniques: Vibration-Controlled Transient Elastography (VCTE), Shear Wave Elastography (SWE) and Magnetic Resonance Elastography (MRE). The Baveno VII presented the "rule of 5" for VCTE: liver stiffness measurement (LSM) ≤15 kPa and platelets >150.000/mm3 exclude CSPH, while an LSM ≥25 kPa is highly suggestive of CSPH. Also, the "rule of 4" for SWE has been proposed: patients with ≥17 kPa could be considered as having CSPH. At last, spleen stiffness measurement (SSM) has been proposed as a more specific technique to predict the presence of CSPH. In conclusion, elastography has gained prestige in the non-invasive evaluation of patients with advanced chronic liver disease by allowing prophylactic measures to be taken when suggesting the presence of CSPH.
Collapse
Affiliation(s)
- Angelo Alves de Mattos
- Universidade Federal de Ciências da Saúde de Porto Alegre, Departamento de Clínica Médica, Porto Alegre, RS, Brasil
- Universidade Federal de Ciências da Saúde de Porto Alegre, Curso de Pós-Graduação em Medicina: Hepatologia, Porto Alegre, RS, Brasil
| | - Angelo Zambam de Mattos
- Universidade Federal de Ciências da Saúde de Porto Alegre, Departamento de Clínica Médica, Porto Alegre, RS, Brasil
- Universidade Federal de Ciências da Saúde de Porto Alegre, Curso de Pós-Graduação em Medicina: Hepatologia, Porto Alegre, RS, Brasil
| | - Giovana Dal Pozzo Sartori
- Universidade Federal de Ciências da Saúde de Porto Alegre, Curso de Pós-Graduação em Medicina: Hepatologia, Porto Alegre, RS, Brasil
| | - Gustavo Tovo Both
- Universidade Luterana do Brasil, Departamento de Clínica Médica, Canoas, RS, Brasil
| | - Cristiane Valle Tovo
- Universidade Federal de Ciências da Saúde de Porto Alegre, Departamento de Clínica Médica, Porto Alegre, RS, Brasil
- Universidade Federal de Ciências da Saúde de Porto Alegre, Curso de Pós-Graduação em Medicina: Hepatologia, Porto Alegre, RS, Brasil
| |
Collapse
|
|
30
|
Sharma S, Agarwal S, Saraya A. An LSM Based Strategy is Comparable to HVPG Measurement to Predict Further Events in Patients with Cirrhosis with Variceal Bleeding as Their Index Decompensation. J Clin Exp Hepatol 2023; 13:774-782. [PMID: 37693274 PMCID: PMC10482994 DOI: 10.1016/j.jceh.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/24/2023] [Indexed: 09/12/2023] Open
Abstract
Background and aims Limited data exist on strategies other than hepatic venous pressure gradient (HVPG) estimation to predict future events in patients with cirrhosis presenting with variceal bleed (VB) but are otherwise compensated. We assessed whether liver stiffness measurement (LSM) during VB episode could accurately predict this risk. Methods Consecutive patients with cirrhosis with VB as their index decompensation event underwent HVPG and LSM estimation during the VB episode in this prospective study. New onset further decompensation events (ascites, VB, encephalopathy) was assessed over follow-up. The performance characteristics of postbleed LSM were compared with model for end stage liver disease (MELD) score and HVPG to predict future decompensation and were cross-validated. Results Mean age of the cohort (n = 68) was 44.2 years and alcohol-related liver disease (55.9%) was the most common etiology. Over a median follow-up of 14 (9-18) months, 18(26.4%) patients developed further decompensation with ascites being the most common event. Patients with further decompensation had a higher median postbleed LSM [60.5 kPa (53-70) vs. 25 kPa (18-34), P < 0.001], HVPG [ 19 mm Hg vs. 16 mmHg, P = 0.005], and MELD score [ 12.5 (11-14.7) vs. 10 (8-12) P < 0.001]. The area under receiver-operator characteristics curve for postbleed LSM [0.928 (95%CI: 0.868-0.988)] was higher than both HVPG [0.733(0.601-0.865), P = 0.003] and MELD score [0.776(0.664-0.889), P = 0.019] to predict further decompensation. Optimism-corrected c-statistic using MELD and postbleed LSM was similar to a combination of HVPG, MELD, and postbleed LSM. Conclusion Postbleed LSM is comparable to HVPG estimation in predicting further decompensation events in patients with otherwise compensated cirrhosis presenting with VB.
Collapse
Affiliation(s)
| | | | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
|
31
|
Qi WL, Wen J, Wen TF, Peng W, Zhang XY, Shen JY, Li X, Li C. Prognosis after splenectomy plus pericardial devascularization vs transjugular intrahepatic portosystemic shunt for esophagogastric variceal bleeding. World J Gastrointest Surg 2023; 15:1641-1651. [PMID: 37701695 PMCID: PMC10494603 DOI: 10.4240/wjgs.v15.i8.1641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/04/2023] [Accepted: 06/26/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Portal hypertension combined with esophagogastric variceal bleeding (EGVB) is a serious complication in patients with hepatitis B virus (HBV)-related cirrhosis in China. Splenectomy plus pericardial devascularization (SPD) and transjugular intrahepatic portosystemic shunt (TIPS) are effective treatments for EGVB. However, a comparison of the effectiveness and safety of those methods is lacking. AIM To compare the prognosis after SPD vs TIPS for acute EGVB after failure of endoscopic therapy or secondary prophylaxis of variceal rebleeding (VRB) in patients with HBV-related cirrhosis combined with portal hypertension. METHODS This retrospective cohort study included 318 patients with HBV-related cirrhosis and EGVB who underwent SPD or TIPS at West China Hospital of Sichuan University during 2009-2013. Propensity score-matched analysis (PSM), the Kaplan-Meier method, and multivariate Cox regression analysis were used to compare overall survival, VRB rate, liver function abnormality rate, and hepatocellular carcinoma (HCC) incidence between the two patient groups. RESULTS The median age was 45.0 years (n = 318; 226 (71.1%) males). During a median follow-up duration of 43.0 mo, 18 (11.1%) and 33 (21.2%) patients died in the SPD and TIPS groups, respectively. After PSM, SPD was significantly associated with better overall survival (OS) (P = 0.01), lower rates of abnormal liver function (P < 0.001), and a lower incidence of HCC (P = 0.02) than TIPS. The VRB rate did not differ significantly between the two groups (P = 0.09). CONCLUSION Compared with TIPS, SPD is associated with higher postoperative OS rates, lower rates of abnormal liver function and HCC, and better quality of survival as acute EGVB treatment after failed endoscopic therapy or as secondary prophylaxis of VRB in patients with HBV-related cirrhosis combined with portal hypertension. There is no significant between-group difference in VRB rates.
