1
|
Papantoniou K, Aggeletopoulou I, Pastras P, Triantos C. The Role of Somatostatin in the Gastrointestinal Tract. BIOLOGY 2025; 14:558. [PMID: 40427747 PMCID: PMC12109247 DOI: 10.3390/biology14050558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2025] [Revised: 05/12/2025] [Accepted: 05/13/2025] [Indexed: 05/29/2025]
Abstract
The gastrointestinal (GI) tract is responsible for food digestion and host protection from harmful stimuli; however, its function as an endocrine organ is also well documented. Somatostatin (SST) was first discovered in the hypothalamus, but the GI tract is its main producer and target organ. SST is a potent inhibitor of many GI functions, including peristalsis, hormone secretion, and gastric acid production, while its anti-inflammatory effects contribute to the integrity of the intestinal barrier. These data make SST and its analogs useful agents in clinical practice. As our understanding of SST metabolism and function evolves, their use in a wide variety of medical conditions can improve patient care.
Collapse
Affiliation(s)
| | | | | | - Christos Triantos
- Division of Gastroenterology, Department of Internal Medicine, University of Patras, 26504 Patras, Greece; (K.P.); (I.A.); (P.P.)
| |
Collapse
|
2
|
Liu D, Testro A, Majumdar A, Sinclair M. The current applications and future directions of terlipressin. Hepatol Commun 2025; 9:e0685. [PMID: 40178480 PMCID: PMC11970894 DOI: 10.1097/hc9.0000000000000685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2024] [Accepted: 02/06/2025] [Indexed: 04/05/2025] Open
Abstract
Terlipressin is a vasopressin analog with potent splanchnic vasoconstrictor properties. It has an established role in managing portal hypertensive bleeding and hepatorenal syndrome-acute kidney injury, with a growing body of evidence demonstrating improved safety and efficacy with continuous infusion-based administration compared to bolus dosing. We discuss previously reported adverse effects of terlipressin and evidence-based strategies to maximize the safety of administration. We also review the literature surrounding emerging indications for terlipressin in decompensated cirrhosis, particularly in the management of refractory ascites. Furthermore, we present data on novel ambulatory programs utilizing long-term continuous terlipressin infusion as bridging therapy for liver transplant candidates with recurrent hepatorenal syndrome-acute kidney injury, diuretic-refractory ascites, or hydrothorax.
Collapse
Affiliation(s)
- Dorothy Liu
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
- Department of Gastroenterology, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Adam Testro
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
- Department of Gastroenterology, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Avik Majumdar
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
- Department of Gastroenterology, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Marie Sinclair
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
- Department of Gastroenterology, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
3
|
Oliva G, Ulloa N. Vasopressin: a review of clinical indications. Clin Exp Emerg Med 2025; 12:94-96. [PMID: 39814346 PMCID: PMC12015599 DOI: 10.15441/ceem.24.351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2024] [Revised: 12/10/2024] [Accepted: 12/11/2024] [Indexed: 01/18/2025] Open
Affiliation(s)
- Gregory Oliva
- Department of Emergency Medicine, Mount Sinai Medical Center Miami Beach, Miami Beach, FL, USA
| | - Nicolas Ulloa
- Department of Emergency Medicine and Critical Care, Herbert Wertheim College of Medicine at Florida International University, Miami Beach, FL, USA
| |
Collapse
|
4
|
Liu Z, Zhang L, Jiang GJ, Chen QQ, Hou YG, Wu W, Malik M, Li G, Zhan LY. Machine Learning-Based Mortality Prediction for Acute Gastrointestinal Bleeding Patients Admitted to Intensive Care Unit. Curr Med Sci 2025; 45:70-81. [PMID: 40014197 DOI: 10.1007/s11596-025-00022-6] [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: 11/15/2024] [Revised: 01/23/2025] [Accepted: 01/29/2025] [Indexed: 02/28/2025]
Abstract
OBJECTIVE The study aimed to develop machine learning (ML) models to predict the mortality of patients with acute gastrointestinal bleeding (AGIB) in the intensive care unit (ICU) and compared their prognostic performance with that of Acute Physiology and Chronic Health Evaluation II (APACHE-II) score. METHODS A total of 961 AGIB patients admitted to the ICU of Renmin Hospital of Wuhan University from January 2020 to December 2023 were enrolled. Patients were randomly divided into the training cohort (n = 768) and the validation cohort (n = 193). Clinical data were collected within the first 24 h of ICU admission. ML models were constructed using Python V.3.7 package, employing 3 different algorithms: XGBoost, Random Forest (RF) and Gradient Boosting Decision Tree (GBDT). The area under the receiver operating characteristic (ROC) curve (AUC) was used to evaluate the performance of different models. RESULTS A total of 94 patients died with an overall mortality of 9.78% (11.32% in the training cohort and 8.96% in the validation cohort). Among the 3 ML models, the GBDT algorithm demonstrated the highest predictive performance, achieving an AUC of 0.95 (95% CI 0.90-0.99), while the AUCs of XGBoost and RF models were 0.89 (95% CI 0.82-0.96) and 0.90 (95% CI 0.84-0.96), respectively. In comparison, the APACHE-II model achieved an AUC of 0.74 (95% CI 0.69-0.87), with a specificity of 70.97% (95% CI 64.07-77.01). When APACHE-II score was incorporated into the GBDT algorithm, the ensemble model achieved an AUC of 0.98 (95% CI 0.96-0.99) with a sensitivity of 85.71% and a specificity up to 95.15%. CONCLUSIONS The GBDT model serves as a reliable tool for accurately predicting the in-hospital mortality for AGIB patients. When integrated with the APACHE-II score, the ensemble GBDT algorithm further enhances predictive accuracy and provides valuable insights for prognostic evaluation.
