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Han X, Cheng XJ, Gao M, Wang CY, Zhao LL, Yang YF, Li J. ICG-r15 predicts esophageal varices in compensated liver cirrhosis: a noninvasive approach. BMC Gastroenterol 2024; 24:390. [PMID: 39487442 PMCID: PMC11529008 DOI: 10.1186/s12876-024-03407-4] [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: 10/08/2023] [Accepted: 09/06/2024] [Indexed: 11/04/2024] Open
Abstract
OBJECTIVE The aim of our study was to evaluate the indocyanine green (ICG) retention test as a noninvasive marker of esophageal varices(EV). METHODS The clinical data of patients diagnosed with compensated liver cirrhosis in Tianjin Second People's Hospital between January 2018 and January 2021 were analysed with SPSS 23.0. RESULT A total of 144 patients (88 M/56 F, 51.7 ± 11.06 years) were enrolled. The ICG retention at 15 min(ICG-r15), PVD, TBIL, Cholinesterase(CHE), AST to ALT ratio(ARR), APRI, splenic area, Lok index, Park index and liver stiffness measurement in the absent or small EV group were lower than those in the medium or large EV group, while the ICG disappareance rate(ICG-K), Effective hepatic blood flow(EHBF), ALB, PLT, and Platelet to Spleen Diameter Ratio(PSDR) were higher, and the differences were significant (P < 0.05). ICG-r15, splenic area, APRI and PLT were independent predictors for medium or large esophageal varices (OR = 1.115, 1.025, 0.281, and 0.987, respectively,P < 0.05). The predictive value of ICG-r15 for medium or large varices was 17.95%, the specificity was 0.849, and the sensitivity was 0.662, the AUROC was 0.815. The cut-off value of PLT for M/L EV was 113.5, and the specificity and sensitivity were 0.616 and 0.887, the AUROC was 0.759. The AUROC of ICG-r15 combined with PLT was 0.866, which was more superior than others. CONCLUSION Although we are far from the replacement of endoscopy, ICG-r15 combined with PLT seems to be able to identify patients with medium or large EV in patients with compensated liver cirrhosis.
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Affiliation(s)
- Xu Han
- Tianjin Second People's Hospital, Tianjin Institute of Hepatology, No. 75 Sudi Road, Nankai District, Tianjin, 300192, China
- Department of Liver Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, No.1 Zhongfu Road, Gulou District, Nanjing, 210003, China
| | - Xiao-Jing Cheng
- Tianjin Second People's Hospital, Tianjin Institute of Hepatology, No. 75 Sudi Road, Nankai District, Tianjin, 300192, China
| | - Min Gao
- Tianjin Second People's Hospital, Tianjin Institute of Hepatology, No. 75 Sudi Road, Nankai District, Tianjin, 300192, China
| | - Chun-Yan Wang
- Tianjin Second People's Hospital, Tianjin Institute of Hepatology, No. 75 Sudi Road, Nankai District, Tianjin, 300192, China
| | - Li-Li Zhao
- Tianjin Second People's Hospital, Tianjin Institute of Hepatology, No. 75 Sudi Road, Nankai District, Tianjin, 300192, China
| | - Yong-Feng Yang
- Department of Liver Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, No.1 Zhongfu Road, Gulou District, Nanjing, 210003, China
| | - Jia Li
- Tianjin Second People's Hospital, Tianjin Institute of Hepatology, No. 75 Sudi Road, Nankai District, Tianjin, 300192, China.
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Cheng H, Zhu Y. Cystatin C/albumin ratio for early diagnosis of esophageal varices in liver cirrhosis. Medicine (Baltimore) 2024; 103:e38481. [PMID: 38941375 PMCID: PMC11466157 DOI: 10.1097/md.0000000000038481] [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: 04/02/2024] [Accepted: 05/16/2024] [Indexed: 06/30/2024] Open
Abstract
The mortality rate related to variceal bleeding is high in patients with liver cirrhosis. Early detection and treatment of varices can reduce the risk of hemorrhage and thus decrease the mortality rate related to variceal bleeding. The study comprised 81 cirrhotic patients in training set, who were categorized into 2 groups: the patients with esophageal varices (EVs group) and the patients without esophageal varices (non-EVs group). The disparity in Cystatin C/albumin ratio (CAR) was assessed between these 2 groups. Subsequently, a regression model was constructed by generating a receiver operating characteristic (ROC) curve to calculate the area under the curve (AUC). Then an external validation was performed in 25 patients. Among patients with cirrhosis in training set, a statistically significant difference in CAR was observed between the EVs group and non-EVs group (P < .05). At the CAR cutoff value of 2.79*10-5, the AUC for diagnosing EVs were 0.666. Further, a multivariate logistic regression model was constructed, after adjusting the model, the AUC for EVs diagnosis were 0.855. And the external validation showed that the model could not be considered as a poor fit. CAR exhibits potential as an early detection marker for EVs in liver cirrhosis, and the regression model incorporating CAR demonstrates a strong capability for early EVs diagnosis.
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Affiliation(s)
- Hui Cheng
- Department of Infectious Diseases, the First Affiliated Hospital of Dalian Medical University, Dalian, China
- Department of Gastroenterology, the Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ying Zhu
- Department of Infectious Diseases, the First Affiliated Hospital of Dalian Medical University, Dalian, China
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Hu XG, Dai JJ, Lu J, Li G, Wang JM, Deng Y, Feng R, Lu KP. Efficacy of transjugular intrahepatic portosystemic shunts in treating cirrhotic esophageal-gastric variceal bleeding. World J Gastrointest Surg 2024; 16:471-480. [PMID: 38463371 PMCID: PMC10921195 DOI: 10.4240/wjgs.v16.i2.471] [Citation(s) in RCA: 1] [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: 11/22/2023] [Revised: 12/15/2023] [Accepted: 01/09/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Esophageal-gastric variceal bleeding (EGVB) represents a severe complication among patients with cirrhosis and often culminates in fatal outcomes. Interventional therapy, a rapidly developing treatment modality over the past few years, has found widespread application in clinical practice due to its minimally invasive characteristics. However, whether transjugular intrahepatic portosystemic shunt (TIPS) treatment has an impact on patient prognosis remains controversial. AIM To probing the efficacy of TIPS for treating cirrhotic EGVB and its influence on the prognosis of patients afflicted by this disease. METHODS A retrospective study was conducted on ninety-two patients presenting with cirrhotic EGVB who were admitted to our hospital between September 2020 and September 2022. Based on the different modes of treatment, the patients were assigned to the study group (TIPS received, n = 50) or the control group (percutaneous transhepatic varices embolization received, n = 42). Comparative analyses were performed between the two groups preoperatively and one month postoperatively for the following parameters: Varicosity status; hemodynamic parameters [portal vein flow velocity (PVV) and portal vein diameter (PVD); platelet count (PLT); red blood cell count; white blood cell count (WBC); and hepatic function [albumin (ALB), total bilirubin (TBIL), and aspartate transaminase (AST)]. The Generic Quality of Life Inventory-74 was utilized to assess quality of life in the two groups, and the 1-year postoperative rebleeding and survival rates were compared. RESULTS Following surgical intervention, there was an improvement in the incidence of varicosity compared to the preoperative status in both cohorts. Notably, the study group exhibited more pronounced enhancements than did the control group (P < 0.05). PVV increased, and PVD decreased compared to the preoperative values, with the study cohort achieving better outcomes (P < 0.05). PLT and WBC counts were elevated postoperatively in the two groups, with the study cohort displaying higher PLT and WBC counts (P < 0.05). No differences were detected between the two groups in terms of serum ALB, TBIL, or AST levels either preoperatively or postoperatively (P < 0.05). Postoperative scores across all dimensions of life quality surpassed preoperative scores, with the study cohort achieving higher scores (P < 0.05). At 22.00%, the one-year postoperative rebleeding rate in the study cohort was significantly lower than that in the control group (42.86%; P < 0.05); conversely, no marked difference was observed in the 1-year postoperative survival rate between the two cohorts (P > 0.05). CONCLUSION TIPS, which has demonstrated robust efficacy in managing cirrhotic EGVB, remarkably alleviates varicosity and improves hemodynamics in patients. This intervention not only results in a safer profile but also contributes significantly to a more favorable prognosis.
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Affiliation(s)
- Xiao-Gang Hu
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Jian-Ji Dai
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Jun Lu
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Gang Li
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Jia-Min Wang
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Yi Deng
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Rui Feng
- Department of Interventional Medicine, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou 310000, Zhejiang Province, China
| | - Kai-Ping Lu
- Department of Vascular Surgery, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou 310000, Zhejiang Province, China
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Lee NHC, Kiddle SJ, Chandankhede S, Agrawal S, Bean DM, Hunt PR, Parker VER, Greasley PJ, Ambery P. Evaluating clinical outcomes and prognosis in patients with cirrhosis and portal hypertension: a retrospective observational cohort study. BMJ Open Gastroenterol 2023; 10:e001234. [PMID: 38030407 PMCID: PMC10689413 DOI: 10.1136/bmjgast-2023-001234] [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: 09/11/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023] Open
Abstract
OBJECTIVE Cirrhosis describes the end-stage of chronic liver disease. Irreversible changes in the liver cause portal hypertension, which can progress to serious complications and death. Only a few studies with small sample sizes have investigated the prognosis of cirrhosis with portal hypertension. We used electronic healthcare records to examine liver-related outcomes in patients with diagnosed/suspected portal hypertension. DESIGN This retrospective observational cohort study used secondary health data between 1 January 2017 and 3 December 2020 from the TriNetX Network, a federated electronic healthcare records platform. Three patient groups with cirrhosis and diagnosed/suspected portal hypertension were identified ('most severe', 'moderate severity' and 'least severe'). Outcomes studied individually and as a composite were variceal haemorrhage, hepatic encephalopathy, complications of ascites and recorded mortality up to 24 months. RESULTS There were 13 444, 23 299, and 23 836 patients in the most severe, moderate severity and least severe groups, respectively. Mean age was similar across groups; most participants were white. The most common individual outcomes at 24 months were variceal haemorrhage in the most severe group, recorded mortality and hepatic encephalopathy in the moderate severity group, and recorded mortality in the least severe group. Recorded mortality rate was similar across groups. For the composite outcome, cumulative incidence was 59% in the most severe group at 6 months. Alcohol-associated liver disease and metabolic-associated steatohepatitis were significantly associated with the composite outcome across groups. CONCLUSION Our analysis of a large dataset from electronic healthcare records illustrates the poor prognosis of patients with diagnosed/suspected portal hypertension.
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Affiliation(s)
| | - Steven J Kiddle
- Data Science & Advanced Analytics, Data Science & Artificial Intelligence, R&D, AstraZeneca, Cambridge, UK
| | | | - Shubh Agrawal
- Real World Evidence, ZS Associates, Bangalore, India
| | - Daniel M Bean
- Data Science & Advanced Analytics, Data Science & Artificial Intelligence, R&D, AstraZeneca, Cambridge, UK
| | - Phillip R Hunt
- Medical Affairs, Cardiovascular, Renal and Metabolism, AstraZeneca, Gaithersburg, Maryland, USA
| | - Victoria E R Parker
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Peter J Greasley
- Early Clinical Development, Research and Early Development, Cardiovascular Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Philip Ambery
- Clinical Late Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
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Yan X, Leng Z, Xu Q, Zhang Z, Xu M, Li J. The influences of timing of urgent endoscopy in patients with acute variceal bleeding: a cohort study. BMC Gastroenterol 2022; 22:506. [PMID: 36482309 PMCID: PMC9733049 DOI: 10.1186/s12876-022-02595-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND There has always been a debate on the optimal timing of endoscopy in patients with acute variceal bleeding (AVB). OBJECTIVE This study aimed to examine the relation between the timing of endoscopy and the short-term outcomes of patients with AVB. METHODS Patients with AVB who underwent endoscopy within 24 h after admission at our tertiary care center from 2014 to 2022 were evaluated retrospectively. The primary outcomes were the 6-week mortality and re-bleeding. The secondary outcomes included the total number of blood units transfused, the length of hospital stay, and the need for salvage therapy. We used Cox proportional hazards model to analyze the predictors of 6-week mortality in all patients as well as in those who were at high risk of further bleeding or death. RESULTS A total of 312 patients were enrolled. Among them, 170 patients (54.49%) underwent urgent endoscopy (< 6 h), and 142 patients (45.51%) underwent early endoscopy (6-24 h). There were no significant differences between the urgent-endoscopy group and the early-endoscopy group, regarding the 6-week mortality (16.47% vs. 10.56%; P value = 0.132) and 6-week re-bleeding rate (11.2% vs. 16.2%; P value = 0.196). In multivariate analysis, time to endoscopy was independent of 6-week mortality (P value = 0.170), but the time between the beginning of bleeding and endoscopy (within 12 h) was significantly associated with low 6-week mortality (OR: 0.16; 95% CI: 0.06-0.46; P value = 0.001). Time to endoscopy was still not associated with 6-week mortality in patients at high risk for further bleeding or death (Glasgow-Blatchford score ≥ 12, n = 138, P value = 0.902). CONCLUSIONS Endoscopy performed within 6 h of admission, rather than within 6 to 24 h, did not improve six-week clinical outcomes in patients in stable condition with AVB and even those who were at high risk of further bleeding and death.