Collapse
Affiliation(s)
- Wei-Li Qi
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jun Wen
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- Section for HepatoPancreatoBiliary Surgery, Department of General Surgery, The Third People’s Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University & The Second Affiliated Hospital of Chengdu, Chongqing Medical University, Chengdu 610041, Sichuan Province, China
| | - Tian-Fu Wen
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Wei Peng
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xiao-Yun Zhang
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jun-Yi Shen
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xiao Li
- Department of Interventional Therapy, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100000, China
| | - Chuan Li
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| |
Collapse
|
|
32
|
Liu L, Nie Y, Liu Q, Zhu X. A Practical Model for Predicting Esophageal Variceal Rebleeding in Patients with Hepatitis B-Associated Cirrhosis. Int J Clin Pract 2023; 2023:9701841. [PMID: 37576938 PMCID: PMC10415078 DOI: 10.1155/2023/9701841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/13/2023] [Accepted: 07/07/2023] [Indexed: 08/15/2023] Open
Abstract
Background Variceal rebleeding is a significant and potentially life-threatening complication of cirrhosis. Unfortunately, currently, there is no reliable method for stratifying high-risk patients. Liver stiffness measurements (LSM) have been shown to have a predictive value in identifying complications associated with portal hypertension, including first-time bleeding. However, there is a lack of evidence to confirm that LSM is reliable in predicting variceal rebleeding. The objective of our study was to evaluate the ability of generating a extreme gradient boosting (XGBoost) algorithm model to improve the prediction of variceal rebleeding. Methods This retrospective analysis examined a cohort of 284 patients with hepatitis B-related cirrhosis. XGBoost models were developed using laboratory data, LSM, and imaging data to predict the risk of rebleeding in the patients. In addition, we compared the XGBoost models with traditional logistic regression (LR) models. We evaluated and compared the two models using the area under the receiver operating characteristic curve (AUROC) and other model performance parameters. Lastly, we validated the models using nomograms and decision curve analysis (DCA). Results During a median follow-up of 66.6 weeks, 72 patients experienced rebleeding, including 21 (7.39%) and 61 (21.48%) patients who rebleed within 6 weeks and 1 year, respectively. In brief, the AUC of the LR models in predicting rebleeding at 6 weeks and 1 year was 0.828 (0.759-0.897) and 0.799 (0.738-0.860), respectively. In contrast, the accuracy of the XGBoost model in predicting rebleeding at 6 weeks and 1 year was 0.985 (0.907-0.731) and 0.931 (0.806-0.935), respectively. LSM and high-density lipoprotein (HDL) levels differed significantly between the rebleeding and nonrebleeding groups, with LSM being a reliable predictor in those models. The XGBoost models outperformed the LR models in predicting rebleeding within 6 weeks and 1 year, as demonstrated by the ROC and DCA curves. Conclusion The XGBoost algorithm model can achieve higher accuracy than the LR model in predicting rebleeding, making it a clinically beneficial tool. This implies that the XGBoost model is better suited for predicting the risk of esophageal variceal rebleeding in patients.
Collapse
Affiliation(s)
- Linxiang Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Jiangxi Clinical Research Center for Gastroenterology, Nanchang, Jiangxi, China
| | - Yuan Nie
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Jiangxi Clinical Research Center for Gastroenterology, Nanchang, Jiangxi, China
| | - Qi Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Jiangxi Clinical Research Center for Gastroenterology, Nanchang, Jiangxi, China
| | - Xuan Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Jiangxi Clinical Research Center for Gastroenterology, Nanchang, Jiangxi, China
| |
Collapse
|
|
33
|
Wang X, Liu G, Wu J, Xiao X, Yan Y, Guo Y, Yang J, Li X, He Y, Yang L, Luo X. Small-Diameter Transjugular Intrahepatic Portosystemic Shunt versus Endoscopic Variceal Ligation Plus Propranolol for Variceal Rebleeding in Advanced Cirrhosis. Radiology 2023; 308:e223201. [PMID: 37606572 DOI: 10.1148/radiol.223201] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
Background Some studies have shown that transjugular intrahepatic portosystemic shunt (TIPS) placement within 72 hours of admission improves survival in patients at high risk who present with acute variceal bleeding. However, the role of small-diameter covered TIPS in the secondary prophylaxis of variceal bleeding is still debatable. Purpose To compare the efficacy of 8-mm TIPS and endoscopic variceal ligation (EVL) plus propranolol in the prevention of variceal rebleeding among participants with advanced cirrhosis. Materials and Methods Between June 2015 and December 2018, participants admitted to the hospital for variceal bleeding were considered for enrollment in this randomized controlled trial (ClinicalTrials.gov). Participants with Child-Pugh class B or C cirrhosis were randomly assigned to receive an 8-mm covered TIPS or EVL and propranolol. The primary end point was recurrent variceal bleeding assessed using Kaplan-Meier curve analysis. Secondary end points included survival and overt hepatic encephalopathy (HE) assessed using Kaplan-Meier curve analysis. Results A total of 100 participants were enrolled, with 50 randomly assigned to the EVL plus propranolol group (median age, 54 years; IQR, 45-60 years; 29 male, 21 female) and 50 randomly assigned to the TIPS group (median age, 49 years; IQR, 43-56 years; 32 male, 18 female). The median follow-up period was 43.4 months. In the TIPS group, variceal rebleeding risk was reduced compared with variceal rebleeding risk in the EVL plus propranolol group (hazard ratio [HR], 0.31; 95% CI: 0.14, 0.69; P = .008), but the incidence of overt HE was higher in the TIPS group (30.0% vs 16.0%, P = .03). No differences in survival were observed between the two groups (1-year survival: TIPS, 98.0%; EVL plus propranolol, 92.0%; 3-year survival: TIPS, 94.0%; EVL plus propranolol, 85.7%; HR, 0.52; 95% CI: 0.19, 1.42; P = .22). Conclusion When compared with EVL plus propranolol, 8-mm TIPS led to reduced variceal rebleeding but did not impact overall survival in participants with Child-Pugh class B or C cirrhosis. Clinical trial registration no. NCT02477384 © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Barth in this issue.