Collapse
Affiliation(s)
- Zhou Liu
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Liang Zhang
- Department of Radiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Gui-Jun Jiang
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Qian-Qian Chen
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Yan-Guang Hou
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Wei Wu
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Muskaan Malik
- The First Clinical Medical School of Wuhan University, Wuhan, 430060, China
| | - Guang Li
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, China.
| | - Li-Ying Zhan
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, China.
| |
Collapse
|
5
|
Al Hayek M, Sawaf B, Abbarh S, Dhoop S, Khashan A, Hassan A, Alzubi AS, Abdelwahed AF, Alzein AIA, Nounou MV, Alastal Y, Elhadi M. Comparison of 12- to 24-Hour Versus 72-Hour Intravenous Terlipressin in Patients With Acute Esophageal Variceal Bleeding: A Systematic Review and Meta-analysis. J Pharm Technol 2025:87551225241311444. [PMID: 39866669 PMCID: PMC11758437 DOI: 10.1177/87551225241311444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2025] Open
Abstract
Objective: To compare the efficacy and safety of 12-24 hours versus 72 hours of intravenous terlipressin therapy in patients with acute esophageal variceal bleeding (AVB). Data sources: A systematic search was conducted using PubMed, Scopus, Cochrane Library, Google Scholar, Web of Science, VHL, and ClinicalTrials.gov for studies published up to February 24, 2024. The search terms included "terlipressin," "variceal bleeding," "short-course," and "72-hour treatment." Study selection and data extraction: Randomized controlled trials (RCTs) comparing 12 to 24 hours with 72 hours of terlipressin therapy in patients with AVB were included. Studies not meeting these criteria or focusing on unrelated outcomes were excluded. Two authors conducted data extraction and bias assessment independently, with discrepancies resolved by a third reviewer. Baseline characteristics and outcomes (rebleeding and mortality within 5 days) were recorded. Results: Four RCTs with 469 patients were included in the analysis. There were no significant differences observed in 5-day rebleeding rates (OR = 0.943; 95% CI [0.384, 2.317]; P = 0.898) or mortality rates (OR = 0.386; 95% CI [0.066, 2.260]; P = 0.291) between terlipressin treatment durations of 12 to 24 hours and 72 hours within the first 5 days posttreatment. In addition, no heterogeneity was found in both variables (P > 0.1). Conclusion: This meta-analysis indicates that there is no significant difference in rebleeding rates or mortality between 12 to 24 hours and 72 hours of terlipressin therapy for AVB within 5 days posttreatment. Shorter treatment durations may offer advantages in terms of resource utilization and adverse event risk but require further validation through studies involving larger patient populations.
Collapse
Affiliation(s)
- Mohammad Al Hayek
- Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic
| | - Bisher Sawaf
- Internal Medicine, The University of Toledo, Toledo, OH, USA
| | - Shahem Abbarh
- Internal Medicine, MedStar Health-Georgetown University, Baltimore, MD, USA
| | - Sudheer Dhoop
- Internal Medicine, The University of Toledo, Toledo, OH, USA
| | | | - Ahmed Hassan
- Faculty of Medicine, South Valley University, Qena, Egypt
| | - Alhasan Saleh Alzubi
- Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, WV, USA
| | | | | | | | - Yaseen Alastal
- Department of Gastroenterology, The University of Toledo, Toledo, OH, USA
| | - Muhammed Elhadi
- College of Medicine, Korea University, Seoul, Republic of Korea
| |
Collapse
|
6
|
Albillos A, Bañares R, Hernández-Gea V. Portal hypertension: recommendations for diagnosis and treatment. Consensus document sponsored by the Spanish Association for the Study of the Liver (AEEH) and the Biomedical Research Network Centre for Liver and Digestive Diseases (CIBERehd). GASTROENTEROLOGIA Y HEPATOLOGIA 2025; 48:502208. [PMID: 39756832 DOI: 10.1016/j.gastrohep.2024.502208] [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: 03/19/2024] [Revised: 04/07/2024] [Accepted: 04/09/2024] [Indexed: 01/07/2025]
Abstract
Portal hypertension is a hemodynamic abnormality that complicates the course of cirrhosis, as well as other diseases that affect the portal venous circulation. The development of portal hypertension compromises prognosis, especially when it rises above a certain threshold known as clinically significant portal hypertension (CSPH). In the consensus conference on Portal Hypertension promoted by the Spanish Association for the Study of the Liver and the Hepatic and Digestive diseases area of the Biomedical Research Networking Center (CIBERehd), different aspects of the diagnosis and treatment of portal hypertension caused by cirrhosis or other diseases were discussed. The outcome of this discussion was a set of recommendations that achieved varying degrees of consensus among panelists and are reflected in this consensus document. The six areas under discussion were: the relevance of CSPH and the non-invasive methods used for its diagnosis and that of cirrhosis, the prevention of the first episode of decompensation and its recurrence, the treatment of acute variceal bleeding and other complications of portal hypertension, the indications for the use of TIPS, and finally, the diagnosis and treatment of liver vascular diseases.
