|
1
|
Nagesh VK, Pulipaka SP, Bhuju R, Martinez E, Badam S, Nageswaran GA, Tran HHV, Elias D, Mansour C, Musalli J, Bhattarai S, Shobana LS, Sethi T, Sethi R, Nikum N, Trivedi C, Jarri A, Westman C, Ahmed N, Philip S, Weissman S, Weinberger J, Bangolo AI. Management of gastrointestinal bleed in the intensive care setting, an updated literature review. World J Crit Care Med 2025; 14:101639. [DOI: 10.5492/wjccm.v14.i1.101639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2024] [Revised: 11/08/2024] [Accepted: 12/02/2024] [Indexed: 12/11/2024] Open
Abstract
Gastrointestinal (GI) bleeding is a critical and potentially life-threatening condition frequently observed in the intensive care unit (ICU). This literature review consolidates current insights on the epidemiology, etiology, management, and outcomes of GI bleeding in critically ill patients. GI bleeding remains a significant concern, especially among patients with underlying risk factors such as coagulopathy, mechanical ventilation, and renal failure. Managing GI bleeding in the ICU requires a multidisciplinary approach, including resuscitation, endoscopic intervention, pharmacologic therapy, and sometimes surgical procedures. Even with enhanced management strategies, GI bleeding in the ICU is associated with considerable morbidity and mortality, particularly when complicated by multi-organ failure. This review reiterates the need for adequate resuscitation and interventions in managing GI bleeding in critically ill patients, aiming to enhance survival rates and improve the quality of care within the ICU setting.
Collapse
Affiliation(s)
- Vignesh K Nagesh
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Sai Priyanka Pulipaka
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Ruchi Bhuju
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Emelyn Martinez
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Shruthi Badam
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Gomathy Aarthy Nageswaran
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Hadrian Hoang-Vu Tran
- Department of Internal Medicine, Hackensack Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Daniel Elias
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Charlene Mansour
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Jaber Musalli
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Sanket Bhattarai
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Lokeash Subramani Shobana
- Department of Internal Medicine, Hackensack Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Tannishtha Sethi
- Department of Internal Medicine, Hackensack Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Ritvik Sethi
- Department of Internal Medicine, Hackensack Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Namrata Nikum
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Chinmay Trivedi
- Department of Gastroenterology, Hackensack University Medical Center, Hackensack, NJ 07061, United States
| | - Amer Jarri
- Department of Pulmonology and Critical Care, HCA Florida Bayonet Point Hospital, Hudson, FL 34667, United States
| | - Colin Westman
- Department of Gastroenterology, Hackensack University Medical Center, Hackensack, NJ 07061, United States
| | - Nazir Ahmed
- Department of Gastroenterology, Hackensack University Medical Center, Hackensack, NJ 07061, United States
| | - Shawn Philip
- Department of Gastroenterology, Hackensack University Medical Center, Hackensack, NJ 07061, United States
| | - Simcha Weissman
- Department of Internal Medicine, Hackensack Palisades Medical Center, North Bergen, NJ 07047, United States
| | - Jonathan Weinberger
- Department of Gastroenterology, Hackensack University Medical Center, Hackensack, NJ 07061, United States
| | - Ayrton I Bangolo
- Department of Hematology & Oncology, John Theurer Cancer Center at Hackensack University Medical Center, Hackensack, NJ 07601, United States
| |
Collapse
|
|
2
|
Scheinberg AR, Martin P, Turkeltaub JA. Terlipressin in the management of liver disease. Expert Opin Pharmacother 2023; 24:1665-1671. [PMID: 37535437 DOI: 10.1080/14656566.2023.2244427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 07/26/2023] [Accepted: 08/01/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Terlipressin is a synthetic vasopressin analog which has been recently approved in the United States by the Food and Drug Administration for the treatment of hepatorenal syndrome. Terlipressin stimulates vasopressin receptors located on the smooth muscle vasculature of the splanchnic circulation and renal tubules which results in splanchnic vasoconstriction with improved renal perfusion and antidiuretic activity, respectively. AREAS COVERED In this review, we discuss available data regarding the FDA approved use of terlipressin, safety, and tolerability, as well as highlight alternative uses in chronic liver disease currently still under investigation. EXPERT OPINION Terlipressin is more efficacious compared to other vasoactive agents including midodrine octreotide and norepinephrine in reversal of hepatorenal syndrome and improves short-term survival. Other potential applications of terlipressin's vasoconstrictor actions reported in the literature include management of variceal hemorrhage and other complications of portal hypertension.