Collapse
Affiliation(s)
- Xiaoze Wang
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| | - Guofeng Liu
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| | - Junchao Wu
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| | - Xue Xiao
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| | - Yuling Yan
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| | - Yuxin Guo
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| | - Jinlin Yang
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| | - Xiao Li
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| | - Yazhou He
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| | - Li Yang
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| | - Xuefeng Luo
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| |
Collapse
|
|
34
|
Yuan Q, Zhao WL, Qin B. Big data and variceal rebleeding prediction in cirrhosis patients. Artif Intell Gastroenterol 2023; 4:1-9. [DOI: 10.35712/aig.v4.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 02/03/2023] [Accepted: 03/10/2023] [Indexed: 06/08/2023] Open
Abstract
Big data has convincing merits in developing risk stratification strategies for diseases. The 6 “V”s of big data, namely, volume, velocity, variety, veracity, value, and variability, have shown promise for real-world scenarios. Big data can be applied to analyze health data and advance research in preclinical biology, medicine, and especially disease initiation, development, and control. A study design comprises data selection, inclusion and exclusion criteria, standard confirmation and cohort establishment, follow-up strategy, and events of interest. The development and efficiency verification of a prognosis model consists of deciding the data source, taking previous models as references while selecting candidate predictors, assessing model performance, choosing appropriate statistical methods, and model optimization. The model should be able to inform disease development and outcomes, such as predicting variceal rebleeding in patients with cirrhosis. Our work has merits beyond those of other colleagues with respect to cirrhosis patient screening and data source regarding variceal bleeding.
Collapse
Affiliation(s)
- Quan Yuan
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400042, China
| | - Wen-Long Zhao
- College of Medical Informatics, Chongqing Medical University, Chongqing 400016, China
- Medical Data Science Academy, Chongqing 400016, China
- Chongqing Engineering Research Centre for Clinical Big-data and Drug Evaluation, Chongqing 400016, China
| | - Bo Qin
- Department of Infectious Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400042, China
| |
Collapse
|
|
35
|
Dong J, Zhang Y, Wu YF, Yue ZD, Fan ZH, Zhang CY, Liu FQ, Wang L. Computed tomography perfusion in differentiating portal hypertension: A correlation study with hepatic venous pressure gradient. World J Gastrointest Surg 2023; 15:664-673. [PMID: 37206083 PMCID: PMC10190718 DOI: 10.4240/wjgs.v15.i4.664] [Citation(s) in RCA: 2] [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: 12/20/2022] [Revised: 01/11/2023] [Accepted: 03/23/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Hepatic venous pressure gradient (HVPG) is the gold standard for diagnosis of portal hypertension (PH), invasiveness and potential risks in the process of measurement limited its widespread use.
AIM To investigate the correlation of computed tomography (CT) perfusion parameters with HVPG in PH, and quantitatively assess the blood supply changes in liver and spleen parenchyma before and after transjugular intrahepatic portosystemic shunt (TIPS).
METHODS Twenty-four PH related gastrointestinal bleeding patients were recruited in this study, and all patients were performed perfusion CT before and after TIPS surgery within 2 wk. Quantitative parameters of CT perfusion, including liver blood volume (LBV), liver blood flow (LBF), hepatic arterial fraction (HAF), spleen blood volume (SBV) and spleen blood flow (SBF), were measured and compared before and after TIPS, and the quantitative parameters between clinically significant PH (CSPH) and non-CSPH (NCSPH) group were also compared. Then the correlation of CT perfusion parameters with HVPG were analyzed, with statistical significance as P < 0.05.
RESULTS For all 24 PH patients after TIPS, CT perfusion parameters demonstrated decreased LBV, increased HAF, SBV and SBF, with no statistical difference in LBF. Compared with NCSPH, CSPH showed higher HAF, with no difference in other CT perfusion parameters. HAF before TIPS showed positive correlation with HVPG (r = 0.530, P = 0.008), while no correlation was found in other CT perfusion parameters with HVPG and Child-Pugh scores.
CONCLUSION HAF, an index of CT perfusion, was positive correlation with HVPG, and higher in CSPH than NCSPH before TIPS. While increased HAF, SBF and SBV, and decreased LBV, were found after TIPS, which accommodates a potential non-invasive imaging tool for evaluation of PH.
Collapse
Affiliation(s)
- Jian Dong
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Yu Zhang
- Department of Interventional Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Yi-Fan Wu
- Department of Interventional Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Zhen-Dong Yue
- Department of Interventional Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Zhen-Hua Fan
- Department of Interventional Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Chun-Yan Zhang
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Fu-Quan Liu
- Department of Interventional Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Lei Wang
- Department of Interventional Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| |
Collapse
|
|
36
|
Calmet FH, Martin P. Acid Test: MELD-Lactate Enhances Prediction in Patients with Variceal Hemorrhage. Dig Dis Sci 2023; 68:723-724. [PMID: 36376574 DOI: 10.1007/s10620-022-07747-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Fernando H Calmet
- Division of Gastroenterology, Department of Medicine, Newton-Wellesley Hospital, Newton, MA, 02462, USA
- Division of Gastroenterology, Department of Medicine, Tufts University School of Medicine, Boston, MA, 02111, USA
| | - Paul Martin
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, FL, 33126, Miami, USA.
| |
Collapse
|
|
37
|
Wang D, Xie T, Ji X, Yan S. Evaluation of transjugular intrahepatic portosystemic shunt and modified sclerotherapy in preventing rebleeding of esophageal and gastric varices. Med Eng Phys 2022; 110:103905. [PMID: 36273997 DOI: 10.1016/j.medengphy.2022.103905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/07/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
Abstract
Esophageal and gastric varices are complications of decompensated portal hypertension due to cirrhosis, and gastrointestinal bleeding and can seriously trigger major bleeding and crisis life. Seriously endangers patients' physical and mental health and attracts great attention in the clinic. To compare the efficacy and safety of MES (combined with lauromacrogol and tissue adhesive) and TIPS in the treatment of esophageal and gastric varices. The 62 cases of esophageal and gastric variceal bleeding in our hospital were retrospectively analyzed. They were divided into the MES group and TIPS group according to the treatment method. The rebleeding rate, complications, 2-year birth rate, treatment cost, and hospitalization time within 2 years after operation were compared between the two groups. Among the 62 patients, there were 32 in the MES group and 30 in the TIPS group. The rebleeding rate within 1 year after operation in the MES group was higher than that in the TIPS group, but the difference was not statistically significant. The rebleeding rate within 2 years after operation in the MES group was 40.63%, significantly higher than 13.33% in the TIPS group (P < 0. 05). In the MES group, the incidence of hepatic encephalopathy after the operation was 9.38%, significantly lower than 33.33% in TIPS group (P < 0. 05). The survival rate within 2 years after operation in MES group (81.25%) and TIPS group (83.33), the difference was not statistically significant (P > 0.05). There was no significant difference in hospital stay between the MES group and TIPS group (P > 0.05). The treatment cost of the MES group was lower than that of the TIPS group (P < 0.05). MES is more suitable for development and promotion in grass-roots hospitals, but TIPS treatment should be carried out as soon as possible for patients with poor efficacy of endoscopic treatment.