Collapse
Affiliation(s)
- Agustín Albillos
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España.
| | - Rafael Bañares
- Servicio de Medicina de Aparato Digestivo, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Universidad Complutense, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España.
| | - Virginia Hernández-Gea
- Servicio de Hepatología, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, España.
| |
Collapse
|
7
|
Albillos A, Bañares R, Hernández-Gea V. Portal hypertension: recommendations for diagnosis and treatment. Consensus document sponsored by the Spanish Association for the Study of the Liver (AEEH) and the Biomedical Research Network Center for Liver and Digestive Diseases (CIBERehd). REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2025; 117:14-57. [PMID: 39350672 DOI: 10.17235/reed.2024.10805/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2025]
Abstract
Portal hypertension is a hemodynamic abnormality that complicates the course of cirrhosis, as well as other diseases that affect the portal venous circulation. The development of portal hypertension compromises prognosis, especially when it rises above a certain threshold known as clinically significant portal hypertension (CSPH). In the consensus conference on Portal Hypertension promoted by the Spanish Association for the Study of the Liver and the Hepatic and Digestive diseases area of the Biomedical Research Networking Center (CIBERehd), different aspects of the diagnosis and treatment of portal hypertension caused by cirrhosis or other diseases were discussed. The outcome of this discussion was a set of recommendations that achieved varying degrees of consensus among panelists and are reflected in this consensus document. The six areas under discussion were: the relevance of clinically significant portal hypertension and the non-invasive methods used for its diagnosis and that of cirrhosis, the prevention of the first episode of decompensation and its recurrence, the treatment of acute variceal bleeding and other complications of portal hypertension, the indications for the use of TIPS, and finally, the diagnosis and treatment of liver vascular diseases.
Collapse
Affiliation(s)
- Agustín Albillos
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, España
| | - Rafael Bañares
- Servicio de Medicina de Aparato Digestivo, Hospital General Universitario Gregorio Marañón
| | - Virginia Hernández-Gea
- Servicio de Hepatología, Hospital Clínic. Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)
| |
Collapse
|
8
|
Laws MB, Wahking R, Blackburn E, Williams W, Schadler A, Fritz MK. Outcomes in Variceal Bleeding Associated With Continuous Octreotide in Patients With Delayed Endoscopy. J Pharm Pract 2024; 37:1107-1115. [PMID: 38240733 DOI: 10.1177/08971900241228948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2024]
Abstract
Background: Variceal hemorrhage treatment includes endoscopy within 12 hours of admission and octreotide therapy for 2-5 days post-endoscopy. Duration of pre-endoscopy octreotide can be prolonged when intervention is delayed. Objective: This study aimed to evaluate the impact of extended pre-endoscopy octreotide on rebleeding after endoscopy when comparing short vs long durations of post-endoscopy octreotide. Methods: This was a single center, retrospective cohort evaluating adult cirrhotic patients with esophageal variceal hemorrhage admitted between July 1, 2017 and June 30, 2020. Study groups included patients receiving octreotide ≥12 hours prior to endoscopy followed by ≤ 48 (short course) or >48 hours (standard course) after endoscopy. The primary outcome was post-endoscopy rebleeding, defined as hemoglobin decrease of ≥2 g/dL from baseline or the requirement of ≥1 unit of packed red blood cells. Results: Of the 169 patients included, 88 patients received short course octreotide after endoscopy, and 81 patients received standard course octreotide after endoscopy. Twenty-nine (33%) patients in the short course group and 43 (53.1%) in the standard course group experienced the primary endpoint (OR 2.3, 95% CI 1.24 - 4.29; P = .008). Conclusion: Extended pre-endoscopy octreotide may be beneficial in preventing rebleeding when intervention is delayed. Further studies are needed to determine the necessary octreotide duration in delayed endoscopy and varying bleeding risk.
Collapse
Affiliation(s)
- Matthew B Laws
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, KY, USA
| | - Rebekah Wahking
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, KY, USA
| | - Erin Blackburn
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, KY, USA
| | - Whitney Williams
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, KY, USA
| | - Aric Schadler
- College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Megan Kunka Fritz
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, KY, USA
| |
Collapse
|
9
|
Dabas MM, Maqbool M, Bedros AW, Mazhar H, Papuashvili P, Umar M, Bajwa AB, Patel DH, Abushalha NB, Khattak A, Ahmed J, Mehdi A. Comparative Effectiveness of Endoscopic Versus Pharmacological Interventions for Variceal Rebleeding in Cirrhosis: A Systematic Review. Cureus 2024; 16:e72085. [PMID: 39575046 PMCID: PMC11579546 DOI: 10.7759/cureus.72085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2024] [Indexed: 11/24/2024] Open
Abstract
Variceal bleeding is a critical complication in cirrhotic patients, significantly increasing morbidity and mortality risks, particularly after an initial bleeding episode. This systematic review evaluates and compares the effectiveness of endoscopic and pharmacological interventions in preventing variceal rebleeding. A comprehensive search of major databases, including PubMed, MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science, was conducted to identify studies published within the past decade. The review focused on randomized controlled trials, clinical trials, and meta-analyses that assessed the efficacy and safety of these treatments in adult cirrhotic patients with a history of variceal bleeding. The findings suggest that endoscopic interventions, such as band ligation and early transjugular intrahepatic portosystemic shunt (TIPS) placement, effectively reduce immediate rebleeding rates and improve short-term survival, particularly in high-risk patients with advanced cirrhosis. In contrast, pharmacological strategies, including beta-blockers and vasoactive agents, provide effective long-term management with fewer adverse events, especially in patients with milder liver disease. The review underscores the importance of a personalized treatment approach that integrates both endoscopic and pharmacological therapies to optimize outcomes and reduce the burden of rebleeding. It also highlights the need for further high-quality research to clarify the long-term benefits, impact on quality of life, and cost-effectiveness of these interventions. These insights form the basis for refining clinical guidelines and improving patient-centered care in the management of variceal rebleeding.