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Affiliation(s)
- Xiaohan Yan
- grid.452753.20000 0004 1799 2798Endoscopy Center, Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Pudong New District, Shanghai, 200120 China
| | - Zhuyun Leng
- grid.452753.20000 0004 1799 2798Endoscopy Center, Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Pudong New District, Shanghai, 200120 China
| | - Qinwei Xu
- grid.452753.20000 0004 1799 2798Endoscopy Center, Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Pudong New District, Shanghai, 200120 China
| | - Zehua Zhang
- grid.452753.20000 0004 1799 2798Endoscopy Center, Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Pudong New District, Shanghai, 200120 China
| | - Meidong Xu
- grid.452753.20000 0004 1799 2798Endoscopy Center, Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Pudong New District, Shanghai, 200120 China
| | - Jingze Li
- grid.452753.20000 0004 1799 2798Endoscopy Center, Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Pudong New District, Shanghai, 200120 China
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Zhang W, Wang Y, Chu J, Liu Y, LingHu E. Investigation report on endoscopic management of esophagogastric variceal bleeding by Chinese endoscopists. Medicine (Baltimore) 2022; 101:e31263. [PMID: 36281109 PMCID: PMC9592513 DOI: 10.1097/md.0000000000031263] [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] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Esophagogastric variceal bleeding (EGVB) is a potentially life-threatening complication of portal hypertension. Endoscopic treatment combined with pharmacotherapy remains the mainstay in the management of acute variceal bleeding. AIM This article intends to highlight the potential differences in the endoscopic management of EGVB in China. METHODS A cross-sectional descriptive study was conducted. Endoscopists from 85 hospitals in 62 cities from 26 provinces were contacted by email. The items in questionnaire involved academic experience, screening, esophagogastric varices (EGV) classification, emergency treatment, and primary and secondary prophylaxis of EGVB by endoscopists with different lengths of experience. RESULTS A total of 85 questionnaires were collected. There was no statistical difference in the selection of items (P < .05 indicated statistical significance). The majority of endoscopists (95.29%) offered EGV screening for patients with liver cirrhosis. The location, diameter, and risk factor classification was selected by 82.35% of endoscopists. Endoscopy + medication was preferred (42.35%) for the primary prophylaxis of moderate-to-severe EGVs. There was no statistical difference in emergency intervention time for active EGVB (P > .05). The response "patients receive emergency endoscopic intervention within 12 hours" was selected by 61.2% of the endoscopists. The preferred emergency treatment for EGVB was combination treatment (40%). Tissue adhesive embolization was selected for the treatment of gastric variceal bleeding by 74.12% of endoscopists; transjugular intrahepatic portosystemic stent shunt/percutaneous transhepatic variceal embolization were selected as remedial measures by 48.23% to 52.94% of endoscopists. In addition, 67.06% of endoscopists elected to perform secondary prophylaxis and treatment within 1 week after hemostasis. Endoscopy and endoscopy + medication were selected by 44.71% and 49.41% of endoscopists, respectively, for secondary prophylaxis. The choice of laboratory indicators did not differ with length of experience. CONCLUSIONS There was no statistical difference in the endoscopic management of EGVB among Chinese endoscopists. The selection of diagnosis/treatment schemes was mainly based on guidelines and physician experience.
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Affiliation(s)
- Wenhui Zhang
- Digestive System Department, Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
- Endoscopy Center, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yanling Wang
- Endoscopy Center, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jindong Chu
- Endoscopy Center, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yingdi Liu
- Department of Gastroenterology, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Enqiang LingHu
- Department of Gastroenterology, First Medical Center of Chinese PLA General Hospital, Beijing, China
- *Correspondence: En-Qiang LingHu, Department of Gastroenterology, First Medical Center of Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100039, China (e-mail: )
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Abstract
PURPOSE OF REVIEW Gastroesophageal varices are common complications of chronic liver diseases (CLDs) and portal hypertension. Small varices have the risk of progressing to larger varices, causing bleeding or even death. Thus, early detection and appropriate management of small varices are necessary. The purpose of this review is to summarize the advance in the recent 5years about diagnosing and managing the small varices in CLDs. RECENT FINDINGS The diagnosing methods of small varices in recent studies include improved endoscopic examinations, such as capsule endoscopy, and many noninvasive methods, including blood tests, ultrasound, computed tomography and magnetic resonance. For the management of small varices, though it is controversial, prevention using nonselective beta-blockers is still an essential part. SUMMARY In this review, we summarize the classification of varices, the invasive and noninvasive diagnostic methods, their performances, and the emerging progression in the management of small varices in the recent 5 years. We hope that this review provides relevant information to understand better and appropriately manage small varices.
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Affiliation(s)
- Ying Zhu
- Department of Infectious Diseases, The First Affiliated Hospital of Dalian Medical University, Dalian
| | - Hui Cheng
- Department of Infectious Diseases, The First Affiliated Hospital of Dalian Medical University, Dalian
- Department of Gastroenterology, The Second Affiliated Hospital of Dalian Medical University, Dalian
| | - Jianyong Chen
- Department of Gastroenterology, Jiangxi Provincial People's Hospital, Nanchang
| | - Yifei Huang
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Hao Liu
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Xiaolong Qi
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
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Rees J, Evison F, Mytton J, Patel P, Trudgill N. The outcomes of emergency hospital admissions with non-malignant upper gastrointestinal bleeding in England between 2003 and 2015. Endoscopy 2021; 53:1210-1218. [PMID: 33601430 DOI: 10.1055/a-1330-7118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Upper gastrointestinal bleeding (UGIB) is a common medical emergency with significant mortality. Despite developments in endoscopic and clinical management, only minor improvements in outcomes have been reported. METHODS This was a retrospective cohort study of patients with non-malignant UGIB emergency admissions in England between 2003 and 2015, using Hospital Episode Statistics. Multilevel logistic regression analysis examined the associations with mortality. RESULTS 242 796 patients with an UGIB admission were identified (58.8 % men; median age 70 [interquartile range (IQR) 53 - 81]). Between 2003 and 2015, falls occurred in both 30-day mortality (7.5 % to 7.0 %; P < 0.001) and age-standardized mortality (odds ratio (OR) 0.74, 95 % confidence interval [CI] 0.69 - 0.80; P < 0.001), including from variceal bleeding (OR 0.63, 95 %CI 0.45 - 0.87; P < 0.005). Increasing co-morbidity (Charlson score > 5, OR 2.94, 95 %CI 2.85 - 3.04; P < 0.001), older age (> 83 years, OR 6.50, 95 %CI 6.09 - 6.94; P < 0.001), variceal bleeding (OR 2.03, 95 %CI 1.89 - 2.18; P < 0.001), and a weekend admission (Sunday, OR 1.18, 95 %CI 1.12 - 1.23; P < 0.001) were associated with 30-day mortality. Of deaths at 30 days, 8.9 % were from ischemic heart disease (IHD) and the cardiovascular age-standardized mortality rate following UGIB was high (IHD deaths within 1 year, 1188.4 [95 %CI 1036.8 - 1353.8] per 100 000 men in 2003). CONCLUSIONS Between 2003 and 2015, 30-day mortality among emergency admissions with non-malignant UGIB fell by 0.5 % to 7.0 %. Mortality was higher among UGIB admissions at the weekend, with important implications for service provision. Patients with UGIB had a much greater risk of subsequently dying from cardiovascular disease and addressing this risk is a key management step in UGIB.
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Affiliation(s)
- James Rees
- Department of Gastroenterology, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Felicity Evison
- Department of Health Informatics, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jemma Mytton
- Department of Health Informatics, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Prashant Patel
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Nigel Trudgill
- Department of Gastroenterology, Sandwell & West Birmingham NHS Trust, West Bromwich, UK
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Acute variceal bleeding and out-of-hours endoscopy: Evaluation of an emergency care setting according to Baveno VI guidelines adherence. Dig Liver Dis 2021; 53:1320-1326. [PMID: 34348881 DOI: 10.1016/j.dld.2021.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The extent to which patients with acute variceal bleeding (AVB) receive recommended care is largely unknown. AIM to evaluate the adherence of the 4 major Baveno VI recommendations [vasoactive agents, prophylactic antibiotic, esophagogastroduodenoscopy (EGD) within 12 hours, endoscopic variceal ligation (EVL)] as a marker of quality of an emergency model. METHODS Retrospective evaluation of AVB admissions to a tertiary centre in which endoscopy was available 24hours-a-day, with a regional out-of-hours service at night (the furthest hospital is 200Km away). Patients were divided in directly admitted or transferred from other centres. RESULTS 210 AVB patients were included; 101 (48.1%) were directly admitted. The majority of patients were submitted to vasoactive agents (85.7%) and prophylactic antibiotics (79%) before EGD. In 178 patients (84.8%) endoscopy was performed within 12h and EVL was the procedure of choice in 116 (74.8%) (only oesophageal varices). No significant differences were observed between directly admitted and transferred patients in adherence rates. Overall rebleeding rate was 8.6%, in-hospital mortality 11.4% and 6-week mortality 20%. CONCLUSION Adherence to quality metrics was high which might have played a vital role for reported outcomes. These results suggest that this model of care, provides accessibility and equity in access to urgent endoscopy.
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Park MK, Lee YB. [Diagnosis and Management of Esophageal and Gastric Variceal Bleeding: Focused on 2019 KASL Clinical Practice Guidelines for Liver Cirrhosis]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 78:152-160. [PMID: 34565784 DOI: 10.4166/kjg.2021.113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 12/14/2022]
Abstract
Varices are a frequent complication of liver cirrhosis and a major cause of mortality in patients with liver cirrhosis. Patients with decompensated cirrhosis complications have a poor prognosis and require careful management. Portal hypertension is the most common complication of liver cirrhosis, which is the key determinant for varices development. Increased intrahepatic vascular resistance to portal flow leads to the development of portal hypertension. Collateral vessels develop at the communication site between the systemic and portal circulation with the progression of portal hypertension. Varices are the representative collaterals, develop gradually with the progression of portal hypertension and may eventually rupture. Variceal bleeding is a major consequence of portal hypertension and causes the death of cirrhotic patients. The present paper reviews the latest knowledge regarding the diagnosis and management of esophageal and gastric variceal bleeding.
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Affiliation(s)
- Min Kyung Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yun Bin Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Mortality of Cirrhosis Induced Variceal Hemorrhage Is Declining: Can We Do More? Crit Care Med 2020; 47:1453-1455. [PMID: 31524694 DOI: 10.1097/ccm.0000000000003945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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KASL clinical practice guidelines for liver cirrhosis: Varices, hepatic encephalopathy, and related complications. Clin Mol Hepatol 2020; 26:83-127. [PMID: 31918536 PMCID: PMC7160350 DOI: 10.3350/cmh.2019.0010n] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 02/06/2023] Open
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Suh JI. Are there Seasonal Variations in the Incidence and Mortality of Esophageal Variceal Bleeding? Clin Endosc 2020; 53:107-108. [PMID: 32164048 PMCID: PMC7137559 DOI: 10.5946/ce.2020.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 02/25/2020] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jeong Ill Suh
- Department of Internal Medicine, Dongguk University Gyeongju Hospital, Dongguk University School of Medicine, Gyeongju, Korea
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14
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Lu Z, Sun X, Zhang W, Jin B, Han J, Wang Y, Han J, Ma X, Liu B, Wu L, Wu Q, Yu X, Li H. Second urgent endoscopy within 48-hour benefits cirrhosis patients with acute esophageal variceal bleeding. Medicine (Baltimore) 2020; 99:e19485. [PMID: 32176084 PMCID: PMC7440074 DOI: 10.1097/md.0000000000019485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Urgent endoscopy (UE) is important to the diagnosis and treatment of liver cirrhosis patients with esophageal variceal bleeding (EVB). It was reported that a second-look endoscopy may benefit acute upper gastrointestinal bleeding (UGIB) caused by peptic ulcer, while whether it could improve UGIB caused by liver cirrhosis associated EVB remains unclear. This study aimed to investigate the characteristics of second UE for liver cirrhosis with EVB and further examined the potential prognostic factors.Patients aged ≥18 years who underwent UE for EVB within 2 hours after the admission were included and divided into scheduled second-look group (n = 245) and uncontrolled bleeding group (n = 352) based on the indications for second UE within 48 hours after initial endoscopy. Demographic and clinical data were collected and analyzed. Univariate and multivariate analysis were used to identify the risk factors for prognosis. The value of different scoring system was compared.Statistical differences were found on history of bleeding and hepatocellular carcinoma, ascites, endoscopic type of bleeding, between scheduled second-look group and uncontrolled bleeding group. Univariate and multivariate logistic regression analysis confirmed that ascites, hemoglobin <60 g/L, AIMS65 score and failure to identify in initial UE were independent risk factors for bleeding uncontrolled after initial UE, and age, bilirubin level, initial unsatisfactory UE hemostasis, failure to identify bleeding on initial UE and tube/urgent TIPS suggested in initial UE were independent risk factors for 42-day mortality.A second-look UE could bring benefit for liver cirrhosis patients with EVB without increasing the complication rate.