Collapse
Affiliation(s)
- Daliang Wang
- The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, 233000, China; Taihe County People's Hospital, Fuyang, Anhui, 236000, China.
| | - Taoli Xie
- Taihe County People's Hospital, Fuyang, Anhui, 236000, China
| | - Xiaowen Ji
- Taihe County People's Hospital, Fuyang, Anhui, 236000, China
| | - Shanjun Yan
- The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, 233000, China.
| |
Collapse
|
|
38
|
Liu K, Zhang R, Shi C, Wu B, Liu S, Tian H, Du H, Li Y, Wang N. Risk factors for emergency endoscopic variceal ligation treatment failure of acute variceal bleeding. Scand J Gastroenterol 2022; 57:1509-1516. [PMID: 35793450 DOI: 10.1080/00365521.2022.2094719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To determine the risk factors for emergency endoscopic variceal ligation (EVL) failure in acute variceal bleeding (AVB). METHODS Data from 161 cirrhosis patients with oesophageal variceal bleeding who underwent emergency EVL treatment at the Second Hospital of Hebei Medical University from January 2018 to May 2021 were retrospectively analysed. Enrolled patients were divided into a successful treatment group and a failed treatment group. The variables studied were demographic, clinical, imaging, laboratory, and endoscopic data from the enrolled patients. RESULTS Of the enrolled patients, 19 patients experienced emergency EVL failure. Of these patients, nine underwent emergency endoscopic treatment again, six patients were treated with a Sengstaken-Blakemore tube for haemostasis and endoscopic treatment, four patients received drug therapy. The presence of portal vein thrombosis (PVT) in the failure group was higher than that in the success group (p < .05). Active bleeding on endoscopy was associated with emergency EVL failure for patients with Child-Pugh class C (p < .05). CONCLUSIONS Child-Pugh class C with active bleeding on endoscopy or the presence of PVT could increase the risk of emergency EVL failure. The patient's condition should be fully evaluated before emergency endoscopic treatment to reduce the risk of failure.
Collapse
Affiliation(s)
- Kunyi Liu
- Hebei Key Laboratory of Gastroenterology, Department of Gastroenterology, Hebei Institute of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Rui Zhang
- Hebei Key Laboratory of Gastroenterology, Department of Gastroenterology, Hebei Institute of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chengyi Shi
- Hebei Key Laboratory of Gastroenterology, Department of Gastroenterology, Hebei Institute of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Botao Wu
- Hebei Key Laboratory of Gastroenterology, Department of Gastroenterology, Hebei Institute of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Siqi Liu
- Hebei Key Laboratory of Gastroenterology, Department of Gastroenterology, Hebei Institute of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Hui Tian
- Hebei Key Laboratory of Gastroenterology, Department of Gastroenterology, Hebei Institute of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Hongwei Du
- Hebei Key Laboratory of Gastroenterology, Department of Gastroenterology, Hebei Institute of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yan Li
- Hebei Key Laboratory of Gastroenterology, Department of Gastroenterology, Hebei Institute of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Na Wang
- Hebei Key Laboratory of Gastroenterology, Department of Gastroenterology, Hebei Institute of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| |
Collapse
|
|
39
|
Singh AD, Bazarbashi AN, Lindenmeyer CC. Endo-hepatology: The changing paradigm of endoscopic ultrasound in cirrhosis. Clin Liver Dis (Hoboken) 2022; 20:209-215. [PMID: 36523865 PMCID: PMC9745261 DOI: 10.1002/cld.1263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/10/2022] [Accepted: 08/16/2022] [Indexed: 12/15/2022] Open
Abstract
Content available: Author Interview and Audio Recording.