Collapse
Affiliation(s)
| | - Muhammad Maqbool
- Internal Medicine, Shaheed Mohtarma Benazir Bhutto Medical College Lyari, Karachi, PAK
| | | | - Hiba Mazhar
- Gastroenterology, Pakistan Kidney and Liver Institute, Lahore, PAK
| | | | - Muhammad Umar
- Internal Medicine, Faisalabad Medical University, Faisalabad, PAK
| | - Aqsa B Bajwa
- Internal Medicine, Shalamar Medical and Dental College, Riyadh, SAU
| | | | | | - Abid Khattak
- Acute Medicine, Sherwood Forest Hospitals NHS Foundation Trust, Sutton-in-Ashfield, GBR
| | - Junaid Ahmed
- Internal Medicine, Chandka Medical College Hospital, Larkana, PAK
| | - Asma Mehdi
- Surgery, Rawalpindi Medical University, Rawalpindi, PAK
| |
Collapse
|
10
|
Lin S, Zheng J, Zhou C, Feng S, Lin Z. Developing a nomogram for forecasting the 28-day mortality rate of individuals with bleeding esophageal varices using model for end-stage liver disease scores. J Gastrointest Surg 2024; 28:1646-1653. [PMID: 39094676 DOI: 10.1016/j.gassur.2024.07.025] [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: 03/28/2024] [Revised: 06/28/2024] [Accepted: 07/27/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND This study aimed to create a nomogram using the model for end-stage liver disease (MELD) that can better predict the risk of 28-day mortality in patients with bleeding esophageal varices. METHODS Data on patients with bleeding esophageal varices were retrospectively collected from the Medical Information Mart for Intensive Care database. Variables were selected using the least absolute shrinkage and selection operator logistic regression model and were used to construct a prognostic nomogram. The nomogram was evaluated against the MELD model using various methods, including receiver operating characteristic (ROC) curve analysis, calibration plotting, net reclassification improvement (NRI), integrated discrimination improvement (IDI), and decision curve analysis (DCA). RESULTS A total of 280 patients were included in the study. The patient's use of vasopressin and norepinephrine, respiratory rate, temperature, mean corpuscular volume, and MELD score were included in the nomogram. The area under the ROC curve, NRI, IDI, and DCA of the nomogram indicated that it performs better than the MELD alone. CONCLUSION A nomogram was created that outperformed the MELD score in forecasting the risk of 28-day mortality in individuals with bleeding esophageal varices.
Collapse
Affiliation(s)
- Siming Lin
- Department of Emergency Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China; Department of Emergency Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jantao Zheng
- Department of Emergency Medicine, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, China
| | - Chanjuan Zhou
- Department of Geriatrics, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, China
| | - Shaodan Feng
- Department of Emergency Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China; Department of Emergency Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Zhihong Lin
- Department of Emergency Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China; Department of Emergency Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China.
| |
Collapse
|
11
|
Shung DL, Laine L. Review article: Upper gastrointestinal bleeding - review of current evidence and implications for management. Aliment Pharmacol Ther 2024; 59:1062-1081. [PMID: 38517201 DOI: 10.1111/apt.17949] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/27/2023] [Accepted: 03/04/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Acute upper gastrointestinal bleeding (UGIB) is a common emergency requiring hospital-based care. Advances in care across pre-endoscopic, endoscopic and post-endoscopic phases have led to improvements in clinical outcomes. AIMS To provide a detailed, evidence-based update on major aspects of care across pre-endoscopic, endoscopic and post-endoscopic phases. METHODS We performed a structured bibliographic database search for each topic. If a recent high-quality meta-analysis was not available, we performed a meta-analysis with random effects methods and odds ratios with 95% confidence intervals. RESULTS Pre-endoscopic management of UGIB includes risk stratification, a restrictive red blood cell transfusion policy unless the patient has cardiovascular disease, and pharmacologic therapy with erythromycin and a proton pump inhibitor. Patients with cirrhosis should be treated with prophylactic antibiotics and vasoactive medications. Tranexamic acid should not be used. Endoscopic management of UGIB depends on the aetiology. For peptic ulcer disease (PUD) with high-risk stigmata, endoscopic therapy, including over-the-scope clips (OTSCs) and TC-325 powder spray, should be performed. For variceal bleeding, treatment should be customised by severity and anatomic location. Post-endoscopic management includes early enteral feeding for all UGIB patients. For high-risk PUD, PPI should be continued for 72 h, and rebleeding should initially be evaluated with a repeat endoscopy. For variceal bleeding, high-risk patients or those with further bleeding, a transjugular intrahepatic portosystemic shunt can be considered. CONCLUSIONS Management of acute UGIB should include treatment plans for pre-endoscopic, endoscopic and post-endoscopic phases of care, and customise treatment decisions based on aetiology and severity of bleeding.