Collapse
Affiliation(s)
- Andrew R Scheinberg
- Department of Medicine, Division of Digestive Health and Liver Diseases, University of Miami, Miami, FL, USA
| | - Paul Martin
- Department of Medicine, Division of Digestive Health and Liver Diseases, University of Miami, Miami, FL, USA
| | - Joshua A Turkeltaub
- Department of Medicine, Division of Digestive Health and Liver Diseases, University of Miami, Miami, FL, USA
| |
Collapse
|
|
3
|
Merola E, Michielan A, de Pretis G. Optimal timing of endoscopy for acute upper gastrointestinal bleeding: a systematic review and meta-analysis. Intern Emerg Med 2021; 16:1331-1340. [PMID: 33570742 DOI: 10.1007/s11739-020-02563-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 11/04/2020] [Indexed: 10/22/2022]
Abstract
Acute upper gastrointestinal bleeding (UGIB) is the most common indication for urgent endoscopy, but the correct timing of endoscopy in these patients is still debated. Our systematic review with meta-analysis was aimed at investigating the potential clinical benefit of very early endoscopy for UGIB patients. We performed an electronic literature search of PubMed, Scopus, Web of Science and the Cochrane Library up to 23rd May 2020 and considered only randomised controlled trials (RCTs) comparing management of UGIB patients by very early vs early endoscopy. Only five RCTs were considered eligible for quantitative analysis, with a total population of 926 cases (468 in the very early endoscopy arm and 458 in the early). The meta-analysis showed no statistically significant benefit for very early endoscopy compared to early endoscopy in terms of risk of rebleeding, mortality, ICU admission, blood transfusion, surgery and length of hospital stay. However, our results showed a significantly higher need for haemostatic treatment when very early endoscopy was performed (RR 1.23, 95% CI 1.06-1.42, p < 0.01) in comparison to early endoscopy.
Collapse
Affiliation(s)
- Elettra Merola
- Department of Gastroenterology, Azienda Provinciale per i Servizi Sanitari di Trento (APSS), Trento, Italy.
| | - Andrea Michielan
- Department of Gastroenterology, Azienda Provinciale per i Servizi Sanitari di Trento (APSS), Trento, Italy
| | - Giovanni de Pretis
- Department of Gastroenterology, Azienda Provinciale per i Servizi Sanitari di Trento (APSS), Trento, Italy
| |
Collapse
|
|
4
|
Roberts D, Best LM, Freeman SC, Sutton AJ, Cooper NJ, Arunan S, Begum T, Williams NR, Walshaw D, Milne EJ, Tapp M, Csenar M, Pavlov CS, Davidson BR, Tsochatzis E, Gurusamy KS. Treatment for bleeding oesophageal varices in people with decompensated liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev 2021; 4:CD013155. [PMID: 33837526 PMCID: PMC8094233 DOI: 10.1002/14651858.cd013155.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Approximately 40% to 95% of people with liver cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed within about one to three years after diagnosis. Several different treatments are available, including, among others, endoscopic sclerotherapy, variceal band ligation, somatostatin analogues, vasopressin analogues, and balloon tamponade. However, there is uncertainty surrounding the individual and relative benefits and harms of these treatments. OBJECTIVES To compare the benefits and harms of different initial treatments for variceal bleeding from oesophageal varices in adults with decompensated liver cirrhosis, through a network meta-analysis; and to generate rankings of the different treatments for acute bleeding oesophageal varices, according to their benefits and harms. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until 17 December 2019, to identify randomised clinical trials (RCTs) in people with cirrhosis and acute bleeding from oesophageal varices. SELECTION CRITERIA We included only RCTs (irrespective of language, blinding, or status) in adults with cirrhosis and acutely bleeding oesophageal varices. We excluded RCTs in which participants had bleeding only from gastric varices, those who failed previous treatment (refractory bleeding), those in whom initial haemostasis was achieved before inclusion into the trial, and those who had previously undergone liver transplantation. DATA COLLECTION AND ANALYSIS We performed a network meta-analysis with OpenBUGS software, using Bayesian methods, and calculated the differences in treatments using odds ratios (OR) and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. We performed also the direct comparisons from RCTs using the same codes and the same technical details. MAIN RESULTS We included a total of 52 RCTs (4580 participants) in the review. Forty-eight trials (4042 participants) were included in one or more comparisons in the review. The trials that provided the information included people with cirrhosis due to varied aetiologies and those with and without a previous history of bleeding. We included outcomes assessed up to six weeks. All trials were at high risk of bias. A total of 19 interventions were compared in the trials (sclerotherapy, somatostatin analogues, vasopressin analogues, sclerotherapy plus somatostatin analogues, variceal band ligation, balloon tamponade, somatostatin analogues plus variceal band ligation, nitrates plus vasopressin analogues, no active intervention, sclerotherapy plus variceal band ligation, balloon tamponade plus sclerotherapy, balloon tamponade plus somatostatin analogues, balloon tamponade plus vasopressin analogues, variceal band ligation plus vasopressin analogues, balloon tamponade plus nitrates plus vasopressin analogues, balloon tamponade plus variceal band ligation, portocaval shunt, sclerotherapy plus transjugular intrahepatic portosystemic shunt (TIPS), and sclerotherapy plus vasopressin analogues). We have reported the effect estimates for the primary and secondary outcomes when there was evidence of differences between the interventions against the reference treatment of sclerotherapy, but reported the other results of the primary and secondary outcomes versus the reference treatment of sclerotherapy without the effect estimates when there was no evidence of differences in order to provide a concise summary of the results. Overall, 15.8% of the trial participants who received the reference treatment of sclerotherapy (chosen because this was the commonest treatment compared in the trials) died during the follow-up periods, which ranged from three days to six weeks. Based on moderate-certainty evidence, somatostatin analogues alone had higher mortality than sclerotherapy (OR 1.57, 95% CrI 1.04 to 2.41; network estimate; direct comparison: 4 trials; 353 participants) and vasopressin analogues alone had higher mortality than sclerotherapy (OR 1.70, 95% CrI 1.13 to 2.62; network estimate; direct comparison: 2 trials; 438 participants). None of the trials reported health-related quality of life. Based on low-certainty evidence, a higher proportion of people receiving balloon tamponade plus sclerotherapy had more serious adverse events than those receiving only sclerotherapy (OR 4.23, 95% CrI 1.22 to 17.80; direct estimate; 1 RCT; 60 participants). Based on moderate-certainty evidence, people receiving vasopressin analogues alone and those receiving variceal band ligation had fewer adverse events than those receiving only sclerotherapy (rate ratio 0.59, 95% CrI 0.35 to 0.96; network estimate; direct comparison: 1 RCT; 219 participants; and rate ratio 0.40, 95% CrI 0.21 to 0.74; network estimate; direct comparison: 1 RCT; 77 participants; respectively). Based on low-certainty evidence, the proportion of people who developed symptomatic rebleed was smaller in people who received sclerotherapy plus somatostatin analogues than those receiving only sclerotherapy (OR 0.21, 95% CrI 0.03 to 0.94; direct estimate; 1 RCT; 105 participants). The evidence suggests considerable uncertainty about the effect of the interventions in the remaining comparisons where sclerotherapy was the control intervention. AUTHORS' CONCLUSIONS Based on moderate-certainty evidence, somatostatin analogues alone and vasopressin analogues alone (with supportive therapy) probably result in increased mortality, compared to endoscopic sclerotherapy. Based on moderate-certainty evidence, vasopressin analogues alone and band ligation alone probably result in fewer adverse events compared to endoscopic sclerotherapy. Based on low-certainty evidence, balloon tamponade plus sclerotherapy may result in large increases in serious adverse events compared to sclerotherapy. Based on low-certainty evidence, sclerotherapy plus somatostatin analogues may result in large decreases in symptomatic rebleed compared to sclerotherapy. In the remaining comparisons, the evidence indicates considerable uncertainty about the effects of the interventions, compared to sclerotherapy.