Collapse
Affiliation(s)
| | - Ahmad Najdat Bazarbashi
- Division of GastroenterologyWashington University in St. Louis/Barnes Jewish HospitalSt. LouisMissouriUSA
| | - Christina C. Lindenmeyer
- Department of Gastroenterology, Hepatology and NutritionDigestive Disease and Surgery institute, Cleveland ClinicClevelandOhioUSA
| |
Collapse
|
|
40
|
Lv Y, Bai W, Zhu X, Xue H, Zhao J, Zhuge Y, Sun J, Zhang C, Ding P, Jiang Z, Zhu X, Ren W, Li Y, Zhang K, Zhang W, Li K, Wang Z, Luo B, Li X, Yang Z, Wang Q, Guo W, Xia D, Yang C, Pan Y, Yin Z, Fan D, Han G. CLIF-C AD score predicts survival benefit from pre-emptive TIPS in individuals with Child-Pugh B cirrhosis and acute variceal bleeding. JHEP Rep 2022; 4:100621. [PMID: 36439638 PMCID: PMC9685385 DOI: 10.1016/j.jhepr.2022.100621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/07/2022] [Accepted: 09/29/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND & AIMS Among individuals with Child-Pugh B cirrhosis and acute variceal bleeding (AVB), the Baveno VII workshop recommended pre-emptive TIPS in those with a Child-Pugh score of 8-9 and active bleeding at initial endoscopy (Child B8-9 + AB criteria). Nevertheless, whether this criterion is superior to the CLIF-Consortium acute decompensation score (CLIF-C ADs) remains unclear. METHODS Data on 1,021 consecutive individuals with Child-Pugh B cirrhosis and AVB from 13 university hospitals in China who were treated with pre-emptive TIPS (n = 297) or drug plus endoscopic treatment (n = 724) between 2010 to 2019 were retrospectively analysed. A competing risk regression model was used to compare the outcomes between the two groups after adjusting for confounders. The concordance-statistic for benefit (c-for-benefit) was used to evaluate a models' ability to predict treatment benefit (risk difference between treatment groups). RESULTS Pre-emptive TIPS was associated with reduced mortality compared to drug plus endoscopic treatment (adjusted hazard ratio 0.62, 95% CI 0.44 to 0.88). A higher baseline CLIF-C AD score was associated with greater survival benefit (i.e., larger absolute mortality risk reduction). After adjusting for confounders, a survival benefit was observed in individuals with CLIF-C ADs ≥48 or Child-Pugh B8-9 with active bleeding, but not in those with CILF-C ADs <48, no active bleeding or Child-Pugh B7 with active bleeding. The c-for-benefit of CILF-C ADs for predicting survival benefit was higher than that of Child B8-9+AB criteria. CONCLUSIONS In individuals with Child-Pugh B cirrhosis and AVB, CLIF-C ADs predicts survival benefit from pre-emptive TIPS and outperforms the Child B8-9+AB criteria. Prospective validation should be performed to confirm this result, especially for other aetiologies of cirrhosis. IMPACT AND IMPLICATIONS In this study, among individuals with Child-Pugh B cirrhosis and acute variceal bleeding, the CLIF-Consortium acute decompensation (CLIF-C AD) score could predict the survival benefit from pre-emptive TIPS, with patients with higher CLIF-C AD scores benefiting more from pre-emptive TIPS. Furthermore, the CLIF-C AD score outperformed the Child B8-9 plus active bleeding criteria in terms of discriminating between those who obtained more benefit vs. less benefit from pre-emptive TIPS. Depending on prospective validation, the CLIF-C AD score could be used as the model of choice to determine who should undergo pre-emptive TIPS.
Collapse
Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
- Military Medical Innovation Center, Fourth Military Medical University, Xi’an, China
| | - Wei Bai
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
- Department of Liver Diseases and Interventional Radiology, Xi’an International Medical Center Hospital of Digestive Diseases, Northwestern University, Xi’an, China
| | - Xuan Zhu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hui Xue
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi’an, China
| | - Jianbo Zhao
- Department of Interventional Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yuzheng Zhuge
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Junhui Sun
- Hepatobiliaryand Pancreatic Intervention Center, Division of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Pengxu Ding
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zaibo Jiang
- Department of Interventional Radiology, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaoli Zhu
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Weixin Ren
- Department of Interventional Radiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yingchun Li
- Department of Interventional Radiology, Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Kewei Zhang
- Department of Vascular Surgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - Wenguang Zhang
- Department of Interventional Radiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Kai Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| | - Zhengyu Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
- Department of Liver Diseases and Interventional Radiology, Xi’an International Medical Center Hospital of Digestive Diseases, Northwestern University, Xi’an, China
| | - Bohan Luo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
- Department of Liver Diseases and Interventional Radiology, Xi’an International Medical Center Hospital of Digestive Diseases, Northwestern University, Xi’an, China
| | - Xiaomei Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
- Department of Liver Diseases and Interventional Radiology, Xi’an International Medical Center Hospital of Digestive Diseases, Northwestern University, Xi’an, China
| | - Zhiping Yang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| | - Qiuhe Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| | - Wengang Guo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
- Department of Liver Diseases and Interventional Radiology, Xi’an International Medical Center Hospital of Digestive Diseases, Northwestern University, Xi’an, China
| | - Dongdong Xia
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
- Department of Liver Diseases and Interventional Radiology, Xi’an International Medical Center Hospital of Digestive Diseases, Northwestern University, Xi’an, China
| | - Changbing Yang
- Military Medical Innovation Center, Fourth Military Medical University, Xi’an, China
| | - Yanglin Pan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
- Department of Liver Diseases and Interventional Radiology, Xi’an International Medical Center Hospital of Digestive Diseases, Northwestern University, Xi’an, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
- Department of Liver Diseases and Interventional Radiology, Xi’an International Medical Center Hospital of Digestive Diseases, Northwestern University, Xi’an, China
| |
Collapse
|
|
41
|
Assessing the Risk of Further Decompensation and Survival in Patients With Cirrhosis With Variceal Bleeding as Their First Decompensation Event. Am J Gastroenterol 2022; 118:833-839. [PMID: 36114777 DOI: 10.14309/ajg.0000000000002018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 09/09/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Limited data exist on long-term outcomes of patients with compensated cirrhosis presenting with acute variceal bleeding (AVB) as an index and lone decompensating event. This study aimed to evaluate the incidence of further decompensation, survival, and risk factors of mortality in these patients. METHODS Patients with otherwise compensated cirrhosis presenting with AVB as their index decompensating event (n = 463) were analyzed in this single-center retrospective study. The incidence of individual decompensation events and survival was estimated using competing risk analysis. Risk factors for poor outcomes were identified. RESULTS The mean age was 47.4 (13.2) years, with most patients (86.5%) being males. Alcohol-related liver disease (42.3%) and viral cirrhosis (22.4%) were the main etiologies with a median Model for End-Stage Liver Disease score of 14 (11-15) at baseline. Over a median follow-up of 42 (24-62) months, 292 patients experienced further decompensations: ascites (n = 283; 96.9%), rebleeding (n = 157; 53.8%), and hepatic encephalopathy (n = 71; 24.3%). Most events occurred with similar frequency across different etiologies, except acute-on-chronic liver failure, which was more common in nonviral cirrhosis (Gray test, P = 0.042). Patients with viral and nonviral cirrhosis had similar survival (5-year survival: 91% and 80.1%, respectively; P = 0.062). Patients with early further decompensations (onset <6 weeks of index AVB event) (n = 40) had a higher mortality (52.5% vs 20.2% for late decompensations; P < 0.001). Active alcohol consumption (hazard ratio [HR]: 9 [5.31-15.3], P < 0.001), high white blood cell count at presentation (HR: 2.5 [1.4-4.4], P = 0.001), and early decompensation (HR: 6.2 [3.6-10.6], P < 0.001) predicted poor survival. DISCUSSION Despite a high incidence of further decompensation, 5-year survival of patients at this stage of cirrhosis is more than 80% across all etiologies in the absence of early further decompensation and active alcohol consumption.