Collapse
Affiliation(s)
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut, USA
- West Haven Veterans Affairs Medical Center, West Haven, Connecticut, USA
| |
Collapse
|
12
|
Rehman H, Rehman ST, Zulfiqar S, Awan S, Abid S. Real-world comparison of terlipressin vs. octreotide as an adjuvant treatment in the management of variceal bleeding. Sci Rep 2024; 14:6692. [PMID: 38509184 PMCID: PMC10954665 DOI: 10.1038/s41598-024-56873-x] [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: 07/06/2023] [Accepted: 03/12/2024] [Indexed: 03/22/2024] Open
Abstract
Variceal bleeding is a major complication and the leading cause of death in patients with cirrhosis and portal hypertension. This study aims to compare the efficacy and safety of terlipressin vs octreotide as an adjuvant to endoscopic management of patients with esophageal variceal bleeding in a real-time scenario. We reviewed the medical records of patients with esophageal variceal bleeding from January 2005 to December 2020 at our tertiary care Aga Khan University Hospital. Mortality was assessed after 6 weeks. A total of 842 patients with variceal bleed were evaluated. 624 patients (74.1%) and 218 patients (25.9%) received Terlipressin and Octreotide respectively. On multiple regression analysis, cardiac events during hospital stay (OR: 11.22), presence of Porto-systemic encephalopathy (OR: 3.79), and elevated bilirubin levels at the time of presentation were found to be independent risk factors for increased six weeks mortality. Moreover, cardiac events during hospital stay (OR: 3.26), Porto-systemic encephalopathy at presentation (OR: 3.06), and octreotide administration (OR: 1.80) were identified as independent risk factors for increased length of hospital stay. Terlipressin and Octreotide have similar outcomes in terms of control of bleeding, hospital stay, mortality, and side effects when used as adjuvant therapy for the management of variceal bleeding.
Collapse
Affiliation(s)
- H Rehman
- Section of Gastroenterology, Department of Medicine, Aga Khan University, National Stadium Road, P.O Box 3500, Karachi, Pakistan
| | - S T Rehman
- Section of Gastroenterology, Department of Medicine, Aga Khan University, National Stadium Road, P.O Box 3500, Karachi, Pakistan
| | - S Zulfiqar
- Section of Gastroenterology, Department of Medicine, Aga Khan University, National Stadium Road, P.O Box 3500, Karachi, Pakistan
| | - S Awan
- Section of Gastroenterology, Department of Medicine, Aga Khan University, National Stadium Road, P.O Box 3500, Karachi, Pakistan
| | - Shahab Abid
- Section of Gastroenterology, Department of Medicine, Aga Khan University, National Stadium Road, P.O Box 3500, Karachi, Pakistan.
| |
Collapse
|
13
|
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
|
14
|
Garbuzenko DV. Contemporary concepts of prevention and management of gastroesophageal variceal bleeding in liver cirrhosis patients. World J Hepatol 2024; 16:126-134. [PMID: 38495286 PMCID: PMC10941750 DOI: 10.4254/wjh.v16.i2.126] [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: 11/30/2023] [Revised: 12/31/2023] [Accepted: 01/29/2024] [Indexed: 02/27/2024] Open
Abstract
This editorial describes the contemporary concepts of prevention and management of gastroesophageal variceal bleeding in liver cirrhosis (LC) patients according to the current guidelines. Gastroesophageal variceal bleeding is the most dangerous complication of portal hypertension in LC patients. Risk stratification and determination of an individual approach to the choice of therapeutic measures aimed at their prevention and management has emerged as one of the top concerns in modern hepatology. According to the current guidelines, in the absence of clinically significant portal hypertension, etiological and non-etiological therapies of LC is advisable for the primary preventing gastroesophageal variceal bleeding, whereas its presence serves as an indication for the administration of non-selective β-blockers, among which carvedilol is the drug of choice. Non-selective β-blockers, as well as endoscopic variceal ligation and transjugular intrahepatic portosystemic shunt can be used to prevent recurrence of gastroesophageal variceal bleeding. Pharmacotherapy with vasoactive drugs (terlipressin, somatostatin, octreotide), endoscopic variceal ligation, endovascular techniques and transjugular intrahepatic portosystemic shunt are recommended for the treatment of acute gastroesophageal variceal bleeding. Objective and accurate risk stratification of gastroesophageal variceal bleeding will allow developing individual strategies for their prevention and management, avoiding the first and further decompensation in LC, which will improve the prognosis and survival of patients suffering from it.
