Endoscopic management and outcome of non-variceal bleeding in patients with liver cirrhosis: A systematic review

Table 1 Main characteristics of all included studies

Ref.	Type of study	Period of enrolment, years	Number of patients1	Number of cirrhotic patients with acute NVGIB	Non-variceal bleeding source	Endoscopic treatment modality	Main outcomes
Paquet et al[30]	Retrospective	1985-1987	339	53	MWS	EIS (polidocanol)	CoB
Baettig et al[35]	Retrospective	1984-1991	480 (28 with Dieulafoy’s lesion)	3	DL	EI + EIS (polidocanol)	CoB; Rebleeding; Mortality
Labenz et al[25]	Retrospective, case series	NR	5	3	GAVE	Nd-YAG LC	CoB; Post treatment TU (median f/up 8 mo)
Schuman et al[31]	Retrospective	1985-1990	42	14	MWS	BICAP electrocoagulation, Epinephrine injection	CoB; Severity of bleeding in relation to liver disease and/or PH2
Ikeda et al[16]	Retrospective	1993-1996	5	4	GAVE	EC or HPC	CoB; Eradication of GAVE; Endoscopic pattern and development of GAVE
Dulai et al[26]	Prospective	1991-1999	744 (26 with GAVE)	7	GAVE	Bipolar EC, HPC, APC	Hct pre- and post-treatment; TU needed; Number of hospitalizations pre- and post-treatment (median f/up 6 mo)
Cheng et al[36]	Retrospective	1999-2001	1393 (29 with DL)	5	DL	EI, EIS, HPC	CoB; Rebleeding; Mortality
Sato et al[17]	Retrospective	2001-2003	8	5	GAVE	APC	Recurrence of GAVE (mean f/up 28 mo); CoT (mean f/up 28 mo)
Higuchi et al[32]	Prospective	1998-2005	37	11	MWS	EBL	CoB; Rebleeding (28 d)
Lecleire et al[27]	Retrospective	2001-2005	30	11	GAVE	APC	CoB; GAVE pattern; Recurrence of symptoms (median f/up 20 mo); CoT (median f/up 20 mo)
Seo et al[18]	Retrospective multicenter	May-October 2005	464	76	GU, DU, OS	EC	CoB; Rebleeding (42 d); Mortality (42 d)
Lecleire et al[33]	Prospective	2001-2008	218	7	MWS	EBL or EI + HC	CoB; Rebleeding; TU needed; Mortality
Fuccio et al[28]	Prospective	2002-2006	20	4	GAVE	APC	Resolution of transfusion dependent anemia (mean f/up 25 mo); CoT (mean f/up 25 mo)
González-González et al[22]	Prospective	2000-2009	160	160	GU, DU, OS	BICAP EC, EI	CoB; Rebleeding; Mortality (in-hospital)
Gad et al[37]	Retrospective	2007-2011	77	77	PHC, OS	APC	CoB; PHC prevalence; PHC endoscopic pattern
Awad et al[38]	Prospective	2009-2010	120	120	Hemorrhoids	EBL, EIS (ethanolamine or N-butyl cyanoacrylate)	CoB; HR; Rebleeding; Pain relief; Patient’s satisfaction
Rudler et al[23]	Prospective	2008-2011	203	29	PU	EI, HC	CoB; Rebleeding; Mortality (30 d); RT
Sato et al[29]	Retrospective	NR	34	13	GAVE	APC, EBL	CoB; Rebleeding; Mortality; GAVE recurrence
Smith et al[34]	Retrospective, case series	NR	4	4	PHG, PHC	Hemospray	CoB; CoT
Morsy et al[24]	Prospective	2011-2012	532	93	GU, DU, OS	EI, APC	Early rebleeding (24 h after stabilising patient); Mortality (in-hospital)
Yang et al[19]	Retrospective	2007-2013	210	210	PU	EI, APC, HC	CoB; Rebleeding; Mortality (in-hospital); Infection (in-hospital); Length of hospital stay
Kuo et al[20]	Retrospective	2008-2014	235	235	PU	EI, APC, HC	CoB; Rebleeding; Mortality (in-hospital); Infection (in-hospital); Length of hospital stay
Ardevol et al[21]	Retrospective multicenter	2005-2012	790	144	PU	EI, Multipolar EC, HC, EIS	CoB; Rebleeding (1-45 d); Mortality (45 d, 1 year); RT

¹Including cirrhotics and non-cirrhotics with acute non-variceal gastrointestinal bleeding and cirrhotics with obscure gastrointestinal bleeding;

NR: Not reported; MWS: Mallory-Weiss syndrome; DL: Dieaulafoy’s lesion; GAVE: Gastric antral vascular ectasia; PHC: Portal hypertensive colopathy; PHG: Portal hypertensive gastropathy; LC: Lasercoagulation; APC: Argon plasma coagulation; EBL: Endoscopic band ligation; EIS: Endoscopic injection sclerotherapy; EI: Epineprhine injection, HPC: Heater probe coagulation; CoB: Control of bleeding; TU: Transfusion units; PH: Portal hypertension; Hct: Hematocrit; CoT: Complications of treatment; PU: Peptic ulcer; GU: Gastric ulcer; DU: Duodenal ulcer; OS: Other sources; HR: Hemorrhoids recurrence; RT: Rescue therapies.