Collapse
|
|
42
|
Jiang X, Chai S, Huang Y, Huang Z, Tan W, Gao Y, Lu X, Meng Z, Zhou H, Kong W, Tang X, Tang Y, Qi T, Liao C, Gan Q, Xiang X, Zhang Y, Wang S, Chen Y, Chen J. Design for a Multicentre Prospective Cohort for the Assessment of Platelet Function in Patients with Hepatitis-B-Virus-Related Acute-on-Chronic Liver Failure. Clin Epidemiol 2022; 14:997-1011. [PMID: 36042872 PMCID: PMC9420418 DOI: 10.2147/clep.s376068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 08/15/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) has high short-term mortality and lacks sufficient medical therapy. Available algorithms are unable to precisely predict short-term outcomes or safely stratify patients with ACLF as emergent liver transplantation candidates. Therefore, a personalized prognostic tool is urgently needed. PURPOSE Platelet function and its clinical significance in ACLF patients with chronic hepatitis B virus (HBV) infection have not been investigated. This study aimed to assess changes in platelet function using thromboelastography (TEG) and platelet mapping (TEG-PM) in HBV-related ACLF patients. METHODS Chronic liver disease patients with acute decompensation or acute hepatic injury were recruited. The derivation cohort enrolled HBV-related patients at Nanfang Hospital. HBV-related and non-HBV-related patients were both enrolled in internal and external validation cohorts at seven university hospitals. TEG and TEG-PM were performed at baseline in the derivation cohort and baseline, day 7, and day 14 in the validation cohorts. The primary outcome was all-cause 28-day mortality. Status check and new-onset complications were recorded during the 3-month follow-up, but status check will extend to 5 years. CONCLUSION AND FUTURE PLANS In this study, 586 participants were enrolled, including 100 in derivation cohort, 133 in internal validation cohort, and 353 in external validation cohort. Biomaterials, including plasma, serum, urine, and some explanted liver tissues, were collected from these patients. A 3-month follow-up with survival status was completed. The baseline characteristics indicated that 51% of the patients had adenosine diphosphate (ADP)-hyporesponsive circulating platelets. The prognostic potential of platelet function will be explored in the derivation cohort (HBV-related ACLF patients) and further substantiated in the validation cohorts (HBV-related and non-HBV-related ACLF patients). Biosamples are currently used to explore the underlying mechanisms related to ADP-hyporesponsive platelets. The ongoing proteomic and metabolic analyses will provide new insights into the pathogenesis of extrahepatic organ failures in ACLF patients.
Collapse
Affiliation(s)
- Xiuhua Jiang
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Shiqi Chai
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Yan Huang
- Department of Infectious Diseases, Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Zuxiong Huang
- Department of Hepatology, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, People’s Republic of China
| | - Wenting Tan
- Department of Infectious Diseases, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People’s Republic of China
| | - Yanhang Gao
- Department of Hepatology, the First Hospital of Jilin University, Changchun, People’s Republic of China
| | - Xiaobo Lu
- Infectious Disease Center, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, People’s Republic of China
| | - Zhongji Meng
- Department of Infectious Diseases, Hubei Clinical Research Center for Precise Diagnosis and Treatment of Liver Cancer, Taihe Hospital, Hubei University of Medicine, Shiyan, People’s Republic of China
| | - Huayou Zhou
- Department of Blood Transfusion, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Wenbing Kong
- Department of Blood Transfusion, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Xiaoting Tang
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Yujun Tang
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Tingting Qi
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Chengjin Liao
- Department of Infectious Diseases, Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Qiaorong Gan
- Department of Hepatology, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, People’s Republic of China
| | - Xiaomei Xiang
- Department of Infectious Diseases, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People’s Republic of China
| | - Yanan Zhang
- Department of Hepatology, the First Hospital of Jilin University, Changchun, People’s Republic of China
| | - Shuai Wang
- Infectious Disease Center, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, People’s Republic of China
| | - Yuanyuan Chen
- Department of Infectious Diseases, Hubei Clinical Research Center for Precise Diagnosis and Treatment of Liver Cancer, Taihe Hospital, Hubei University of Medicine, Shiyan, People’s Republic of China
| | - Jinjun Chen
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
- Hepatology Unit, Zengcheng Branch, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| |
Collapse
|
|
43
|
A Liver Stiffness Measurement-Based Nomogram Predicts Variceal Rebleeding in Hepatitis B-Related Cirrhosis. DISEASE MARKERS 2022; 2022:4107877. [PMID: 35692881 PMCID: PMC9184154 DOI: 10.1155/2022/4107877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 04/03/2022] [Accepted: 04/11/2022] [Indexed: 11/17/2022]
Abstract
Background Cirrhosis esophageal variceal rebleeding is a major complication of chronic cirrhosis. The hepatic venous pressure gradient (HVPG) can predict the risk of rebleeding in patients with cirrhosis and has a good correlation with liver stiffness measurement (LSM). However, there are currently few studies based on liver stiffness to predict the risk of rebleeding in patients with liver cirrhosis. This study is aimed at exploring whether liver stiffness can predict rebleeding in patients with hepatitis B virus-related cirrhosis and developing an easy-to-use nomogram for predicting the risk of rebleeding in patients with liver cirrhosis undergoing secondary prevention. Methods A prospective analysis of 289 cirrhosis patients was performed. Univariate and multivariate analyses were used to identify independent prognostic factors to create a nomogram. The performance of the nomogram was evaluated by using a bootstrapped-concordance index and calibration plots. Results Use of a nonselective beta-blocker (NSBB) drug, LSM, hemoglobin, and platelet count were identified as factors that could predict rebleeding. We created a nomogram for rebleeding in cirrhosis by using these risk factors. The predictive ability of the nomogram was assessed by the C-index (0.772, 95% CI 0.732–0.822). The results of the calibration plots showed that the actual observation and prediction values obtained by the nomogram had good consistency. Conclusions LSM can predict the risk of rebleeding in patients with cirrhosis, while the nomogram is a conventional tool for doctors to facilitate a personalized prognostic evaluation.