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Affiliation(s)
- Zheng Lu
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Xiaotian Sun
- Department of Internal Medicine, Clinic of August First Film Studio, Beijing South Medical District, Chinese PLA General Hospital, Beijing, China
| | - Wenhui Zhang
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Bo Jin
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | | | - Yanling Wang
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Jun Han
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Xuemei Ma
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Bo Liu
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Libing Wu
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Qin Wu
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Xiaoli Yu
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Hanwei Li
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
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15
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Brenner A, Afolabi A, Ahmad SM, Arribas M, Chaudhri R, Coats T, Cuzick J, Gilmore I, Hawkey C, Jairath V, Javaid K, Kayani A, Mutti M, Nadeem MA, Shakur-Still H, Stanworth S, Veitch A, Roberts I. Tranexamic acid for acute gastrointestinal bleeding (the HALT-IT trial): statistical analysis plan for an international, randomised, double-blind, placebo-controlled trial. Trials 2019; 20:467. [PMID: 31362765 PMCID: PMC6668177 DOI: 10.1186/s13063-019-3561-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 07/08/2019] [Indexed: 12/29/2022] Open
Abstract
Background Acute gastrointestinal (GI) bleeding is an important cause of mortality worldwide. Bleeding can occur from the upper or lower GI tract, with upper GI bleeding accounting for most cases. The main causes include peptic ulcer/erosive mucosal disease, oesophageal varices and malignancy. The case fatality rate is around 10% for upper GI bleeding and 3% for lower GI bleeding. Rebleeding affects 5–40% of patients and is associated with a four-fold increased risk of death. Tranexamic acid (TXA) decreases bleeding and the need for blood transfusion in surgery and reduces death due to bleeding in patients with trauma and postpartum haemorrhage. It reduces bleeding by inhibiting the breakdown of fibrin clots by plasmin. Due to the methodological weaknesses and small size of the existing trials, the effectiveness and safety of TXA in GI bleeding is uncertain. The Haemorrhage ALleviation with Tranexamic acid – Intestinal system (HALT-IT) trial aims to provide reliable evidence about the effects of TXA in acute upper and lower GI bleeding. Methods The HALT-IT trial is an international, randomised, double-blind, placebo-controlled trial of tranexamic acid in 12,000 adults (increased from 8000) with acute upper or lower GI bleeding. Eligible patients are randomly allocated to receive TXA (1-g loading dose followed by 3-g maintenance dose over 24 h) or matching placebo. The main analysis will compare those randomised to TXA with those randomised to placebo on an intention-to-treat basis, presenting the results as effect estimates (relative risks) and confidence intervals. The primary outcome is death due to bleeding within 5 days of randomisation and secondary outcomes are: rebleeding; all-cause and cause-specific mortality; thromboembolic events; complications; endoscopic, radiological and surgical interventions; blood transfusion requirements; disability (defined by a measure of patient’s self-care capacity); and number of days spent in intensive care or high-dependency units. Subgroup analyses for the primary outcome will consider time to treatment, location of bleeding, cause of bleed and clinical Rockall score. Discussion We present the statistical analysis of the HALT-IT trial. This plan was published before the treatment allocation was unblinded. Trial registration Current Controlled Trials, ID: ISRCTN11225767. Registered on 3 July 2012; Clinicaltrials.gov, ID: NCT01658124. Registered on 26 July 2012. Electronic supplementary material The online version of this article (10.1186/s13063-019-3561-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amy Brenner
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Adefemi Afolabi
- Department of Surgery, College of Medicine, University of Ibadan, University College Hospital, Queen Elizabeth Road, Ibadan, 200001, Nigeria
| | - Syed Masroor Ahmad
- Department of Medicine Unit III, Jinnah Postgraduate Medical Centre, Rafiq Shaheed Road, Karachi, 75510, Pakistan
| | - Monica Arribas
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Rizwana Chaudhri
- Rawalpindi Medical University, Holy Family Hospital, Rawalpindi, Pakistan
| | - Timothy Coats
- Department of Cardiovascular Sciences, University of Leicester, Infirmary Square, Leicester, LE1 5WW, UK
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, EC1M 6BQ, UK
| | | | - Christopher Hawkey
- Faculty of Medicine and Health Sciences, University of Nottingham, Queens Medical Centre, Nottingham, NG7 2UH, UK
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, University Hospital, Western University, London, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Kiran Javaid
- Rawalpindi Medical University and London School of Hygiene and Tropical Medicine (RMU-LSHTM) Collaboration, Room No 294, Holy family Hospital, Said Pur Road, Rawalpindi, Pakistan
| | - Aasia Kayani
- Rawalpindi Medical University and London School of Hygiene and Tropical Medicine (RMU-LSHTM) Collaboration, Room No 294, Holy family Hospital, Said Pur Road, Rawalpindi, Pakistan
| | - Muttiullah Mutti
- Rawalpindi Medical University, Holy Family Hospital, Rawalpindi, Pakistan
| | - Muhammad Arif Nadeem
- Department of Medicine, Services Hospital Unit III, Medical Unit III, Jail Road, Lahore, Pakistan
| | - Haleema Shakur-Still
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and Oxford BRC Haematology Theme, Oxford, UK
| | - Andrew Veitch
- Department of Gastroenterology, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Ian Roberts
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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16
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Gado A, Ebeid B, Abdelmohsen A, Axon A. Predictors of mortality in patients with acute upper gastrointestinal hemorrhage who underwent endoscopy and confirmed to have variceal hemorrhage. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2014.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Ahmed Gado
- Department of Medicine, Bolak Eldakror Hospital, Giza, Egypt
| | - Basel Ebeid
- Department of Tropical Medicine and Infectious Diseases, Beny Suef University, Beny Suef, Egypt
| | - Aida Abdelmohsen
- Department of Community Medicine, National Research Center, Giza, Egypt
| | - Anthony Axon
- Department of Gastroenterology, The General Infirmary at Leeds, Leeds, United Kingdom
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17
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Gado A, Ebeid B, Abdelmohsen A, Gado T, Axon A. Endoscopy audit over 10 years in a community hospital in Egypt. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2017.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Ahmed Gado
- Department of Medicine, Bolak Eldakror Hospital, Giza, EgyptDepartment of Medicine, Bolak Eldakror Hospital, Giza, Egypt
| | - Basel Ebeid
- Department of Tropical Medicine and Infectious Diseases, Beny Suef University, Beny Suef, EgyptDepartment of Tropical Medicine and Infectious Diseases, Beny Suef University, Beny Suef, Egypt
| | - Aida Abdelmohsen
- Department of Community Medicine, National Research Center, Giza, EgyptDepartment of Community Medicine, National Research Center, Giza, Egypt
| | - Tarek Gado
- Department of Medicine, Cairo university, Giza, EgyptDepartment of Medicine, Cairo university, Giza, Egypt
| | - Anthony Axon
- Department of Gastroenterology, The General Infirmary at Leeds, Leeds, United KingdomDepartment of Gastroenterology, The General Infirmary at Leeds, Leeds, United Kingdom
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18
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Bishay K, Tandon P, Fisher S, Yelle D, Carrigan I, Wooller K, Kelly E. Clinical Factors Associated with Mortality in Cirrhotic Patients Presenting with Upper Gastrointestinal Bleeding. J Can Assoc Gastroenterol 2019; 3:127-134. [PMID: 32395687 PMCID: PMC7204794 DOI: 10.1093/jcag/gwy075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 03/03/2019] [Indexed: 12/13/2022] Open
Abstract
Background Whether certain clinical or laboratory characteristics are able to differentiate cirrhotic patients with upper gastrointestinal bleeds (UGIB) at high-risk inpatient mortality is unknown. The objective of this study is to elucidate patient factors at presentation that are associated with in-hospital mortality. Methods A retrospective analysis of cirrhotic patients presenting with UGIB was performed. Baseline characteristics at admission including demographics, clinical and laboratory characteristics were collected. Factors associated with in-hospital mortality were evaluated with logistic regression analyses. The discriminative power of MELD score was evaluated with the use of area under the receiver operating characteristic (ROC) curve. Results One hundred and sixteen patients were included in this study. MELD score at presentation was higher in the death cohort (24.0 versus 14.8, P < 0.001) and remained significantly associated with mortality after multivariable adjustment (P < 0.001). ROC analysis of MELD score for death yielded an area under the curve of 0.88. At admission, the death group had lower systolic blood pressure (103 mmHg versus 123 mmHg, P=0.008 and more frequently presented with bright red blood per rectum (46.7% versus 11.9%, P = 0.003). Bilirubin and international normalized ratio were also higher, and albumin was lower in patients who died. Conclusions Among cirrhotic patients presenting with UGIB, the severity of symptoms and impairment in hepatic synthetic function is associated with in-hospital mortality. Admission MELD score may be useful in predicting in-hospital mortality.
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Affiliation(s)
- Kirles Bishay
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, Ottawa, Ontario, Canada.,Division of General Internal Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Parul Tandon
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, Ottawa, Ontario, Canada.,Division of General Internal Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Stacey Fisher
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Dominique Yelle
- Division of General Internal Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian Carrigan
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Krista Wooller
- Division of General Internal Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Erin Kelly
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, Ottawa, Ontario, Canada.,Division of General Internal Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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19
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Mukthinuthalapati VVPK, Akinyeye S, Fricker ZP, Syed M, Orman ES, Nephew L, Vilar-Gomez E, Slaven J, Chalasani N, Balakrishnan M, Long MT, Attar BM, Ghabril M. Early predictors of outcomes of hospitalization for cirrhosis and assessment of the impact of race and ethnicity at safety-net hospitals. PLoS One 2019; 14:e0211811. [PMID: 30840670 PMCID: PMC6402644 DOI: 10.1371/journal.pone.0211811] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 01/21/2019] [Indexed: 12/30/2022] Open
Abstract
Background Safety-net hospitals provide care for racially/ethnically diverse and disadvantaged urban populations. Their hospitalized patients with cirrhosis are relatively understudied and may be vulnerable to poor outcomes and racial/ethnic disparities. Aims To examine the outcomes of patients with cirrhosis hospitalized at regionally diverse safety-net hospitals and the impact of race/ethnicity. Methods A study of patients with cirrhosis hospitalized at 4 safety-net hospitals in 2012 was conducted. Demographic, clinical factors, and outcomes were compared between centers and racial/ethnic groups. Study endpoints included mortality and 30-day readmission. Results In 2012, 733 of 1,212 patients with cirrhosis were hospitalized for liver-related indications (median age 55 years, 65% male). The cohort was racially diverse (43% White, 25% black, 22% Hispanic, 3% Asian) with cirrhosis related to alcohol and viral hepatitis in 635 (87%) patients. Patients were hospitalized mainly for ascites (35%), hepatic encephalopathy (20%) and gastrointestinal bleeding (GIB) (17%). Fifty-four (7%) patients died during hospitalization and 145 (21%) survivors were readmitted within 30 days. Mortality rates ranged from 4 to 15% by center (p = .007) and from 3 to 10% by race/ethnicity (p = .03), but 30-day readmission rates were similar. Mortality was associated with Model for End-stage Liver Disease (MELD), acute-on-chronic liver failure, hepatocellular carcinoma, sodium and white blood cell count. Thirty-day readmission was associated with MELD and Charlson Comorbidity Index >4, with lower risk for GIB. We did not observe geographic or racial/ethnic differences in hospital outcomes in the risk-adjusted analysis. Conclusions Hospital mortality and 30-day readmission in patients with cirrhosis at safety-net hospitals are associated with disease severity and comorbidities, with lower readmissions in patients admitted for GIB. Despite geographic and racial/ethnic differences in hospital mortality, these factors were not independently associated with mortality.
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Affiliation(s)
- V. V. Pavan Kedar Mukthinuthalapati
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indianapolis, United States of America
- Department of Medicine, Cook County Health and Hospitals System, Chicago, Illinois, United States of America
| | - Samuel Akinyeye
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, United States of America
| | - Zachary P. Fricker
- Evans Department of Medicine, Section of Gastroenterology, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Moinuddin Syed
- Department of Medicine, Cook County Health and Hospitals System, Chicago, Illinois, United States of America
| | - Eric S. Orman
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indianapolis, United States of America
| | - Lauren Nephew
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indianapolis, United States of America
| | - Eduardo Vilar-Gomez
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indianapolis, United States of America
| | - James Slaven
- Department of Biostatistics, Indiana University, Indianapolis, Indianapolis, United States of America
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indianapolis, United States of America
| | - Maya Balakrishnan
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, United States of America
| | - Michelle T. Long
- Evans Department of Medicine, Section of Gastroenterology, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Bashar M. Attar
- Department of Gastroenterology and Hepatology, Cook County Health and Hospitals System, Chicago, Illinois, United States of America
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indianapolis, United States of America
- * E-mail:
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20
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Zhou X, Tripathi D, Song T, Shao L, Han B, Zhu J, Han D, Liu F, Qi X. Terlipressin for the treatment of acute variceal bleeding: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2018; 97:e13437. [PMID: 30508958 PMCID: PMC6283114 DOI: 10.1097/md.0000000000013437] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND AIM Acute variceal bleeding (AVB) is life-threatening. We aimed to systematically review the current evidence regarding the efficacy and safety of terlipressin for AVB in liver cirrhosis. METHODS We searched the PubMed, EMBASE, and Cochrane Library databases. The reference list was also hand-searched. Using a random-effect model, we combined the data obtained according to the different time points when the events developed. Odds ratio (OR) and weighted mean difference (WMD) were calculated. Quality of evidence was evaluated by the GRADE methodology. RESULTS Thirty randomized controlled trials with 3344 patients were included. Compared with no vasoactive drug, terlipressin significantly improved the control of bleeding within 48 hours (OR = 2.94, P = .0008) and decreased the in-hospital mortality (OR = 0.31, P = .008). Compared with somatostatin, terlipressin had a significantly higher risk of complications (OR = 2.44, P = .04). Compared with octreotide, terlipressin had a significantly inferior control of bleeding within 24 hours (OR = 0.37, P = .007). Compared with vasopressin, terlipressin had a significantly lower risk of complications (OR = 0.15, P = .02). Compared with terlipressin combined with endoscopic variceal ligation, terlipressin alone had significantly higher 5-day treatment failure (OR = 14.46, P = .01) and transfusion requirements within 49 to 120 hours (WMD = 1.20, P = .002). No outcome was significantly different between terlipressin and sclerotherapy. Compared with balloon tamponade, terlipressin significantly decreased the 30-day rebleeding (OR = 0.05, P = .001) and transfusion requirements (WMD = -2.70, P = .02). Quality of evidence was very low to moderate. CONCLUSION Our findings were in accordance with the current recommendations regarding terlipressin for the treatment of AVB in cirrhosis. However, due to low quality of evidence, further studies are recommended.