Collapse
|
15
|
Kneiseler G, Dechêne A. [Gastrointestinal bleeding in old age]. Z Gerontol Geriatr 2024; 57:59-70. [PMID: 38108897 DOI: 10.1007/s00391-023-02258-0] [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: 05/09/2023] [Accepted: 07/25/2023] [Indexed: 12/19/2023]
Abstract
Gastrointestinal bleeding is a frequent symptom, with increasing age as a risk factor. Upper, middle and lower gastrointestinal bleeding are differentiated depending on the location, whereby only upper and lower gastrointestinal bleeding are elucidated in this article. The symptomatology varies depending on the localization of the bleeding. German and international clinical guidelines currently exist for the preclinical and clinical management of gastrointestinal bleeding. The main focus of the article is on pre-endoscopic management of upper gastrointestinal nonvariceal and variceal bleeding, including the risk stratification, transfusion and coagulation management as well as the initial pharmacological treatment. In addition, current developments in endoscopic and interventional treatment of gastrointestinal bleeding are highlighted.
Collapse
Affiliation(s)
- Guntje Kneiseler
- Medizinische Klinik 6 (Schwerpunkte Gastroenterologie, Hepatologie, Endokrinologie und Ernährungsmedizin) am Klinikum Nürnberg, Universitätsklinik der Paracelsus Medizinischen Privatuniversität Nürnberg, Prof.-Ernst-Nathan-Str. 1, 90419, Nürnberg, Deutschland
| | - Alexander Dechêne
- Medizinische Klinik 6 (Schwerpunkte Gastroenterologie, Hepatologie, Endokrinologie und Ernährungsmedizin) am Klinikum Nürnberg, Universitätsklinik der Paracelsus Medizinischen Privatuniversität Nürnberg, Prof.-Ernst-Nathan-Str. 1, 90419, Nürnberg, Deutschland.
| |
Collapse
|
16
|
Kneiseler G, Dechêne A. [Gastrointestinal bleeding in old age]. Z Gerontol Geriatr 2024; 57:59-70. [PMID: 38108897 DOI: 10.1007/s11377-024-00781-z] [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: 05/09/2023] [Accepted: 07/25/2023] [Indexed: 01/03/2025]
Abstract
Gastrointestinal bleeding is a frequent symptom, with increasing age as a risk factor. Upper, middle and lower gastrointestinal bleeding are differentiated depending on the location, whereby only upper and lower gastrointestinal bleeding are elucidated in this article. The symptomatology varies depending on the localization of the bleeding. German and international clinical guidelines currently exist for the preclinical and clinical management of gastrointestinal bleeding. The main focus of the article is on pre-endoscopic management of upper gastrointestinal nonvariceal and variceal bleeding, including the risk stratification, transfusion and coagulation management as well as the initial pharmacological treatment. In addition, current developments in endoscopic and interventional treatment of gastrointestinal bleeding are highlighted.
Collapse
Affiliation(s)
- Guntje Kneiseler
- Medizinische Klinik 6 (Schwerpunkte Gastroenterologie, Hepatologie, Endokrinologie und Ernährungsmedizin) am Klinikum Nürnberg, Universitätsklinik der Paracelsus Medizinischen Privatuniversität Nürnberg, Prof.-Ernst-Nathan-Str. 1, 90419, Nürnberg, Deutschland
| | - Alexander Dechêne
- Medizinische Klinik 6 (Schwerpunkte Gastroenterologie, Hepatologie, Endokrinologie und Ernährungsmedizin) am Klinikum Nürnberg, Universitätsklinik der Paracelsus Medizinischen Privatuniversität Nürnberg, Prof.-Ernst-Nathan-Str. 1, 90419, Nürnberg, Deutschland.
| |
Collapse
|
17
|
Garcia-Tsao G, Abraldes JG, Rich NE, Wong VWS. AGA Clinical Practice Update on the Use of Vasoactive Drugs and Intravenous Albumin in Cirrhosis: Expert Review. Gastroenterology 2024; 166:202-210. [PMID: 37978969 DOI: 10.1053/j.gastro.2023.10.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 10/08/2023] [Accepted: 10/16/2023] [Indexed: 11/19/2023]
Abstract
DESCRIPTION Cirrhosis is a major cause of morbidity and mortality in the United States and worldwide. It consists of compensated, decompensated, and further decompensated stages; median survival is more than 15 years, 2 years, and 9 months for each stage, respectively. With each stage, there is progressive worsening of portal hypertension and the vasodilatory-hyperdynamic circulatory state, resulting in a progressive decrease in effective arterial blood volume and renal perfusion. Vasoconstrictors reduce portal pressure via splanchnic vasoconstriction and are used in the management of variceal hemorrhage. Intravenous (IV) albumin increases effective arterial blood volume and is used in the prevention of acute kidney injury (AKI) and death after large-volume paracentesis and in patients with spontaneous bacterial peritonitis (SBP). The combination of vasoconstrictors and albumin is used in the reversal of hepatorenal syndrome (HRS-AKI), the most lethal complication of cirrhosis. Because a potent vasoconstrictor, terlipressin, was recently approved by the US Food and Drug Administration, and because recent trials have explored use of IV albumin in other settings, it was considered that a best practice update would be relevant regarding the use of vasoactive drugs and IV albumin in the following 3 specific scenarios: variceal hemorrhage, ascites and SBP, and HRS. METHODS This expert review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership. It underwent internal peer review through standard procedures of Gastroenterology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Some of the statements are unchanged from published guidelines because of lack of new evidence in the literature. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality and evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Vasoactive drugs should be initiated as soon as the diagnosis of variceal hemorrhage is suspected or confirmed, preferably before diagnostic and/or therapeutic endoscopy. BEST PRACTICE ADVICE 2: After initial endoscopic hemostasis, vasoactive drugs should be continued for 2-5 days to prevent early rebleeding. BEST PRACTICE ADVICE 3: Octreotide is the vasoactive drug of choice in the management of variceal hemorrhage based on its safety profile. BEST PRACTICE ADVICE 4: IV albumin should be administered at the time of large-volume (>5 L) paracentesis. BEST PRACTICE ADVICE 5: IV albumin may be considered in patients with SBP. BEST PRACTICE ADVICE 6: Albumin should not be used in patients (hospitalized or not) with cirrhosis and uncomplicated ascites. BEST PRACTICE ADVICE 7: Vasoconstrictors should not be used in the management of uncomplicated ascites, after large-volume paracentesis or in patients with SBP. BEST PRACTICE ADVICE 8: IV albumin is the volume expander of choice in hospitalized patients with cirrhosis and ascites presenting with AKI. BEST PRACTICE ADVICE 9: Vasoactive drugs (eg, terlipressin, norepinephrine, and combination of octreotide and midodrine) should be used in the treatment of HRS-AKI, but not in other forms of AKI in cirrhosis. BEST PRACTICE ADVICE 10: Terlipressin is the vasoactive drug of choice in the treatment of HRS-AKI and use of concurrent albumin can be considered when accounting for patient's volume status. BEST PRACTICE ADVICE 11: Terlipressin treatment does not require intensive care unit monitoring and can be administered intravenously through a peripheral line. BEST PRACTICE ADVICE 12: Terlipressin use is contraindicated in patients with hypoxemia and in patients with ongoing coronary, peripheral, or mesenteric ischemia, and should be used with caution in patients with acute-on-chronic liver failure grade 3. The benefits may not outweigh the risks in patients with serum creatinine >5 mg/dL and in patients listed for transplantation with a Model for End-stage Liver Disease ≥35.
Collapse
Affiliation(s)
- Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University, New Haven, Connecticut; Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut.
| | - Juan G Abraldes
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Nicole E Rich
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Vincent Wai-Sun Wong
- Medical Data Analytics Centre, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong.
| |
Collapse
|
18
|
Pallio S, Melita G, Shahini E, Vitello A, Sinagra E, Lattanzi B, Facciorusso A, Ramai D, Maida M. Diagnosis and Management of Esophagogastric Varices. Diagnostics (Basel) 2023; 13:1031. [PMID: 36980343 PMCID: PMC10047815 DOI: 10.3390/diagnostics13061031] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/03/2023] [Accepted: 03/04/2023] [Indexed: 03/30/2023] Open
Abstract
Acute variceal bleeding (AVB) is a potentially fatal complication of clinically significant portal hypertension and is one of the most common causes of acute upper gastrointestinal bleeding. Thus, esophagogastric varices represent a major economic and population health issue. Patients with advanced chronic liver disease typically undergo an upper endoscopy to screen for esophagogastric varices. However, upper endoscopy is not recommended for patients with liver stiffness < 20 KPa and platelet count > 150 × 109/L as there is a low probability of high-risk varices. Patients with high-risk varices should receive primary prophylaxis with either nonselective beta-blockers or endoscopic band ligation. In cases of AVB, patients should receive upper endoscopy within 12 h after resuscitation and hemodynamic stability, whereas endoscopy should be performed as soon as possible if patients are unstable. In cases of suspected variceal bleeding, starting vasoactive therapy as soon as possible in combination with endoscopic treatment is recommended. On the other hand, in cases of uncontrolled bleeding, balloon tamponade or self-expandable metal stents can be used as a bridge to more definitive therapy such as transjugular intrahepatic portosystemic shunt. This article aims to offer a comprehensive review of recommendations from international guidelines as well as recent updates on the management of esophagogastric varices.