Collapse
|
|
44
|
Miura K, Maeda H, Morimoto N, Watanabe S, Tsukui M, Takaoka Y, Nomoto H, Goka R, Kotani K, Yamamoto H. Utility of FibroScan-based scoring systems to narrow the risk group of nonalcoholic fatty liver disease with comorbidities. World J Gastrointest Pathophysiol 2022; 13:96-106. [PMID: 35720167 PMCID: PMC9157683 DOI: 10.4291/wjgp.v13.i3.96] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 03/21/2022] [Accepted: 05/14/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Vibration-controlled transient elastography (VCTE) is proposed as a second step of examination to assess liver fibrosis in patients with nonalcoholic fatty liver disease (NAFLD) after triaging by the fibrosis-4 (FIB-4) index. Recently, VCTE-based scoring systems, including FibroScan-AST (FAST), Agile 3+, and Agile 4, emerged to determine the status of NAFLD. However, the significance of these scoring systems remains unknown in narrowing the high-risk group of NAFLD patients with comorbidities, including hepatocellular carcinoma (HCC) and esophagogastric varices (EGV).
AIM To clarify the significance of VCTE-based scoring systems to narrow the high-risk group of NAFLD patients with comorbidities.
METHODS We performed a cross-sectional study to investigate the usefulness of VCTE-based scoring systems and other fibrosis markers to narrow the high-risk group of patients with NAFLD. FIB-4 index was used for the first triage. Risk groups of FAST, Agile 3+, and Agile 4 were stratified according to the published data. Among the 191 patients with NAFLD, there were 26 (14%) and 25 patients (13%) with HCC and EGV, respectively.
RESULTS When 1.3 was used as a cutoff value, the FIB-4 index narrowed the risk group to 120 patients, in which all patients with HCC and/or EGV were included. High risk group of Agile 3+ could subsequently narrow the risk group. The prevalence of HCC and EGV at this step were 33% (26/80) and 31% (25/80), respectively. In further narrowing of EGV, Agile 4 aggregated the patients with EGV into 43 patients, of whom 23 (53%) had EGV. FAST failed to narrow the risk group of patients with comorbidities. When 2.6 was used as a cutoff value of the FIB-4 index, three patients with HCC and two patients with EGV were missed at the first triage.
CONCLUSION Agile 3+ and Agile 4 are useful to narrow the NAFLD patient group, in which patients may have HCC and/or EGV.
Collapse
Affiliation(s)
- Kouichi Miura
- Department of Medicine, Division of Gastroenterology, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke 329-0498, Tochigi, Japan
| | - Hiroshi Maeda
- Department of Medicine, Division of Gastroenterology, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke 329-0498, Tochigi, Japan
| | - Naoki Morimoto
- Department of Medicine, Division of Gastroenterology, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke 329-0498, Tochigi, Japan
| | - Shunji Watanabe
- Department of Medicine, Division of Gastroenterology, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke 329-0498, Tochigi, Japan
| | - Mamiko Tsukui
- Department of Medicine, Division of Gastroenterology, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke 329-0498, Tochigi, Japan
| | - Yoshinari Takaoka
- Department of Medicine, Division of Gastroenterology, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke 329-0498, Tochigi, Japan
| | - Hiroaki Nomoto
- Department of Medicine, Division of Gastroenterology, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke 329-0498, Tochigi, Japan
| | - Rie Goka
- Department of Medicine, Division of Gastroenterology, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke 329-0498, Tochigi, Japan
| | - Kazuhiko Kotani
- Division of Community and Family Medicine, Center for Community Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke 329-0498, Japan
| | - Hironori Yamamoto
- Department of Medicine, Division of Gastroenterology, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke 329-0498, Tochigi, Japan
| |
Collapse
|
|
45
|
Evaluation and management of emergencies in the patient with cirrhosis. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2022; 87:198-215. [PMID: 35570104 DOI: 10.1016/j.rgmxen.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/28/2021] [Indexed: 01/10/2023] Open
Abstract
The approach to and management of critically ill patients is one of the most versatile themes in emergency medicine. Patients with cirrhosis of the liver have characteristics that are inherent to their disease that can condition modification in acute emergency treatment. Pathophysiologic changes that occur in cirrhosis merit the implementation of an analysis as to whether the overall management of a critically ill patient can generally be applied to patients with cirrhosis of the liver or if they should be treated in a special manner. Through a review of the medical literature, the available information was examined, and the evidence found on the special management required by those patients was narratively synthesized, selecting the most representative decompensations within chronic disease that require emergency treatment.
Collapse
|
|
46
|
Baiges A, Hernández-Gea V. Management of Liver Decompensation in Advanced Chronic Liver Disease: Ascites, Hyponatremia, and Gastroesophageal Variceal Bleeding. Clin Drug Investig 2022; 42:25-31. [PMID: 35476218 PMCID: PMC9205794 DOI: 10.1007/s40261-022-01147-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2022] [Indexed: 12/26/2022]
Abstract
Portal hypertension is a major complication of cirrhosis characterized by a pathological hepatic venous pressure gradient (HVPG) ≥ 5 mmHg. The structural changes observed in the liver leading to intrahepatic vascular resistance and, consequently, portal hypertension appear in the early stages of cirrhosis. Clinically significant portal hypertension (HVPG ≥ 10 mmHg) is associated with several clinical consequences, such as ascites, hyponatremia, gastroesophageal variceal bleeding, hepatorenal syndrome, cardiopulmonary complications, adrenal insufficiency, and hepatic encephalopathy. The diagnosis and management of these complications depend on their early identification and treatment. Regarding ascites, diuretics are a useful treatment, although plasma sodium levels must be properly controlled to avoid hyponatremia. The management of hypovolemic hyponatremia usually consists in stopping diuretics and the administration of volume. On the contrary, hypervolemic hyponatremia is managed with fluid and sodium restriction. Transjugular intrahepatic portosystemic shunt (TIPS) should be considered in patients with refractory ascites. Primary prophylaxis of variceal bleeding should be based mainly on non-selective beta-blockers. Management of acute gastroesophageal variceal bleeding includes vasoactive drugs and endoscopic band ligation and, in patients at high risk of failure and rebleeding, preemptive use of TIPS. Secondary prophylaxis with a combination of non-selective beta-blockers and endoscopic band ligation is the treatment of choice. This article focuses on the management of ascites, hyponatremia, and gastroesophageal variceal bleeding.