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Affiliation(s)
- Xinmiao Zhou
- Meta-Analysis Interest Group & Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area
- Postgraduate College, Jinzhou Medical University, Jinzhou
- Department of Gastroenterology, No. 463 Hospital of Chinese PLA
| | - Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Tingxue Song
- Meta-Analysis Interest Group & Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area
- Department of Gastroenterology, No. 463 Hospital of Chinese PLA
| | - Lichun Shao
- Department of Gastroenterology, No. 463 Hospital of Chinese PLA
| | - Bing Han
- Meta-Analysis Interest Group & Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area
- Postgraduate College, Jinzhou Medical University, Jinzhou
| | - Jia Zhu
- Meta-Analysis Interest Group & Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, P.R. China
| | - Dan Han
- Meta-Analysis Interest Group & Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area
| | - Fufang Liu
- Meta-Analysis Interest Group & Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area
- Postgraduate College, Jinzhou Medical University, Jinzhou
| | - Xingshun Qi
- Meta-Analysis Interest Group & Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area
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21
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The Role of Therapeutic Endoscopy in Patients With Cirrhosis-Related Causes of Gastrointestinal Bleeding. Curr Gastroenterol Rep 2018; 20:31. [PMID: 29886513 DOI: 10.1007/s11894-018-0637-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW This article aims to review current therapeutic endoscopic treatments available for the management of gastrointestinal bleeding related to cirrhosis. RECENT FINDINGS Endoscopic band ligation is an effective treatment for primary prophylaxis, acute bleeding, and secondary prophylaxis of esophageal varices as well as for acute bleeding and secondary prophylaxis of select gastric varices. Sclerotherapy is a treatment option for acute bleeding and secondary prophylaxis of esophageal varices when band ligation is technically difficult. Cyanoacrylate glue injection is an effective treatment for acute bleeding of gastric and ectopic varices. Argon plasma coagulation is first-line and radiofrequency ablation is second-line treatment for chronic bleeding secondary to gastric antral vascular ectasia. There are a variety of endoscopic treatment modalities for cirrhosis-related gastrointestinal bleeding, and the appropriate therapy depends on the location of the bleed, history or presence of acute bleeding, and risk factors for intervention-related adverse events.
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22
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Mandal AK, Paudel MS, KC S, Chaudhary S, Paudel BN, Poudyal NS, Shrestha B, Karki B, Thapa S, Khadka D, Kanth R, Kafle P. Factors Predicting Mortality of Acute Variceal Bleeding in Liver Cirrhosis. JNMA J Nepal Med Assoc 2018; 56:493-496. [PMID: 30058631 PMCID: PMC8997329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Acute variceal bleeding in liver cirrhosis is an immediate life-threatening condition and amajor complication of portal hypertension associated with higher morbidity, mortality and hospital costs than any other causes of UGI bleeding. Therefore, early stratification and initiation of therapy based on several factors can reduce mortality associated with it. We aimed to study the predictors of mortality in acute variceal bleeding in LC. METHODS An observational prospective study was conducted in Gastroenterology and Hepatology units of Bir Hospital, Kathmandu, Nepal from April 1, 2016 to May 30, 2017. Patients were included if they had underlying liver cirrhosis and presented upper GI bleeding which were proven to be secondary to variceal bleeding. RESULTS Seventy-five patients with mean age of 52.5 years were available or the analysis. The M:F ratio was 2.1:1. There were 66 patients in mortality group and 9 in survivor group. The mean CTP and MELD score were 10.17±1.66 and 20.40±8.29 respectively. Among the predictors of the mortality studied, CTP score, MELD score, mean arterial pressure, Serum bilirubin, serum creatinine, need of FFP as well as PRP transfusion, presence of hepatorenal syndrome and hepatic encephalopathy were high in mortality group with statistical significance. On multivariate analysis, high CTP and high serum creatinine level were only significant predictors of mortality. Receiver operating curve for predicting accuracy of mortality was significant with higher MELD and higher CTP score. CONCLUSIONS Strong predictors of mortality in patients with cirrhosis presenting with variceal bleeding are CTP score and high serum creatinine level.
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Affiliation(s)
- Amrendra Kumar Mandal
- Gastroenterology Unit, Department of Medicine, Bir Hospital, NAMS, Kathmandu, Nepal,Correspondence: Dr. Amrendra Kumar Mandal, Gastroenterology Unit, Bir Hospital, NAMS, Kathmandu, Nepal. . Phone: +977-9851247755
| | - Mukesh Sharma Paudel
- Gastroenterology Unit, Department of Medicine, Bir Hospital, NAMS, Kathmandu, Nepal
| | - Sudhamshu KC
- Hepatology Unit, Department of Medicine, Bir Hospital, NAMS, Kathmandu, Nepal
| | - Sitaram Chaudhary
- Gastroenterology Unit, Department of Medicine, Bir Hospital, NAMS, Kathmandu, Nepal
| | - Bidhan Nidhi Paudel
- Gastroenterology Unit, Department of Medicine, Bir Hospital, NAMS, Kathmandu, Nepal
| | - Nandu Silwal Poudyal
- Gastroenterology Unit, Department of Medicine, Bir Hospital, NAMS, Kathmandu, Nepal
| | - Barun Shrestha
- Gastroenterology Unit, Department of Medicine, Bir Hospital, NAMS, Kathmandu, Nepal
| | - Binod Karki
- Gastroenterology Unit, Department of Medicine, Bir Hospital, NAMS, Kathmandu, Nepal
| | - Suresh Thapa
- Gastroenterology Unit, Department of Medicine, Bir Hospital, NAMS, Kathmandu, Nepal
| | - Dibas Khadka
- Gastroenterology Unit, Department of Medicine, Bir Hospital, NAMS, Kathmandu, Nepal
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23
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Conejo I, Guardascione MA, Tandon P, Cachero A, Castellote J, Abraldes JG, Amitrano L, Genescà J, Augustin S. Multicenter External Validation of Risk Stratification Criteria for Patients With Variceal Bleeding. Clin Gastroenterol Hepatol 2018; 16:132-139.e8. [PMID: 28501536 DOI: 10.1016/j.cgh.2017.04.042] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 03/27/2017] [Accepted: 04/13/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Early placement of a transjugular intrahepatic portosystemic shunts (TIPS) is considered the treatment of choice for patients with acute variceal bleeding (AVB) and cirrhosis who have a high risk of death (Child-Pugh class B with active bleeding at endoscopy or Child-Pugh class C). It has been proposed that patients of Child-Pugh class B, even with active bleeding, should not be considered high risk. Alternative criteria have been proposed for identification of high-risk patients, such as Child-Pugh class C with plasma level of creatinine of 1 mg/dL or more (ChildC-C1) and a model for end-stage liver disease (MELD) score of 19 or more. We analyzed outcomes of a large cohort of patients with AVB who received the standard of care at different centers to validate these systems of risk stratification. METHODS We performed an observational study of 915 patients with liver cirrhosis and AVB who received standard treatment (drugs, antibiotics, and endoscopic ligation, with TIPS as the rescue treatment), over different time periods between 2006 and 2014 in Canada and Europe. All patients were followed until day 42 (week 6) after index AVB or death. Child-Pugh and MELD scores were calculated at time of hospital admission. The primary outcome was mortality 6 weeks after index AVB among patients who met the early TIPS criteria (Child-Pugh class B with active bleeding at endoscopy or Child-Pugh class C), MELD19 criteria (patients with MELD scores of 19 or more), and ChildC-C1 criteria. RESULTS Among 915 patients with AVB, 18% died within 6 weeks. Among the 523 patients who met the early TIPS criteria, 17% died within 6 weeks. All 3 rules discriminated patients at high risk of death from those with low risk: 28.3% of the patients classified as high risk by the early TIPS criteria died whereas only 7.0% of patients classified as low risk died; 46.0% of patients classified as high risk by the MELD19 criteria died vs 8.1% of patients classified as low risk; 51.9% of patients classified as high risk by the ChildC-C1 criteria died compared with 10.9% of patients classified as low risk. Mortality was significantly lower among patients with Child-Pugh class B (11.7%) than with Child-Pugh class C (35.6%) (P ≤ .001). Mortality was similar between patients with Child-Pugh class B cirrhosis with or without active bleeding (11.7%). Patients with Child-Pugh class A cirrhosis or MELD scores of 11 or less had low mortality (2%-4%), patients with Child-Pugh class B cirrhosis or MELD scores of 12 to 18 had intermediate mortality (10%-12%), and patients with Child-Pugh class C cirrhosis or MELD scores of 19 or more had high mortality (22%-46%). CONCLUSIONS Patients with Child-Pugh class B cirrhosis and AVB who receive standard therapy, regardless of the presence of active bleeding, have 3-fold lower mortality than patients with Child-Pugh C cirrhosis and might not need TIPS. Patients with Child-Pugh class C and/or MELD scores of 19 or more should be considered at high risk of death. These findings might help refine criteria for early TIPS.
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Affiliation(s)
- Irene Conejo
- Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Puneeta Tandon
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Canada
| | - Alba Cachero
- Gastroenterology Department, Hepatology Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomédica de Bellvitge, Universitat de Barcelona, Barcelona, Spain
| | - Josep Castellote
- Gastroenterology Department, Hepatology Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomédica de Bellvitge, Universitat de Barcelona, Barcelona, Spain
| | - Juan G Abraldes
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Canada
| | - Lucio Amitrano
- Gastroenterology Unit, AORN A. Cardarelli, Naples, Italy
| | - Joan Genescà
- Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain.
| | - Salvador Augustin
- Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain.
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Abstract
Bleeding from gastroesophageal varices is a serious complication in patients with liver cirrhosis and portal hypertension. Although there has been significance improvement in the prognosis of variceal bleeding with advancement in diagnostic and therapeutic modalities for its management, mortality rate still remains high. Therefore, appropriate prevention and rapid, effective management of bleeding from gastroesophageal varices is very important. Recently, various studies about management of gastoesophageal varices, including prevention of development and aggravation of varices, prevention of first variceal bleeding, management of acute variceal bleeding, and prevention of variceal rebleeding, have been published. The present article reviews published articles and practice guidelines to present the most optimal management of patients with gastroesophageal varices.
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Affiliation(s)
- Yeon Seok Seo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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Tag-Adeen M, Alsenbesy M, Ghweil AA, Abd Elrazek MAH, Elgohary EA, Sallam MM, Ismael A, Nawara A. Liver stiffness measurement and spleen diameter as predictors for the presence of esophageal varices in chronic hepatitis C patients. Medicine (Baltimore) 2017; 96:e8621. [PMID: 29145280 PMCID: PMC5704825 DOI: 10.1097/md.0000000000008621] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Although it is an invasive and unpleasant procedure, esophagogastroduodenoscopy (EGD) is still the gold standard for esophageal varices (EV) detection. The aim of this study was to investigate liver stiffness measurement (LSM) and spleen diameter as simple noninvasive tools for EV prediction in chronic hepatitis C patients (CHC).A total of 123 Egyptian patients with CHC have been included and were classified based on screening EGD result into 2 groups; group A (without EV) and group B (with EV). Group (B) was subclassified according to EV grade into 4 subgroups: (B1, grade I), (B2, grade II), (B3, grade III), and (B4, grade IV). LSM was taken for each patient on the next day by an independent Fibroscan operator and correlated to the EGD result. Demographic, clinical, and biochemical data were recorded and analyzed using advanced data-mining computational technology.Mean LSM was 9.94 ± 6 kPa for group A and 33.32 ± 14 kPa for group B, whereas it was 21.22 ± 3, 25.72 ± 6, 33.82 ± 8, and 46.1 ± 15 kPa for subgroups B1, B2, B3, and B4, respectively. Mean spleen diameter was 11.09 ± 1.7 cm for group A and 16.58 ± 1.6 cm for group B. However, LSM ≥17 kPa was the only independent factor for EV prediction; splenic longitudinal span ≥15 cm was a complementary predictor when LSM was <17 kPa. The overall accuracy was 98.33 ± 3.33, Mikro = 98.26%.LSM ≥17 kPa and spleen diameter ≥15 cm is a simple noninvasive algorithm that could be used for prediction of EV and discrimination among its different grades.