Table 2 Main characteristics of studies including patients with cirrhosis and acute upper gastrointestinal bleeding due to peptic ulcers

Ref.	Patients (n)	Cirrhotic patients with NVAGIB (n)	Non-variceal bleeding source: peptic ulcer/other (n)	Patients received endoscopic treatment (n)	Endoscopic treatment modality (n)	Failure to control bleeding, n (%)	Rebleeding, n (%)	Mortality, n (%)	Rescue therapy
Seo et al[18]	464	76	GU: 48; DU: 16; OL: 12	48	EC: 201	1/76 (1.3%)	2/76 (2.6%)	42 d: 11/76 (14.5%)	NR
González-González et al[22]	160	160	GU: 39; DU: 33; GU + DU: 9; EU: 3	43	EI: 7; BICAP EC: 6; CT: 30	NR	3/160 (1.9%)	In-hospital: 22 (13.8%)	S: 0
Rudler et al[23]	203	29	DU: 19; GU: 7; MU: 3	20	EI: 9; EI + HC: 11	NR	2/29 (7%)	30 d: 1/29 (3%)	AE: 3; S: 0
Morsy et al[24]	532	93	DU: 25; EU: 5; GU: 3	42	EI: 23; APC: 19	NR	4/93 (4.3%)	In-hospital: 13/93 (14%)	NR
Yang et al[19]	210	210	GU: 133; DU: 66; GU + DU: 11	210	EI: 80; APC: 41; HC: 13; EI + APC: 36; EI + HC: 40	7 (3.3%)	47 (22.4%)	In-hospital: 37/210 (17.6%)	NR
Kuo et al[20]	235	235	GU:146; DU: 73; GU + DU: 16	235	EI: 84; APC: 50; HC: 20; CT: 81	8 (3.4%)	48 (20.4%)	In-hospital: 40/235 (17%)	NR
Ardevol et al[21]	790	144	DU: 79; GU: 62; SU: 3	88	EI: NR; Multipolar EC: NR; HC: NR; EIS: NR	14 (10%)	15 (10%)	6 wk: 24/144 (17%)	SET: 11; AE: 3; S: 2

¹Endoscopic treatment modality only mentioned for 20/48 patients;

NVAGIB: Non-variceal acute gastrointestinal bleeding; GU: Gastric ulcer; DU: Duodenal ulcer; EU: Esophageal ulcer; OL: Other lesions; MU: Multiple ulcers; EC: Electrocoagulation; EI: Epinephrine injection; HC: Hemoclips; CT: Combination therapy; APC: Argon plasma coagulation; EIS: Endoscopic injection sclerotherapy; NR: Not reported; S: Surgery; AE: Arterial embolisation; SET: Second endoscopic treatment.

Table 3 Main characteristics of studies including patients with cirrhosis and acute upper gastrointestinal bleeding due to gastric antral vascular ectasia

Ref.	Patients (n)	Cirrhotic patients with overt bleeding (n)	Patients received endoscopic treatment (n)	Endoscopic treatment modality (n)	Failure to control initial overt bleeding, n (%)	Endoscopic sessions needed (n)	GAVE eradication, n (%)	Mortality during follow-up, n (%)	Follow-up period (mo)
Labenz et al[25]	5	3	5	NA-YAG LC	0	2-8	0	0	2-12 (median = 6)
Ikeda et al[16]	5	4	5	EC: NR; HPC: NR	0	NR	0	NR	64.8 (mean)
Dulai et al[26]	744 (26 with GAVE)	7	26	Bipolar EC: 13; HPC: 7; APC: 6	0	Median = 3 (2-5)	0	NR	3-10 (median = 6)
Sato et al[17]	8	5	8	APC	0	Mean = 1.8 (1-3)	6/8 (75%)	NR	28 (mean)
Lecleire et al[27]	30 (17 cirrhotics)	11	30	APC	0	Mean = 2.2	NR	9/17 (53%)	Cirrhotics: 20 (median); Non-cirrhotics: 24 (median)
Fuccio et al[28]	20	4	20	APC	0	Median = 3 (1-10)	14/20 (70%)	8/20 (40%)	1-47 (mean = 25)
Sato et al[29]	34 (32 cirrohtics)	13	34	APC (22); EBL (12)	0	APC: Mean = 2.3 (1-3); EBL: Mean = 3 (2-4)	APC: 7/22 (32%); EBL 11/12 (92%)	9/34 (26%)	APC: 16.6 (mean); EBL: 14.6 (mean)

GAVE: Gastric antral vascular ectasia; LC: Lasercoagulation; EC: Electrocoagulation; NR: Not reported; HPC: Heater probe coagulation; APC: Argon plasma coagulation; EBL: Endoscopic band ligation.

Table 4 Main characteristics of studies including patients with cirrhosis and acute upper gastrointestinal bleeding

Ref.	Patients (n)	Patients with MWS bleeding (n)	Cirrhotic patients with MWS bleeding (n)	Patients with MWS received endoscopic treatment (n)	Endoscopic treatment modalities (n)	Failure to control initial overt bleeding, n (%)	Rebleeding, n (%)	Mortality during follow-up, n (%)
Paquet et al[30]	339	55	53	53	ES (polidocanol)	0	NR	NR
Schuman et al[31]	79	42	14	4	EI; BICAP EC	0	NR	3/42 (7%)
Higuchi et al[32]	37	37	11	37	EBL	0	1/37 (2.7%)	1/37 (2.7%)
Lecleire et al[33]	218	218	7	56	EBL: 27; EI + HC: 29	0	5/56 (9%) (Hemoclips + Epinephrine)	0
González-González et al[22]	160	18	18	0	EI: 0; BICAP EC : 0	NR	NR	22/160 (13.8%)

ES: Esophageal sclerotherapy; EI: Epinephrine injection; EC: Electrocoagulation; NR: Not reported; EBL: Endoscopic band ligation; HC: Hemoclips.