Collapse
Affiliation(s)
- Socrate Pallio
- Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy;
| | - Giuseppinella Melita
- Human Pathology of Adult and Child Department, University of Messina, 98100 Messina, Italy
| | - Endrit Shahini
- Gastroenterology Unit, National Institute of Gastroenterology “S. de Bellis” Research Hospital, Castellana Grotte, 70013 Bari, Italy
| | - Alessandro Vitello
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, 93100 Caltanissetta, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Instituto San Raffaele Giglio, 90015 Cefalù, Italy
| | - Barbara Lattanzi
- Gastroenterology and Emergency Endoscopy Unit, Sandro Pertini Hospital, 00100 Rome, Italy
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, 00161 Foggia, Italy
| | - Daryl Ramai
- Gastroenterology & Hepatology, University of Utah Health, Salt Lake City, UT 84132, USA
| | - Marcello Maida
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, 93100 Caltanissetta, Italy
| |
Collapse
|
19
|
Chooklin SM, Chuklin SS. Modern tactics for acute variceal bleeding in liver cirrhosis (Baveno VII guidelines). KLINICHESKAIA KHIRURGIIA 2022. [DOI: 10.26779/2522-1396.2022.3-4.87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Modern tactics for acute variceal bleeding in liver cirrhosis (Baveno VII guidelines)
Collapse
|
20
|
Gralnek IM, Camus Duboc M, Garcia-Pagan JC, Fuccio L, Karstensen JG, Hucl T, Jovanovic I, Awadie H, Hernandez-Gea V, Tantau M, Ebigbo A, Ibrahim M, Vlachogiannakos J, Burgmans MC, Rosasco R, Triantafyllou K. Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54:1094-1120. [PMID: 36174643 DOI: 10.1055/a-1939-4887] [Citation(s) in RCA: 114] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
1: ESGE recommends that patients with compensated advanced chronic liver disease (ACLD; due to viruses, alcohol, and/or nonobese [BMI < 30 kg/m2] nonalcoholic steatohepatitis) and clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] > 10 mmHg and/or liver stiffness by transient elastography > 25 kPa) should receive, if no contraindications, nonselective beta blocker (NSBB) therapy (preferably carvedilol) to prevent the development of variceal bleeding.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in those patients unable to receive NSBB therapy with a screening upper gastrointestinal (GI) endoscopy that demonstrates high risk esophageal varices, endoscopic band ligation (EBL) is the endoscopic prophylactic treatment of choice. EBL should be repeated every 2-4 weeks until variceal eradication is achieved. Thereafter, surveillance EGD should be performed every 3-6 months in the first year following eradication.Strong recommendation, moderate quality evidence. 3: ESGE recommends, in hemodynamically stable patients with acute upper GI hemorrhage (UGIH) and no history of cardiovascular disease, a restrictive red blood cell (RBC) transfusion strategy, with a hemoglobin threshold of ≤ 70 g/L prompting RBC transfusion. A post-transfusion target hemoglobin of 70-90 g/L is desired.Strong recommendation, moderate quality evidence. 4 : ESGE recommends that patients with ACLD presenting with suspected acute variceal bleeding be risk stratified according to the Child-Pugh score and MELD score, and by documentation of active/inactive bleeding at the time of upper GI endoscopy.Strong recommendation, high quality of evidence. 5 : ESGE recommends the vasoactive agents terlipressin, octreotide, or somatostatin be initiated at the time of presentation in patients with suspected acute variceal bleeding and be continued for a duration of up to 5 days.Strong recommendation, high quality evidence. 6 : ESGE recommends antibiotic prophylaxis using ceftriaxone 1 g/day for up to 7 days for all patients with ACLD presenting with acute variceal hemorrhage, or in accordance with local antibiotic resistance and patient allergies.Strong recommendation, high quality evidence. 7 : ESGE recommends, in the absence of contraindications, intravenous erythromycin 250 mg be given 30-120 minutes prior to upper GI endoscopy in patients with suspected acute variceal hemorrhage.Strong recommendation, high quality evidence. 8 : ESGE recommends that, in patients with suspected variceal hemorrhage, endoscopic evaluation should take place within 12 hours from the time of patient presentation provided the patient has been hemodynamically resuscitated.Strong recommendation, moderate quality evidence. 9 : ESGE recommends EBL for the treatment of acute esophageal variceal hemorrhage (EVH).Strong recommendation, high quality evidence. 10 : ESGE recommends that, in patients at high risk for recurrent esophageal variceal bleeding following successful endoscopic hemostasis (Child-Pugh C ≤ 13 or Child-Pugh B > 7 with active EVH at the time of endoscopy despite vasoactive agents, or HVPG > 20 mmHg), pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours (preferably within 24 hours) must be considered.Strong recommendation, high quality evidence. 11 : ESGE recommends that, for persistent esophageal variceal bleeding despite vasoactive pharmacological and endoscopic hemostasis therapy, urgent rescue TIPS should be considered (where available).Strong recommendation, moderate quality evidence. 12 : ESGE recommends endoscopic cyanoacrylate injection for acute gastric (cardiofundal) variceal (GOV2, IGV1) hemorrhage.Strong recommendation, high quality evidence. 13: ESGE recommends endoscopic cyanoacrylate injection or EBL in patients with GOV1-specific bleeding.Strong recommendations, moderate quality evidence. 14: ESGE suggests urgent rescue TIPS or balloon-occluded retrograde transvenous obliteration (BRTO) for gastric variceal bleeding when there is a failure of endoscopic hemostasis or early recurrent bleeding.Weak recommendation, low quality evidence. 15: ESGE recommends that patients who have undergone EBL for acute EVH should be scheduled for follow-up EBLs at 1- to 4-weekly intervals to eradicate esophageal varices (secondary prophylaxis).Strong recommendation, moderate quality evidence. 16: ESGE recommends the use of NSBBs (propranolol or carvedilol) in combination with endoscopic therapy for secondary prophylaxis in EVH in patients with ACLD.Strong recommendation, high quality evidence.
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
| | - Marine Camus Duboc
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA) & Assistance Publique-Hôpitaux de Paris (AP-HP), Endoscopic Center, Saint Antoine Hospital, Paris, France
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, IRCSS-S. Orsola-Malpighi, Hospital, Bologna, Italy
| | - John Gásdal Karstensen
- Gastroenterology Unit, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Tomas Hucl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ivan Jovanovic
- Euromedik Health Care System, Visegradska General Hospital, Belgrade, Serbia
| | - Halim Awadie
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Marcel Tantau
- University of Medicine and Pharmacy 'Iuliu Hatieganu' Cluj-Napoca, Romania
| | - Alanna Ebigbo
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | | | - Jiannis Vlachogiannakos
- Academic Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Marc C Burgmans
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| |
Collapse
|