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Affiliation(s)
- Mohammed Tag-Adeen
- Department of Internal Medicine, Qena School of Medicine, South Valley University, Qena
| | - Mohamed Alsenbesy
- Department of Internal Medicine, Qena School of Medicine, South Valley University, Qena
| | - Ali Abdelrahman Ghweil
- Department of Tropical Medicine and Gastroenterology, Qena School of Medicine, South Valley University, Qena
| | | | - Elsayed A. Elgohary
- Department of Internal Medicine, Zagazig School of Medicine, Zagazig University, As-Sharqia, Egypt
| | - Mohammad M. Sallam
- Department of Internal Medicine, Zagazig School of Medicine, Zagazig University, As-Sharqia, Egypt
| | - Ali Ismael
- Department of Internal Medicine, Zagazig School of Medicine, Zagazig University, As-Sharqia, Egypt
| | - Abdallah Nawara
- Department of Internal Medicine, Zagazig School of Medicine, Zagazig University, As-Sharqia, Egypt
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Suboptimal Implementation of Evidence-based Therapy for Acute Variceal Hemorrhage: A Systematic Review of Observational Studies. Clin Gastroenterol Hepatol 2017; 15:1373-1381.e7. [PMID: 28249809 DOI: 10.1016/j.cgh.2017.02.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 02/08/2017] [Accepted: 02/21/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Gastroenterologists should strive to improve the outcomes associated with acute variceal hemorrhage (AVH) by optimizing care delivery and clinician preparedness through training. Unfortunately, data regarding contemporary outcomes and management of AVH are limited. METHODS We performed a systematic review of cohort studies examining outcomes and management of AVH from January 1990 to September 2016. We pooled data on mortality and utilization of medical therapy, endoscopic interventions, balloon tamponade (BT), and salvage procedures (portal decompressive surgery or transjugular portosystemic shunt). RESULTS The pooled 6-week mortality rate after AVH was 17.7% (95% confidence interval [CI], 14.4%-21.7%). Sclerotherapy was used in 18.7% of cases (95% CI, 9.2%-34.3%), and no endoscopic intervention was provided in 14.3% of patients (95% CI, 9.7%-20.6%). The overall rate of BT use was 10.8% (95% CI, 8.2%-14.1%). Salvage procedures were used in 5.7% (95% CI, 3.7%-8.6%), falling to 1.7% (95% CI, 0.7%-3.8%) among patients treated after 2000. Although pooled rates of timely endoscopy and vasoactive medication use were high (85.8% and 83.0%, respectively), only half of patients received prophylactic antibiotics (52.8%; 95% CI, 40.0%-66.2%). In studies that enrolled patients exclusively after 2000, 13.8% of patients (95% CI, 7.0%-25.4%) received sclerotherapy, salvage transjugular portosystemic shunt fell to 1.7% (95% CI, 0.7%-3.8%), BT use fell slightly to 8.7% (95% CI, 6.4%-11.6%), and vasoactive medication and prophylactic antibiotic use rose to 91.4% (95% CI, 86.0%-94.9%) and 62.7% (95% CI, 48.9%-74.9%), respectively. CONCLUSIONS AVH is associated with high mortality rates and suboptimal implementation of evidence-based therapies including prophylactic antibiotics and endoscopic interventions, suggesting a need for quality improvement. In addition, the frequent need for BT and sclerotherapy suggests that specific attention to these procedures in gastroenterology training curricula may be warranted.
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Application of chronic liver failure-sequential organ failure assessment score for the predication of mortality after esophageal variceal hemorrhage post endoscopic ligation. PLoS One 2017; 12:e0182529. [PMID: 28767684 PMCID: PMC5540601 DOI: 10.1371/journal.pone.0182529] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 07/19/2017] [Indexed: 12/21/2022] Open
Abstract
Background Esophageal variceal hemorrhage (EVH) is one of the high mortality complications in cirrhotic patients. Endoscopic variceal ligation (EVL) is currently the standard therapy for EVH. However, some patients have expired during hospitalization or survived shortly after management. Aim To evaluate hospital and 6-week mortality by receiver operating characteristic (ROC) curve of chronic liver failure-sequential organ failure assessment (CLIF-SOFA) score compared to a model for end-stage liver disease (MELD) score and Child–Turcotte–Pugh (CTP) class. Methods We retrospectively collected 714 cirrhotic patients with EVH post EVL between July 2010 and June 2016 at Taitung MacKay Memorial Hospital, Taiwan. CLIF-SOFA score, MELD score, and CTP class were calculated for all patients admitted. Results Among the 714 patients, the overall hospital and 6-week mortality rates were 6.9% (49/715) and 13.1% (94/715) respectively. For predicting hospital death, area under receiver operating characteristic curve (AUROC) values of CLIF-SOFA score, MELD score, and CTP class were 0.964, 0.876, and 0.846. For predicting 6-week death, AUROC values of CLIF-SOFA score, MELD score, and CTP class were 0.943, 0.817, and 0.834. CLIF-SOFA score had higher AUROC value with statistical significance under pairwise comparison than did MELD score and CTP class in prediction of not only hospital but also 6-week mortality. The history of hepatocellular carcinoma was the risk factor for 6-week mortality. For patients with hepatocellular carcinoma the cut-point of CLIF-SOFA score was 5.5 for 6-week mortality and 6.5 for hospital mortality on admission. For patients without hepatocellular carcinoma, the cut-point of CLIF-SOFA score was 6.5 for both 6-week and hospital mortality. Conclusion CLIF-SOFA score predicted post-EVL prognosis well. For patients without hepatocellular carcinoma, CLIF-SOFA score ≥6 suggests higher 6-week mortality and CLIF-SOFA score ≥7 suggests higher hospital mortality. For patients with hepatocellular carcinoma, CLIF-SOFA score ≥7 suggests higher 6-week and hospital mortality.
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Kim SG, Kim TY, Sohn JH, Um SH, Seo YS, Baik SK, Kim MY, Jang JY, Jeong SW, Lee B, Kim YS, Suk KT, Kim DJ. A Randomized, Multi-Center, Open-Label Study to Evaluate the Efficacy of Carvedilol vs. Propranolol to Reduce Portal Pressure in Patients With Liver Cirrhosis. Am J Gastroenterol 2016; 111:1582-1590. [PMID: 27575713 DOI: 10.1038/ajg.2016.327] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 07/03/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Propranolol has been used as prophylaxis for variceal bleeding in patients with cirrhosis. More recent data suggest that carvedilol may be more effective for reducing the hepatic venous pressure gradient (HVPG) than propranolol. The primary aim of this study was to evaluate the hemodynamic response to carvedilol compared with propranolol. METHODS A total of 110 patients with a baseline HVPG value >12 mm Hg were allocated randomly to receive either carvedilol or propranolol. The HVPG measurement was repeated after 6 weeks of daily medication. The primary end point was a ≥20% fall in HVPG compared with baseline or <12 mm Hg. RESULTS The difference in the proportion of responders in the carvedilol (49.1%) vs. propranolol (30.9%) groups did not reach statistical significance in the intention-to-treat analysis (P=0.08). However, among patients with a model for end-stage liver disease (MELD) score ≥15, carvedilol resulted in a significantly greater response than that of propranolol (7/12, 58.3% vs. 0/10, 0%; P=0.005). Similarly, carvedilol was superior to propranolol in patients with Child-Pugh score ≥9 (46.2 vs. 0%; P=0.046). The presence of ascites also had a significant influence on the response rate (51.5 vs. 24.2%; P=0.042). A MELD score ≥15 was the only significant predictor of response among these post hoc groups after adjusting for multiple comparisons (P=0.005). Severe adverse events were higher in the carvedilol group although drug-associated adverse events were not different. CONCLUSIONS Overall, carvedilol offered no clear advantage over propranolol but it may be more effective in advanced cirrhotic patients with a MELD score≥15 in reducing the portal pressure gradient. However, this potential benefit may come with a cost of increased risk of side-effects and outcome data over a longer term is needed to understand the relative risk benefit.
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Affiliation(s)
- Sang G Kim
- Division of Gastroenterology and Hepatology, Soonchunhyang University College of Medicine, Bucheon, Korea.,SGK and TYK equally contributed to the manuscript
| | - Tae Y Kim
- Institute of Medical Science, Hanyang University, Seoul, Korea.,SGK and TYK equally contributed to the manuscript
| | - Joo H Sohn
- Division of Gastroenterology and Hepatology, Hanyang University College of Medicine, Guri, Korea
| | - Soon H Um
- Division of Gastroenterology and Hepatology, Korea University College of Medicine, Seoul, Korea
| | - Yeon S Seo
- Division of Gastroenterology and Hepatology, Korea University College of Medicine, Seoul, Korea
| | - Soon K Baik
- Division of Gastroenterology and Hepatology, Yonsei University College of Medicine, Wonju, Korea
| | - Moon Y Kim
- Division of Gastroenterology and Hepatology, Yonsei University College of Medicine, Wonju, Korea
| | - Jae Y Jang
- Division of Gastroenterology and Hepatology, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Soung W Jeong
- Division of Gastroenterology and Hepatology, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Bora Lee
- Department of Biostatistic Consulting, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Young S Kim
- Division of Gastroenterology and Hepatology, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Ki T Suk
- Division of Gastroenterology and Hepatology, Hallym University College of Medicine, Chuncheon, Korea
| | - Dong J Kim
- Division of Gastroenterology and Hepatology, Hallym University College of Medicine, Chuncheon, Korea
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No difference in mortality between terlipressin and somatostatin treatments in cirrhotic patients with esophageal variceal bleeding and renal functional impairment. Eur J Gastroenterol Hepatol 2016; 28:1275-9. [PMID: 27455080 PMCID: PMC5051540 DOI: 10.1097/meg.0000000000000703] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To study the differences in mortality between terlipressin and somatostatin treatments in cirrhotic patients with esophageal variceal bleeding (EVB) and renal functional impairment (RFI). METHODS The National Health Insurance Database, part of the Taiwan National Health Insurance Program, was used to enroll cirrhotic patients who had received endoscopic variceal ligation plus somatostatin or terlipressin for EVB and who were hospitalized between 1 January 2007 and 31 December 2010. The differences in mortality between the two vasoactive agents were compared and the risk factors for 30-day mortality because of EVB were identified. RESULTS A total of 2324 cirrhotic patients with EVB were enrolled. The 30-day mortality data showed no significant differences between the somatostatin and the terlipressin groups (P=0.232). The risk of 30-day mortality was significantly higher in male patients [hazard ratio (HR): 1.50, P=0.002] and patients with hepatic encephalopathy (HR: 1.82, P<0.001), ascites (HR: 1.32, P=0.008), bacterial infections (HR: 2.10, P<0.001), hepatocellular carcinoma (HR: 2.09, P<0.001), and RFI (HR: 3.89, P<0.001). A subgroup analysis of cirrhotic patients with RFI was carried out. The overall 30-day mortality was higher in patients treated with somatostatin than in those treated with terlipressin (52.6 vs. 42.3%), but the difference failed to reach significance (adjust HR: 1.49, 95% confidence interval: 0.94-2.37, P=0.091). CONCLUSION RFI was the most important risk factor for 30-day mortality in EVB patients. Terlipressin and somatostatin had similar effects on 30-day mortality in cirrhotic patients with EVB and RFI.
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Ribeiro JP, Matuguma SE, Cheng S, Herman P, Sakai P, D'Albuquerque LAC, Maluf-Filho F. Results of treatment of esophageal variceal hemorrhage with endoscopic injection of n-butyl-2-cyanoacrylate in patients with Child-Pugh class C cirrhosis. Endosc Int Open 2015; 3:E584-9. [PMID: 26716117 PMCID: PMC4683151 DOI: 10.1055/s-0034-1392600] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 06/16/2015] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND AND STUDY AIMS The results of endoscopic treatment with elastic band ligation for esophageal variceal bleeding in patients with Child-Pugh class C cirrhosis remain poor. In comparison with treatment with elastic band ligation, we have found lower rates of rebleeding and mortality with n-butyl-2-cyanoacrylate injections. Thus, the aim of the current study was to describe our unit's 10 years of experience with injection of n-butyl-2-cyanoacrylate to control esophageal variceal ruptures in patients with Child-Pugh class C cirrhosis. PATIENTS AND METHODS A single-center, retrospective study was conducted. Sixty-three patients with Child-Pugh class C cirrhosis had been admitted to the center with an acute episode of esophageal variceal bleeding. All were treated with injection of n-butyl-2-cyanoacrylate. The patients were assigned to 1 of 2 groups according to their Child-Pugh class C cirrhosis scores: group I (score range, 10 through 13 points) and group II (score, 14 or 15 points). The 3 variables studied were rates of initial failure to control bleeding, failure to prevent rebleeding (secondary prophylaxis), and mortality. Patients in the 2 groups (group I, n = 50; group II, n = 13) had similar characteristics. RESULTS Bleeding was successfully controlled in almost 75 % of the patients during the first 5 days after treatment, with no significant differences observed between groups I and II. There were no significant differences between the 2 groups with respect to mortality rate for the first 5 days after treatment. Thirty-four patients (54 %) were free of bleeding at 6 weeks after treatment, with a significant difference noted between the groups: group I, 64 %, versus group II, 15.4 % (P < 0.001). The overall mortality rate was 44.4 %, with a significant difference noted between the groups: group I, 34 %, versus group II, 84.6 % (P < 0.001). CONCLUSION Endoscopic injection of n-butyl-2-cyanoacrylate is a valid treatment option to control esophageal variceal bleeding in patients with a Child-Pugh class C cirrhosis score in the range of 10 through 13 points.