Collapse
Affiliation(s)
- Danielle Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Lawrence Mj Best
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Nicola J Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Sivapatham Arunan
- General and Colorectal Surgery, Ealing Hospital and Imperial College, London, Northwood, UK
| | | | - Norman R Williams
- Surgical & Interventional Trials Unit (SITU), UCL Division of Surgery & Interventional Science, London, UK
| | - Dana Walshaw
- Acute Medicine, Barts and The London NHS Trust, London, UK
| | | | | | - Mario Csenar
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Chavdar S Pavlov
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Kurinchi Selvan Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| |
Collapse
|
|
5
|
Zhang J, Liu J, Wu Y, Romeiro FG, Levi Sandri GB, Zhou X, Li M, Qi X. Effect of terlipressin on renal function in cirrhotic patients with acute upper gastrointestinal bleeding. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:340. [PMID: 32355784 PMCID: PMC7186671 DOI: 10.21037/atm.2020.02.135] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 02/07/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Renal dysfunction is a serious morbidity in cirrhotic patients with acute upper gastrointestinal bleeding (AUGIB). Terlipressin is the first-line treatment choice for acute variceal bleeding and hepatorenal syndrome (HRS). This study aimed to assess the effect of terlipressin on renal function in patients with liver cirrhosis and AUGIB. METHODS We retrospectively reviewed 40 cirrhotic patients with AUGIB treated with terlipressin by an attending physician between January 2016 and June 2018. We analyzed the change of renal function parameters, including cystatin C (CysC) and creatinine (Cr), during the use of terlipressin and after terlipressin was stopped. We also identified the factors associated with renal function improvement in patients without active bleeding during the use of terlipressin. RESULTS During the use of terlipressin, CysC value was significantly reduced (1.3±0.8 vs. 1.1±0.7, P=0.001); Cr value was reduced, but the reduction was not statistically significant (68.8±24 vs. 65.5±23, P=0.817); the rate of CysC reduction was significantly higher in patients treated with terlipressin than those treated with somatostatin/octreotide (73.1% vs. 0%, P=0.005); the rate of Cr reduction was not significantly different between patients treated with terlipressin and somatostatin/octreotide (61.5% vs. 20%, P=0.148); no factor associated with CysC reduction was identified; higher hemoglobin, red blood cell, and platelet and lower prothrombin time and international normalized ratio at baseline were significantly associated with Cr reduction. After terlipressin was stopped, neither CysC nor Cr value was significantly reduced (P=0.852 and P=0.296). CONCLUSIONS Terlipressin may be beneficial on preventing renal function impairment in cirrhotic patients with AUGIB.
Collapse
Affiliation(s)
- Jingqiao Zhang
- Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Jie Liu
- Department of Pharmaceutical Sciences, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Yunhai Wu
- ICU, The Sixth Hospital of Shenyang, Shenyang 110006, China
| | - Fernando Gomes Romeiro
- Department of Internal Medicine, Botucatu Medical School, Universidade Estadual Paulista (UNESP), Botucatu, SP, Brazil
| | | | - Xinmiao Zhou
- Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
- Postgraduate College, Jinzhou Medical University, Jinzhou 121001, China
| | - Miaomiao Li
- Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
- Postgraduate College, Dalian Medical University, Dalian 116044, China
| | - Xingshun Qi
- Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
| |
Collapse
|
|
6
|
Zou Z, Yan X, Lu H, Qi X, Gu Y, Li X, Wu B, Qi X. Comparison of drugs facilitating endoscopy for patients with acute variceal bleeding: a systematic review and network meta-analysis. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:717. [PMID: 32042733 PMCID: PMC6989971 DOI: 10.21037/atm.2019.12.26] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND We aimed to compare the efficacy of different drugs facilitating endoscopy in patients with acute variceal bleeding. METHODS Databases were searched to identify randomized controlled trials which compared the efficacy of vasoactive drugs (vasopressin, terlipressin, octreotide, somatostatin) with placebo or each other. The primary outcomes were 6-week and 5-day mortality. Secondary outcomes were 5-day rebleeding, control of initial bleeding and adverse events. Pairwise and network meta-analysis were performed. RESULTS We identified 14 RCTs involved 2,187 patients. Four drugs had comparable clinical efficacy in all involving outcomes, except for adverse events. However, we do exhibit a superiority when vasopressin (OR, 4.40; 95% CI: 1.04-19.57), terlipressin (OR, 4.58; 95% CI: 1.63-13.63), octreotide (OR, 5.79; 95% CI: 2.41-16.71) and somatostatin (OR, 5.15; 95% CI: 1.40-27.39) were compared to placebo respectively as for initial hemostasis. In addition, only octreotide was more effective than placebo in decreasing 5-day rebleeding (OR, 0.44; 95% CI: 0.22-0.90). Meanwhile, octreotide was shown to have the highest probability ranking the best to improve initial hemostasis (mean rank =1.8) and carries a lowest risk of adverse events (9.1%) and serious adverse events (0.0%) compared to other drugs. CONCLUSIONS Balanced with curative effect and tolerability, octreotide may be the preferred vasoactive drug facilitating endoscopy.