Collapse
Affiliation(s)
- Anna Baiges
- Servicio de Hepatología, Hemodinámica Hepática. Hospital Clínic, Barcelona, Spain.
| | | |
Collapse
|
|
47
|
Velarde-Ruiz Velasco JA, García-Jiménez ES, Aldana-Ledesma JM, Tapia-Calderón DK, Tornel-Avelar AI, Lazcano-Becerra M, Chávez-Ramírez RM, Cano-Contreras AD, Remes-Troche JM, Colunga-Lozano LE, Montaño-Loza A. Evaluation and management of emergencies in the patient with cirrhosis. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2022; 87:198-215. [PMID: 35570104 DOI: 10.1016/j.rgmx.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/28/2021] [Indexed: 01/04/2025]
Abstract
The approach to and management of critically ill patients is one of the most versatile themes in emergency medicine. Patients with cirrhosis of the liver have characteristics that are inherent to their disease that can condition modification in acute emergency treatment. Pathophysiologic changes that occur in cirrhosis merit the implementation of an analysis as to whether the overall management of a critically ill patient can generally be applied to patients with cirrhosis of the liver or if they should be treated in a special manner. Through a review of the medical literature, the available information was examined, and the evidence found on the special management required by those patients was narratively synthesized, selecting the most representative decompensations within chronic disease that require emergency treatment.
Collapse
Affiliation(s)
- J A Velarde-Ruiz Velasco
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico; Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Mexico.
| | - E S García-Jiménez
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - J M Aldana-Ledesma
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - D K Tapia-Calderón
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - A I Tornel-Avelar
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - M Lazcano-Becerra
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - R M Chávez-Ramírez
- Unidad de Cuidados Intensivos, Hospital de Gineco-obstetricia, UMAE CMNO IMSS, Guadalajara, Jalisco, Mexico
| | - A D Cano-Contreras
- Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Mexico
| | - J M Remes-Troche
- Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Mexico
| | - L E Colunga-Lozano
- Departamento de Clínicas Médicas, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - A Montaño-Loza
- División of Gastroenterología y Unidad de Hígado, University of Alberta Hospital, Edmonton, Alberta, Canada
| |
Collapse
|
|
48
|
Bazerbachi F, Levy MJ, WongKeeSong LM. Endoscopic Treatment of Portal Hypertension and Its Complications. TECHNIQUES AND INNOVATIONS IN GASTROINTESTINAL ENDOSCOPY 2022; 24:76-89. [DOI: 10.1016/j.tige.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
|
|
49
|
de Mattos ÂZ, Terra C, Farias AQ, Bittencourt PL, Alliance of Brazilian Centers for Cirrhosis Care–the ABC Group. Primary prophylaxis of variceal bleeding in patients with cirrhosis: A comparison of different strategies. World J Gastrointest Endosc 2021; 13:628-637. [PMID: 35070024 PMCID: PMC8716979 DOI: 10.4253/wjge.v13.i12.628] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 08/07/2021] [Accepted: 11/22/2021] [Indexed: 02/06/2023] Open
Abstract
Patients with cirrhosis and esophageal varices bleed at a yearly rate of 5%-15%, and, when variceal hemorrhage develops, mortality reaches 20%. Patients are deemed at high risk of bleeding when they present with medium or large-sized varices, when they have red signs on varices of any size and when they are classified as Child-Pugh C and have varices of any size. In order to avoid variceal bleeding and death, individuals with cirrhosis at high risk of bleeding must undergo primary prophylaxis, for which currently recommended strategies are the use of traditional non-selective beta-blockers (NSBBs) (i.e., propranolol or nadolol), carvedilol (a NSBB with additional alpha-adrenergic blocking effect) or endoscopic variceal ligation (EVL). The superiority of one of these alternatives over the others is controversial. While EVL might be superior to pharmacological therapy regarding the prevention of the first bleeding episode, either traditional NSBBs or carvedilol seem to play a more prominent role in mortality reduction, probably due to their capacity of preventing other complications of cirrhosis through the decrease in portal hypertension. A sequential strategy, in which patients unresponsive to pharmacological therapy would be submitted to endoscopic treatment, or the combination of pharmacological and endoscopic strategies might be beneficial and deserve further investigation.
Collapse
Affiliation(s)
- Ângelo Zambam de Mattos
- Graduate Program in Medicine: Hepatology, Federal University of Health Sciences of Porto Alegre, Porto Alegre 90050-170, Brazil
| | - Carlos Terra
- Department of Internal Medicine, Universidade do Estado do Rio de Janeiro, Rio de Janeiro 20950000, Brazil
| | - Alberto Queiroz Farias
- Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo 05403-000, Brazil
| | | | | |
Collapse
|
|
50
|
Khan F, Tripathi D. Role of early transjugular intrahepatic portosystemic stent-shunt in acute variceal bleeding: An update of the evidence and future directions. World J Gastroenterol 2021; 27:7612-7624. [PMID: 34908802 PMCID: PMC8641052 DOI: 10.3748/wjg.v27.i44.7612] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/27/2021] [Accepted: 10/29/2021] [Indexed: 02/06/2023] Open
Abstract
Variceal bleeding is a serious complication of cirrhosis and portal hypertension. Despite the improvement in management of acute variceal bleed (AVB), it still carries significant mortality. Portal pressure is the main driver of variceal bleeding and also a main predictor of decompensation. Reduction in portal pressure has been the mainstay of management of variceal bleeding. Transjugular intrahepatic porto-systemic stent shunt (TIPSS) is a very effective modality in reducing the portal hypertension and thereby, controlling portal hypertensive bleeding. However, its use in refractory bleeding (rescue/salvage TIPSS) is still associated with high mortality. "Early" use of TIPSS as a "pre-emptive strategy" in patients with AVB at high risk of failure of treatment has shown to be superior to standard treatment in several studies. While patients with Child C cirrhosis (up to 13 points) clearly benefit from early-TIPSS strategy, it's role in less severe liver disease (Child B) and more severe disease (Child C > 13 points) remains less clear. Moreover, standard of care has improved in the last decade leading to improved 1-year survival in high-risk patients with AVB as compared to earlier "early" TIPSS studies. Lastly in the real world, only a minority of patients with AVB fulfil the stringent criteria for early TIPSS. Therefore, there is unmet need to explore role of early TIPSS in management of AVB in well-designed prospective studies. In this review, we have appraised the role of early TIPSS, patient selection and discussed future directions in the management of patients with AVB.
Collapse
Affiliation(s)
- Faisal Khan
- Gastroenterology Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom
| | - Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham, NHS Foundation Trust and University of Birmingham, Birmingham B15 2TH, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TH, United Kingdom
| |
Collapse
|