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Affiliation(s)
- Joao Paulo Ribeiro
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | | | - Spencer Cheng
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | - Paulo Herman
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | - Paulo Sakai
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil,Laboratory of Investigation of University of São Paulo – LIM37, São Paulo, Brazil
| | - Luiz Augusto Carneiro D'Albuquerque
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil,Laboratory of Investigation of University of São Paulo – LIM37, São Paulo, Brazil
| | - Fauze Maluf-Filho
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil,Laboratory of Investigation of University of São Paulo – LIM37, São Paulo, Brazil,Corresponding author Fauze Maluf-Filho, MD, PhD Av. Brigadeiro Luis Antonio, 4161CEP 01402-001São Paulo – SPBrazil+55-11-3884-7599
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de Souza AR, La Mura V, Berzigotti A, García-Pagán JC, Abraldes JG, Bosch J. Prognosis of acute variceal bleeding: Is being on beta-blockers an aggravating factor? A short-term survival analysis. Hepatology 2015; 62:1840-6. [PMID: 26340692 DOI: 10.1002/hep.28151] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 09/01/2015] [Indexed: 12/13/2022]
Abstract
UNLABELLED Nonselective beta-blockers (NSBB) are widely used because they have been proved effective in the prophylaxis of acute variceal bleeding (AVB). However, a significant proportion of patients still experience AVB while on treatment with NSBB, and its impact on prognosis of AVB is unknown. The present study was aimed at assessing the effect of being on prophylactic therapy with NSBB on 5-day failure and 6-week mortality of patients with cirrhosis admitted with AVB. Included were 142 patients: 49 were receiving prophylactic therapy with NSBB (NSBB group) and 93 were not (control group). There were some differences in the baseline characteristics between the groups: higher proportion of alcoholic etiology and active alcoholism (37% versus 10%), higher platelet count, and lower hematocrit at admission in the control group. However, the severity of AVB and initial treatment were similar. Five-day failure occurred in 20% of patients (14% in NSBB versus 24% in controls, P = 0.27). The adjusted odds ratio for 5-day failure under NSBB was 2.46 (95% confidence interval 0.53-11.37, P = 0.25). Nineteen patients (13%) died, and two had liver transplantation within 6 weeks. The probability of survival at 6 weeks was 96% in the NSBB group and 82% in the control group (P = 0.02). After adjusting by propensity score and Model for End-Stage Liver Disease score, the NSBB adjusted odds ratio for 6-week mortality was 0.38 (95% confidence interval 0.05-2.63, P = 0.32). The estimated association between NSBB with both 5-day failure and 6-week mortality was homogenous across all Model for End-Stage Liver Disease spectrums. CONCLUSION Prophylactic NSBB treatment is not a negative prognostic indicator for the short-term survival of patients with cirrhosis admitted with AVB.
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Affiliation(s)
- Andrea Ribeiro de Souza
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic-IDIBAPS, University of Barcelona and Centro de Investigación, Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Vincenzo La Mura
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic-IDIBAPS, University of Barcelona and Centro de Investigación, Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Annalisa Berzigotti
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic-IDIBAPS, University of Barcelona and Centro de Investigación, Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Juan Carlos García-Pagán
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic-IDIBAPS, University of Barcelona and Centro de Investigación, Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Juan G Abraldes
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic-IDIBAPS, University of Barcelona and Centro de Investigación, Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Jaime Bosch
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic-IDIBAPS, University of Barcelona and Centro de Investigación, Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
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Vlaisavljević Ž, Popović D, Balović A. Gender, Age, Etiology, and Complications in Liver Transplant Candidates. Gastroenterol Nurs 2015; 38:379-383. [PMID: 26422272 DOI: 10.1097/sga.0000000000000132] [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] [Indexed: 11/26/2022] Open
Abstract
Liver cirrhosis is the end stage of chronic liver disease (CLD), which is characterized by the appearance of fibrosis and regenerated nodules. It can be caused by different etiological factors. The only therapeutic modality is liver transplantation. The objective of this study was to describe the basic demographic characteristics, etiology, and complications of CLD in liver transplant candidates in patients of both genders. Autoimmune chronic disease was significantly more frequent in females (p = .022), whereas alcoholic liver disease was more frequent in males (p = .038). There was no difference between gender in other causes of CLD. Ascites was significantly higher in males (p = .041), whereas for other complications there was no difference between genders. Candidates for liver transplantation of different genders are different in the frequency of autoimmune and alcoholic liver disease, and the frequency of ascites. Frequency of other etiologies and complications does not relate to gender.
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Affiliation(s)
- Željko Vlaisavljević
- Željko Vlaisavljević, BS, RN, HCM, is Senior Nurse, Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia. Dušan Popović, MD, is Specialist, Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia. Ana Balović, MD, is Medical Doctor, Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia
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Ribeiro JP, Matuguma SE, Cheng S, Herman P, Sakai P, D'Albuquerque LAC, Maluf-Filho F. Results of treatment of esophageal variceal hemorrhage with endoscopic injection of n-butyl-2-cyanoacrylate in patients with Child-Pugh class C cirrhosis. Endosc Int Open 2015. [PMID: 26716117 DOI: 10.1055/s-0034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS The results of endoscopic treatment with elastic band ligation for esophageal variceal bleeding in patients with Child-Pugh class C cirrhosis remain poor. In comparison with treatment with elastic band ligation, we have found lower rates of rebleeding and mortality with n-butyl-2-cyanoacrylate injections. Thus, the aim of the current study was to describe our unit's 10 years of experience with injection of n-butyl-2-cyanoacrylate to control esophageal variceal ruptures in patients with Child-Pugh class C cirrhosis. PATIENTS AND METHODS A single-center, retrospective study was conducted. Sixty-three patients with Child-Pugh class C cirrhosis had been admitted to the center with an acute episode of esophageal variceal bleeding. All were treated with injection of n-butyl-2-cyanoacrylate. The patients were assigned to 1 of 2 groups according to their Child-Pugh class C cirrhosis scores: group I (score range, 10 through 13 points) and group II (score, 14 or 15 points). The 3 variables studied were rates of initial failure to control bleeding, failure to prevent rebleeding (secondary prophylaxis), and mortality. Patients in the 2 groups (group I, n = 50; group II, n = 13) had similar characteristics. RESULTS Bleeding was successfully controlled in almost 75 % of the patients during the first 5 days after treatment, with no significant differences observed between groups I and II. There were no significant differences between the 2 groups with respect to mortality rate for the first 5 days after treatment. Thirty-four patients (54 %) were free of bleeding at 6 weeks after treatment, with a significant difference noted between the groups: group I, 64 %, versus group II, 15.4 % (P < 0.001). The overall mortality rate was 44.4 %, with a significant difference noted between the groups: group I, 34 %, versus group II, 84.6 % (P < 0.001). CONCLUSION Endoscopic injection of n-butyl-2-cyanoacrylate is a valid treatment option to control esophageal variceal bleeding in patients with a Child-Pugh class C cirrhosis score in the range of 10 through 13 points.
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Affiliation(s)
- Joao Paulo Ribeiro
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | | | - Spencer Cheng
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | - Paulo Herman
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | - Paulo Sakai
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil ; Laboratory of Investigation of University of São Paulo - LIM37, São Paulo, Brazil
| | - Luiz Augusto Carneiro D'Albuquerque
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil ; Laboratory of Investigation of University of São Paulo - LIM37, São Paulo, Brazil
| | - Fauze Maluf-Filho
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil ; Laboratory of Investigation of University of São Paulo - LIM37, São Paulo, Brazil
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Sinclair M, Vaughan R, Angus PW, Gow PJ, Parker F, Hey P, Efthymiou M. Risk factors for band-induced ulcer bleeding after prophylactic and therapeutic endoscopic variceal band ligation. Eur J Gastroenterol Hepatol 2015; 27:928-932. [PMID: 25951490 DOI: 10.1097/meg.0000000000000387] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Endoscopic variceal band ligation (EVBL) aims to eradicate high-risk oesophageal varices. There is a small risk of precipitating bleeding from EVBL-induced oesophageal ulceration, which is associated with significant mortality. We explore the risk factors and outcome of EVBL-induced ulcer bleeding. METHODS Retrospective review of our endoscopy database between 2007 and 2012 identified upper endoscopies during which EVBL was performed. Patient demographics, biochemistry and endoscopic findings were recorded as were the complications of EVBL-induced ulcer bleeding and death. RESULTS A total of 749 episodes of EVBL were performed in 347 patients with a mean Model for End-stage Liver Disease (MELD) score of 15.8. In all, 609 procedures were performed for prophylaxis and 140 for acute haemorrhage. There were 21 episodes (2.8% of procedures) of EVBL-induced ulcer bleeding in 18 patients, five of whom subsequently died (28%). On multivariable analysis, acute variceal haemorrhage was the only significant predictor of EVBL-induced ulcer bleeding [odds ratio (OR) 6.25 (2.57-15.14), P<0.0001]. In 609 procedures performed for prophylaxis, the EVBL-induced ulcer bleeding rate was 1.5%, with 22% mortality. In this group, higher MELD score and reflux oesophagitis were associated significantly with EVBL-induced ulcer bleeding [OR 25.53 (2.14-303.26), P=0.010 and OR 1.07 (1.01-1.13), P=0.019, respectively]. CONCLUSION Our EVBL-induced ulcer bleeding rate was low, but associated with significant mortality. Highest rates were observed following EVBL for acute variceal haemorrhage, for which EVBL is unavoidable. The incidence was lower following prophylactic EVBL, with the MELD score being the predominant risk factor. Reflux oesophagitis requires further investigation as a potentially modifiable risk factor for EVBL-induced ulcer bleeding.
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Affiliation(s)
- Marie Sinclair
- aGastroenterology and Liver Transplant Unit, Austin Hospital bDepartment of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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Marinho RT, Duarte H, Gíria J, Nunes J, Ferreira A, Velosa J. The burden of alcoholism in fifteen years of cirrhosis hospital admissions in Portugal. Liver Int 2015; 35:746-55. [PMID: 24750642 DOI: 10.1111/liv.12569] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 04/17/2014] [Indexed: 12/27/2022]
Abstract
BACKGROUND & AIMS Deploying a longitudinal perspective, we observe how cirrhosis caused mortality rates in Portugal are converging with the levels reported in the European Union (15 countries). However, we still lack analysis of the burden of alcoholic cirrhosis in terms of hospital admissions and associated mortality. As Portugal may be considered a paradigmatic case in Europe, our aim was to characterize the evolution of hospital admissions for alcoholic cirrhosis between 1993 and 2008 and draw conclusions for other countries. METHODS Retrospective analysis of the hepatic cirrhosis admissions in 97 Portuguese state hospitals was carried out based on the National Registry. RESULTS We report a convergence in terms of mortality rates resulting from cirrhosis between Portugal and European Union (a differential of 6.7 deaths per 100 000 habitants in 1994 to 0.4 in 2008). We accounted for 81 543 hospital admissions for cirrhosis: 84% for alcoholic cirrhosis and 16% for non-alcoholic cirrhosis. Hospital admissions have increased 29% in men and with no increase in women. In the male, alcoholic cirrhosis patient group aged between 40 and 54, the rise in hospital admissions was more pronounced with an increase of around 45%. These patients underwent longer lengths of stay and reported higher mortality rates and passing away 20 years earlier than the average national expectancy of life. CONCLUSIONS These data draw attention to the burden of alcohol consumption not only in Portugal but also in other countries and its impacts on hospital systems and on policy making.
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Affiliation(s)
- Rui T Marinho
- Department of Gastroenterology and Hepatology, University Hospital of Santa Maria, Medical School of Lisbon, Lisbon, Portugal
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Hshieh TT, Kaung A, Hussain S, Curry MP, Sundaram V. The international normalized ratio does not reflect bleeding risk in esophageal variceal hemorrhage. Saudi J Gastroenterol 2015; 21:254-8. [PMID: 26228370 PMCID: PMC4542425 DOI: 10.4103/1319-3767.161646] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND/AIMS The international normalized ratio (INR) has not been validated as a predictor of bleeding risk in cirrhotics. The aim of this study was to determine whether elevation in the INR correlated with risk of esophageal variceal hemorrhage and whether correction of the INR prior to endoscopic therapy affects failure to control bleeding. PATIENTS AND METHODS Patient records were retrospectively reviewed from January 1, 2000 to December 31, 2010. Cases were cirrhotics admitted to the hospital due to bleeding esophageal varices. Controls were cirrhotics with a history of non-bleeding esophageal varices admitted with ascites or encephalopathy. All variceal bleeders were treated with octreotide, antibiotics, and band ligation. Failure to control bleeding was defined according to the Baveno V criteria. RESULTS We analyzed 74 cases and 74 controls. The mean INR at presentation was lower in those with bleeding varices compared to non-bleeders (1.61 vs 1.74, P = 0.03). Those with bleeding varices had higher serum sodium (136.1 vs 133.8, P = 0.02), lower hemoglobin (9.59 vs 11.0, P < 0.001), and lower total bilirubin (2.47 vs 5.50, P < 0.001). Multivariable logistic regression showed total bilirubin to inversely correlate with bleeding (OR = 0.74). Bleeders received a mean of 1.14 units of fresh frozen plasma (FFP) prior to endoscopy (range 0-11 units). Of the 14 patients (20%) with failure to control bleeding, median INR (1.8 vs 1.5, P = 0.02) and median units of FFP transfused (2 vs 0, P = 0.01) were higher than those with hemostasis after the initial endoscopy. CONCLUSIONS The INR reflects liver dysfunction, not bleeding risk. Correction of INR with FFP has little effect on hemostasis.
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Affiliation(s)
- Tammy T. Hshieh
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston Massachusetts, US
| | - Aung Kaung
- Department of Medicine and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, US
| | - Syed Hussain
- Division of Digestive Diseases, University of Cincinnati College of Medicine, Cincinnati, Ohio, US
| | - Michael P. Curry
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston Massachusetts, US
| | - Vinay Sundaram
- Department of Medicine and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, US,Address for correspondence: Dr. Vinay Sundaram, 8900 Beverly Boulevard, Los Angeles, CA 90048. E-mail:
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Bettinger D, Knüppel E, Euringer W, Spangenberg HC, Rössle M, Thimme R, Schultheiß M. Efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPSS) in 40 patients with hepatocellular carcinoma. Aliment Pharmacol Ther 2015; 41:126-36. [PMID: 25329493 DOI: 10.1111/apt.12994] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 07/23/2014] [Accepted: 09/29/2014] [Indexed: 01/17/2023]
Abstract
BACKGROUND Portal hypertension and hepatocellular carcinoma (HCC) are major complications of advanced liver cirrhosis. Thus, patients are often affected by both complications. Transjugular intrahepatic portosystemic shunt (TIPSS) is an effective treatment for portal hypertension and its complications. However, no established guidelines for the treatment of symptomatic portal hypertension in HCC patients are currently available. In addition, only limited information exists about the consequence of TIPSS implantation in patients with HCC. AIM To evaluate the efficacy, safety and overall survival in HCC patients who underwent TIPSS implantation. METHODS Forty HCC patients with portal hypertension who were treated with TIPSS between 1995 and 2012 were included in the analysis. Medical records and imaging studies were analysed. The indication for TIPSS implantation, procedure-related complications, treatment success and overall survival were assessed. RESULTS TIPSS implantation was performed in 23 patients (57.5%) due to treatment refractory ascites, in 14 patients (35.0%) due to recurrent variceal bleeding and in three patients (7.5%) due to ascites and variceal bleeding. Primary technical success was assessed in all patients. After TIPSS implantation, no variceal bleeding reoccurred and ascites was controlled in 74.1%. No severe procedure-related complications and no deterioration of liver function were observed. Post-TIPSS hepatic encephalopathy occurred in 40.0% of all patients. 30-day, 90-day-, 1-year- and 5-year survival rates were 97.5%, 75.0%, 42.5% and 7.5%, respectively. Median overall survival after TIPSS implantation was 180 days. CONCLUSION Transjugular intrahepatic portosystemic shunt implantation is an effective and safe treatment for portal hypertension in patients with HCC.
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Affiliation(s)
- D Bettinger
- Department of Medicine II, University Hospital Freiburg, Freiburg, Germany
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Kumar AS, Sibia RS. Predictors of in-hospital mortality among patients presenting with variceal gastrointestinal bleeding. Saudi J Gastroenterol 2015; 21:43-6. [PMID: 25672238 PMCID: PMC4355862 DOI: 10.4103/1319-3767.151226] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIM The recent years have witnessed an increase in number of people harboring chronic liver diseases. Gastroesophageal variceal bleeding occurs in 30% of patients with cirrhosis, and accounts for 80%-90% of bleeding episodes. We aimed to assess the in-hospital mortality rate among subjects presenting with variceal gastrointestinal bleeding and (2) to investigate the predictors of mortality rate among subjects presenting with variceal gastrointestinal bleeding. PATIENTS AND METHODS This retrospective study was conducted from treatment records of 317 subjects who presented with variceal upper gastrointestinal bleeding to Government Medical College, Patiala, between June 1, 2010, and May 30, 2014. The data thus obtained was compiled using a preset proforma, and the details analyzed using SPSSv20. RESULTS Cirrhosis accounted for 308 (97.16%) subjects with bleeding varices, with extrahepatic portal vein obstruction 9 (2.84%) completing the tally. Sixty-three (19.87%) subjects succumbed to death during hospital stay. Linear logistic regression revealed independent predictors for in-hospital mortality, including higher age (P = 0.000), Child-Pugh Class (P = 0.002), altered sensorium (P = 0.037), rebleeding within 24 h of admission (P = 0.000), low hemoglobin level (P = 0.023), and serum bilirubin (P = 0.002). CONCLUSION Higher age, low hemoglobin, higher Child-Pugh Class, rebleeding within 24 h of admission, higher serum bilirubin, and lower systolic blood pressure are the independent predictors of in-hospital mortality among subjects presenting with variceal gastrointestinal bleeding.
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Affiliation(s)
- Amith S. Kumar
- Department of Internal Medicine, Rajindra Hospital/Government Medical College, Patiala, Punjab, India
| | - Raminderpal S. Sibia
- Department of Internal Medicine, Rajindra Hospital/Government Medical College, Patiala, Punjab, India,Address for correspondence: Asst. Prof. Raminderpal Singh Sibia, Department of Internal Medicine, Rajindra Hospital/Government Medical College, Patiala - 147 001, Punjab, India. E-mail:
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Wang C, Han J, Xiao L, Jin CE, Li DJ, Yang Z. Efficacy of vasopressin/terlipressin and somatostatin/octreotide for the prevention of early variceal rebleeding after the initial control of bleeding: a systematic review and meta-analysis. Hepatol Int 2014; 9:120-9. [PMID: 25788386 DOI: 10.1007/s12072-014-9594-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 11/10/2014] [Indexed: 01/10/2023]
Abstract
PURPOSE Our purpose was to conduct a meta-analysis to compare the effectiveness of vasopressin/terlipressin and somatostatin/octreotide on variceal re-bleeding within and after 5 days of initial control bleeding. METHODS A search was conducted of PubMed, the Cochrane database, and Google Scholar until June 31, 2014 using combinations of the search terms: esophageal varices, variceal re-bleeding, recurrent variceal hemorrhage, early re-bleeding, vasopressin, somatostatin, terlipressin, octreotide. Inclusion criteria were: (1) randomized controlled trials, (2) patients with esophageal or esophageal and gastric varices confirmed by endoscopy, (3) re-bleeding control was evaluated, (4) treatment with somatostatin/vasopressin. Outcome measures were the re-bleeding rates within 5 days (≤ 5 days) or after 5 days (>5 days) after initial treatment. RESULTS Six studies were included in the analysis. Five studies had complete data of re-bleeding rate within 5 days after initial treatment, and the combined odds ratio (OR) of 0.87 [95% confidence interval (CI) 0.51, 1.50] indicated that there was no difference in the re-bleeding rate between patients treated with vasopressin/terlipressin or somatostatin/octreotide. Two studies had complete data of the re-bleeding rate 5 days after initial treatment, and the combined OR of 1.12 (95% CI 0.64, 1.95) indicated there was no difference in the re-bleeding rate between patients who were treated with vasopressin/terlipressin or somatostatin/octreotide. CONCLUSION There is no difference between vasopressin/terlipressin and somatostatin/octreotide in prevention of re-bleeding after the initial treatment of bleeding esophageal varices.
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Affiliation(s)
- Chao Wang
- Department of General Surgery, Tongji Hospital, Tongji Medical College, Science and Technology of Huazhong University, No. 1095 Liberation Avenue, Wuhan, 430030, China,
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Epidemiology, diagnosis and early patient management of esophagogastric hemorrhage. Gastroenterol Clin North Am 2014; 43:765-82. [PMID: 25440924 DOI: 10.1016/j.gtc.2014.08.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Acute variceal bleeding (AVB) is a potentially life-threatening complication of cirrhosis and portal hypertension. Combination therapy with vasoactive drugs and endoscopic variceal ligation is the first-line treatment in the management of AVB after adequate hemodynamic resuscitation. Short-term antibiotic prophylaxis, early resuscitation, early use of lactulose for prevention of hepatic encephalopathy, targeting of conservative goals for blood transfusion, and application of early transjugular intrahepatic portosystemic shunts in patients with AVB have further improved the prognosis of AVB. This article discusses the epidemiology, diagnosis, and nonendoscopic management of AVB.
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Higher free serum cortisol is associated with worse survival in acute variceal bleeding because of cirrhosis: a prospective study. Eur J Gastroenterol Hepatol 2014; 26:1125-32. [PMID: 25089543 DOI: 10.1097/meg.0000000000000158] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Critical illness-related corticosteroid insufficiency has been reported in acute variceal bleeding (AVB). In cirrhosis, free serum cortisol (FC) is considered optimal to assess adrenal function. Salivary cortisol (SC) is considered a surrogate for FC. We evaluated FC and its prognostic role in AVB. METHODS Total serum cortisol, SC, cortisol-binding globulin, and FC (Coolens' formula) were evaluated in AVB (n=38) and in stable cirrhosis (CC) (n=31). A Cox proportional hazards model was evaluated for 6-week survival. RESULTS In AVB, the median FC and SC levels were higher with worse liver dysfunction [Child-Pugh (CP) A/B/C: 1.59/2.62/3.26 μg/dl, P=0.019; CPA/B/C: 0.48/0.897/1.81 μg/ml, P<0.001, respectively]. In AVB compared with CC, median total serum cortisol: 24.3 versus 11.6 μg/dl (P<0.001), SC: 0.86 versus 0.407 μg/ml (P<0.001); FC 2.4 versus 0.57 μg/dl (P<0.001). In AVB, 5-day rebleeding was 10.5%, and 6-week and total mortality were 21.1 and 23.7%, respectively. Independent associations with 6-week mortality in AVB were FC at least 3.2 μg/dl (P<0.001), hepatocellular carcinoma (P<0.001), CPC (P<0.001), and early rebleeding (P<0.001). Among patients with normal cortisol-binding globulin (n=14) and albumin (n=31), the factors were hepatocellular carcinoma (P=0.003), CP (P=0.003), and FC (P=0.036). SC was also found to be an independent predictor of 6-week mortality (P<0.001). Area under the curve of FC for predicting 6-week mortality was 0.79. CONCLUSION Higher FC is present in cirrhosis with AVB compared with CC and is associated independently with bleeding-related mortality. However, whether high FC solely indicates the severity of illness or whether there is significant adrenal insufficiency cannot be discerned.
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Triantos C, Kalafateli M. Endoscopic treatment of esophageal varices in patients with liver cirrhosis. World J Gastroenterol 2014; 20:13015-13026. [PMID: 25278695 PMCID: PMC4177480 DOI: 10.3748/wjg.v20.i36.13015] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 01/15/2014] [Accepted: 05/26/2014] [Indexed: 02/06/2023] Open
Abstract
Variceal bleeding is a life-threatening complication of portal hypertension with a six-week mortality rate of approximately 20%. Patients with medium- or large-sized varices can be treated for primary prophylaxis of variceal bleeding using two strategies: non-selective beta-blockers (NSBBs) or endoscopic variceal ligation (EVL). Both treatments are equally effective. Patients with acute variceal bleeding are critically ill patients. The available data suggest that vasoactive drugs, combined with endoscopic therapy and antibiotics, are the best treatment strategy with EVL being the endoscopic procedure of choice. In cases of uncontrolled bleeding, transjugular intrahepatic portosystemic shunt (TIPS) with polytetrafluoroethylene (PTFE)-covered stents are recommended. Approximately 60% of the patients experience rebleeding, with a mortality rate of 30%. Secondary prophylaxis should start on day six following the initial bleeding episode. The combination of NSBBs and EVL is the recommended management, whereas TIPS with PTFE-covered stents are the preferred option in patients who fail endoscopic and pharmacologic treatment. Apart from injection sclerotherapy and EVL, other endoscopic procedures, including tissue adhesives, endoloops, endoscopic clipping and argon plasma coagulation, have been used in the management of esophageal varices. However, their efficacy and safety, compared to standard endoscopic treatment, remain to be further elucidated. There are safety issues accompanying endoscopic techniques with aspiration pneumonia occurring at a rate of approximately 2.5%. In conclusion, future research is needed to improve treatment strategies, including novel endoscopic techniques with better efficacy, lower cost, and fewer adverse events.
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Seo YS, Park SY, Kim MY, Kim JH, Park JY, Yim HJ, Jang BK, Kim HS, Hahn T, Kim BI, Heo J, An H, Tak WY, Baik SK, Han KH, Hwang JS, Park SH, Cho M, Um SH. Lack of difference among terlipressin, somatostatin, and octreotide in the control of acute gastroesophageal variceal hemorrhage. Hepatology 2014; 60:954-63. [PMID: 24415445 DOI: 10.1002/hep.27006] [Citation(s) in RCA: 138] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 01/05/2014] [Indexed: 12/26/2022]
Abstract
UNLABELLED Vasoactive drugs are recommended to be started as soon as possible in suspected variceal bleeding, even before diagnostic endoscopy. However, it is still unclear whether the therapeutic efficacies of the various vasoactive drugs used are comparable. The aim of this prospective, multicenter, randomized, noninferiority trial was to characterize the effects of terlipressin, somatostatin, and octreotide when they are initiated before endoscopic treatment in patients with acute variceal bleeding. Patients with liver cirrhosis and significant upper gastrointestinal bleeding were randomly assigned to receive early administration of terlipressin, somatostatin, or octreotide, followed by endoscopic treatment. Patients with nonvariceal bleeding were excluded after endoscopy. The primary endpoint was 5-day treatment success, defined as control of bleeding without rescue treatment, rebleeding, or mortality, with a noninferiority margin of 0.1. In total, 780 patients with variceal bleeding were enrolled: 261 in the terlipressin group; 259 in the somatostatin group; and 260 in the octreotide group. At the time of initial endoscopy, active bleeding was noted in 43.7%, 44.4%, and 43.5% of these patients, respectively (P=0.748), and treatment success was achieved by day 5 in 86.2%, 83.4%, and 83.8% (P=0.636), with similar rates of control of bleeding without rescue treatment (89.7%, 87.6%, and 88.1%; P=0.752), rebleeding (3.4%, 4.8%, and 4.4%; P=0.739), or mortality (8.0%, 8.9%, and 8.8%; P=0.929). The absolute values of the lower bound of confidence intervals for terlipressin versus somatostatin, terlilpressin versus octreotide, and octreotide versus somatostatin were 0.095, 0.090, and 0.065, respectively. CONCLUSION Hemostatic effects and safety did not differ significantly between terlipressin, somatostatin, and octreotide as adjuvants to endoscopic treatment in patients with acute gastroesophageal variceal bleeding.
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Affiliation(s)
- Yeon Seok Seo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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Jairath V, Rehal S, Logan R, Kahan B, Hearnshaw S, Stanworth S, Travis S, Murphy M, Palmer K, Burroughs A. Acute variceal haemorrhage in the United Kingdom: patient characteristics, management and outcomes in a nationwide audit. Dig Liver Dis 2014; 46:419-26. [PMID: 24433997 DOI: 10.1016/j.dld.2013.12.010] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 12/03/2013] [Accepted: 12/07/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite advances in treatment, acute variceal haemorrhage remains life-threatening. AIM To describe contemporary characteristics, management and outcomes of patients with cirrhosis and acute variceal haemorrhage and risk factors for rebleeding and mortality. METHODS Multi-centre clinical audit conducted in 212 UK hospitals. RESULTS In 526 cases of acute variceal haemorrhage, 66% underwent endoscopy within 24h with 64% (n=339) receiving endoscopic therapy. Prior to endoscopy, 57% (n=299) received proton pump inhibitors, 44% (n=232) vasopressors and 27% (n=144) antibiotics. 73% (n=386) received red cell transfusion, 35% (n=184) fresh frozen plasma and 14% (n=76) platelets, with widely varying transfusion thresholds. 26% (n=135) experienced further bleeding and 15% (n=80) died by day 30. The Model for End Stage Liver Disease score was the best predictor of mortality (area under the receiver operating curve=0.74, P<0.001). Neither the clinical nor full Rockall scores were useful predictors of outcome. Coagulopathy was strongly associated with rebleeding (odds ratio 2.23, 95% CI 1.22-4.07, P=0.01, up to day 30) and mortality (odds ratio 3.06, 95% CI 1.29-7.26, P=0.01). CONCLUSIONS Although mortality has improved following acute variceal haemorrhage, rebleeding rates remain appreciably high. There are notable deficiencies in the use of vasopressors and endoscopic therapy. More work is needed to understand the optimum transfusion strategies. Better risk stratification tools are required to identify patients needing more intensive support.
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Affiliation(s)
- Vipul Jairath
- NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK; Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK.
| | | | - Richard Logan
- Division of Epidemiology and Public Health & Nottingham Digestive Disease Centre, University of Nottingham, UK
| | | | | | | | - Simon Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - Michael Murphy
- NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK
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Bai M, Qi X, Yang M, Han G, Fan D. Combined therapies versus monotherapies for the first variceal bleeding in patients with high-risk varices: a meta-analysis of randomized controlled trials. J Gastroenterol Hepatol 2014; 29:442-52. [PMID: 24118091 DOI: 10.1111/jgh.12396] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM The effect of combined therapies (among non-selected beta-blockers [NSBB], endoscopic therapy, and other treatments) on the first variceal bleeding has been evaluated in several randomized controlled trials previously, and the results were controversial. We performed this meta-analysis to assess the effect of combined therapies in patients with high-risk varices without previous variceal bleeding. METHODS The Cochrane Library, The Cochrane Hepato-Biliary Group Controlled Trials Register, MEDLINE, and EMBASE were searched for eligible trials. Manual searches were also performed for additional studies. Upper gastrointestinal bleeding, variceal bleeding, mortality, and adverse events were evaluated as end-points by meta-analysis. RESULTS Twelve randomized controlled trials with 1571 patients were included. Compared with the NSBB (propranolol or nadolol) or endoscopic therapy alone, all of the combined therapies did not demonstrate significant improvements in variceal bleeding, total upper gastrointestinal bleeding, and mortality. Only the combinations of isosorbide-mononitrate or spironolactone with NSBB tended to decrease the risk of variceal bleeding when compared with the use of NSBB alone (isosorbide-mononitrate plus NSBB vs NSBB: odds ratio = 0.67, 95% confidence interval 0.40-1.13, P = 0.13; spironolactone plus NSBB vs NSBB: odds ratio = 0.41, 95% confidence interval 0.10-1.69, P = 0.22). Adverse events were more frequently observed in the combined therapy groups. CONCLUSIONS Based on the available evidences, no combined therapy can be recommended as the first-line treatment for the primary prevention of variceal bleeding currently. Further studies with large sample sizes and long-term follow up are warranted.
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Affiliation(s)
- Ming Bai
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
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Lee YY, Tee HP, Mahadeva S. Role of prophylactic antibiotics in cirrhotic patients with variceal bleeding. World J Gastroenterol 2014; 20:1790-1796. [PMID: 24587656 PMCID: PMC3930977 DOI: 10.3748/wjg.v20.i7.1790] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 10/21/2013] [Accepted: 01/06/2014] [Indexed: 02/06/2023] Open
Abstract
Bacterial infections are common in cirrhotic patients with acute variceal bleeding, occurring in 20% within 48 h. Outcomes including early rebleeding and failure to control bleeding are strongly associated with bacterial infection. However, mortality from variceal bleeding is largely determined by the severity of liver disease. Besides a higher Child-Pugh score, patients with hepatocellular carcinoma are particularly susceptible to infections. Despite several hypotheses that include increased use of instruments, greater risk of aspiration pneumonia and higher bacterial translocation, it remains debatable whether variceal bleeding results in infection or vice versa but studies suggest that antibiotic prophylaxis prior to endoscopy and up to 8 h is useful in reducing bacteremia and spontaneous bacterial peritonitis. Aerobic gram negative bacilli of enteric origin are most commonly isolated from cultures, but more recently, gram positives and quinolone-resistant organisms are increasingly seen, even though their clinical significance is unclear. Fluoroquinolones (including ciprofloxacin and norfloxacin) used for short term (7 d) have the most robust evidence and are recommended in most expert guidelines. Short term intravenous cephalosporin (especially ceftriaxone), given in a hospital setting with prevalent quinolone-resistant organisms, has been shown in studies to be beneficial, particularly in high risk patients with advanced cirrhosis.
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Mustafa MZ, Stanley A. Variceal rebleeding: use of drug therapy and endoscopic band ligation. Expert Rev Gastroenterol Hepatol 2014; 8:179-83. [PMID: 24387735 DOI: 10.1586/17474124.2014.876358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Patients surviving a variceal bleed are at high risk of re-bleeding with a mortality of 25-50% during a 1-2 year follow-up. Several studies and meta-analyses have demonstrated reduced rates of oesophageal variceal rebleeding with the use of β-blockers. However, their use can be limited by contraindications or intolerance to therapy. Other trials have shown that addition of nitrates may improve the efficacy of β-blockers in prevention of variceal re-bleeding. Endoscopic variceal band ligation (VBL) has been shown in meta-analyses to decrease the rates of rebleeding and mortality compared with endoscopic sclerotherapy. Studies comparing combined drug therapy with VBL have shown similar rebleeding rates although there is a suggestion that survival may be higher in those given drug therapy. Recent data suggest that combined VBL and drug therapy reduces the risk of rebleeding from oesophageal varices compared with either therapy alone; however there appears to be no reduction in overall mortality.
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Li ZY, Li B, Wu YL, Xie QP. Acute pancreatitis associated left-sided portal hypertension with severe gastrointestinal bleeding treated by transcatheter splenic artery embolization: a case report and literature review. J Zhejiang Univ Sci B 2014; 14:549-54. [PMID: 23733433 DOI: 10.1631/jzus.b1200247] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Left-sided portal hypertension (LSPH) followed by acute pancreatitis is a rare condition with most patients being asymptomatic. In cases where gastrointestinal (GI) bleeding is present, however, the condition is more complicated and the mortality is very high because of the difficulty in diagnosing and selecting optimal treatment. A successfully treated case with severe GI bleeding by transcatheter splenic artery embolization is reported in this article. The patient exhibited severe uncontrollable GI bleeding and was confirmed as gastric varices secondary to LSPH by enhanced computed tomography (CT) scan and CT-angiography. After embolization, the bleeding stopped and stabilized for the entire follow-up period without any severe complications. In conclusion, embolization of the splenic artery is a simple, safe, and effective method of controlling gastric variceal bleeding caused by LSPH in acute pancreatitis.
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Affiliation(s)
- Zhi-yu Li
- Department of Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
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Taefi A, Cho WK, Nouraie M. Decreasing trend of upper gastrointestinal bleeding mortality risk over three decades. Dig Dis Sci 2013; 58:2940-8. [PMID: 23828142 DOI: 10.1007/s10620-013-2765-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 06/14/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Upper gastrointestinal bleeding (UGIB) causes over $1 billion in medical expenses annually. AIMS The purpose of this study was to examine changes of UGIB mortality risks and trends over the last three decades. METHODS We analyzed the National Hospital Discharge Sample from 1979 to 2009. Patients with primary ICD-9 code representing a diagnosis of UGIB were included. The UGIB mortality risks and trends in each decade by anatomical sites, bleeding causes, comorbidities, and other important variables were analyzed. RESULTS UGIB mortality risk decreased by 35.4 % from 4.8 % in the first decade to 3.1 % in the third decade (P < 0.001). Age and number of hospitalization days were significant risk factors in all decades. Most significant decreases were observed in patients over 65 years and during the first day of admission. Gastric (P < 0.001) and esophageal (P = 0.018) bleedings showed significant decreasing mortality risk trends. Duodenal bleeding mortality risk was stable in three decades. Mortality risk declined significantly among patients with renal failure (from 50.0 to 4.0 %) and heart failure (from 17.9 to 5.2 %; both P < 0.001) while changes in cases with ischemic heart disease, cancer, and liver failure were less significant. CONCLUSION UGIB morality risks, especially of the first hospital day and geriatric patients, significantly decreased over the last three decades, presumably from recent advances in emergency medical care. Mortality risk of gastric, but not duodenal, bleeding had the most significant reduction. Critical care improvements in patients with various comorbidities may explain significant UGIB mortality risk reductions. This study provides invaluable insight into the causes and trends of UGIB mortality risks for future studies.
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Affiliation(s)
- Amir Taefi
- Department of Medicine, MedStar Washington Hospital Center, 110 Irving St, NW Suite 3A3-A7, Washington, DC, 20010-2975, USA
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Abstract
BACKGROUND Acute variceal bleeding is a severe complication in patients with cirrhosis. The Asian Pacific Association for Study of the Liver (APASL) severity score was proposed in 2011. This score is used for evaluating the severity of acute variceal bleeding. However, as this score is largely based on expert opinion, it requires validation. AIM To determine the value of the APASL severity score. METHODS We retrospectively reviewed the medical records of patients treated for acute variceal bleeding at Konkuk University Hospital from 2006 to 2011. The APASL severity score, Child-Pugh score, and Model for End-Stage Liver Disease (MELD) score were calculated, and predictive values for treatment failure, rebleeding, and in-hospital mortality were compared by the area under the receiver operating curve (AUROC). RESULTS A total of 136 patients were enrolled, and all patients were treated by endoscopic variceal ligation (EVL) and terlipressin combination therapy. Most patients were male (n = 123, 90.4 %), and the most common etiology was alcohol (n = 91, 66.9 %). Thirteen treatment failures, eight rebleedings, and seven in-hospital mortalities occurred. The AUROCs of the APASL severity score, Child-Pugh score, and MELD score were 0.760, 0.681, and 0.607 for treatment failure; 0.660, 0.714, and 0.677 for rebleeding; and 0.872, 0.847, and 0.735 for in-hospital mortality. A significant difference was only observed between the APASL severity score and MELD score for treatment failure (p = 0.0259). CONCLUSION APASL severity score was a useful method for predicting treatment failure. However, the predictive value for rebleeding and in-hospital mortality were not satisfactory.
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