Collapse
Affiliation(s)
- Ziyuan Zou
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou 730000, China
- The First School of Clinical Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Xinwen Yan
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou 730000, China
- The First School of Clinical Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Huanpeng Lu
- The First School of Clinical Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110840, China
| | - Ye Gu
- Department of Gastroenterology, The Sixth Peoples Hospital of Shenyang, Shenyang 110003, China
| | - Xun Li
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou 730000, China
| | - Bin Wu
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, China
| | - Xiaolong Qi
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou 730000, China
| |
Collapse
|
|
7
|
Chuah YY, Hsu PI, Tsai WL, Yu HC, Tsay FW, Chen WC, Lin KH, Lee YY, Wang HM. Short-term vasoactive agent treatment driven by physicians' preference in acute esophageal variceal bleeding in a tertiary center. PeerJ 2019; 7:e7913. [PMID: 31720102 PMCID: PMC6842295 DOI: 10.7717/peerj.7913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 09/17/2019] [Indexed: 11/20/2022] Open
Abstract
Background Vasoactive drugs are frequently used in combination with endoscopic variceal ligation (EVL) in treatment of acute esophageal variceal bleeding (EVB). The aim of study was to assess physicians’ preference of vasoactive agents in acute EVB, their reasons of preference and efficacy and safety of these short course regimens. Methods Cirrhotic patients with suspected EVB were screened (n = 352). Eligible patients were assigned based on the physician’s preference to either somatostatin (group S) or terlipressin (group T) followed by EVL. In group S, intravenous bolus (250 µg) of somatostatin followed by 250 µg/hour was continued for three days. In group T, 2 mg bolus injection of terlipressin was followed by 1 mg infusion every 6 h for three days. Results A total of 150 patients were enrolled; 41 in group S and 109 in group T. Reasons for physician preference was convenience in administration (77.1%) for group T and good safety profile (73.2%) for group S. Very early rebleeding within 49–120 h occurred in one patient in groups S and T (p = 0.469). Four patients in group S and 14 patients in group T have variceal rebleeding episodes within 6–42 d (p = 0.781). Overall treatment-related adverse effects were compatible in groups S and T (p = 0.878), but the total cost of terlipressin and somatostatin differed i.e., USD 621.32 and USD 496.43 respectively. Conclusions Terlipressin is the preferred vasoactive agent by physicians in our institution for acute EVB. Convenience in administration and safety profile are main considerations of physicians. Safety and hemostatic effects did not differ significantly between short-course somatostatin or terlipressin, although terlipressin is more expensive.
Collapse
Affiliation(s)
- Yoen Young Chuah
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Department of Medicine, Ping Tung Christian Hospital, Ping Tung, Taiwan; Department of Nursing, Meiho University, Taiwan
| | - Ping-I Hsu
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Lun Tsai
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsien-Chung Yu
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Feng-Woei Tsay
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Chi Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Kung Hung Lin
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia.,Gut Research Group, Faculty of Medicine, The National University of Malaysia, Kuala Lumpur, Malaysia
| | - Huay-Min Wang
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| |
Collapse
|
|
8
|
Yan X, Shao R, Wang Y, Mao X, Lei J, Zhang L, Zheng J, Liu A, Zhao H, Gao F, Wang J, Li P, Yao S, Xu M, Xu J, Liu D, Mi Y, Gong X, Ye J, Deng M, Dang T, Ji J, Shao C, Liu C, Gu Y, Wu Y, Wang F, Teng G, Li X, Qi X, Ju S, Qi X. Functional magnetic resonance imaging-based assessment of terlipressin vs. octreotide on renal function in cirrhotic patients with acute variceal bleeding (CHESS1903): study protocol of a multicenter randomized controlled trial. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:586. [PMID: 31807567 PMCID: PMC6861789 DOI: 10.21037/atm.2019.09.141] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Acute variceal bleeding is one of the critical complications in patients with liver cirrhosis. Severe renal vasoconstriction in consequence of low peripheral vascular resistance triggers the reduction of glomerular filtration rate (GFR), and thus induces acute kidney injury (AKI)/hepato-renal syndrome (HRS). Terlipressin and octreotide have been used in the management of cirrhotic patients with variceal bleeding. Also, terlipressin has been recommended as the international first-line pharmacological therapy for the treatment of HRS. In addition, the use of renal functional magnetic resonance imaging (fMRI) has become increasingly prevalent in research and clinical applications. However, the renal function-protective effect of terlipressin and octreotide and the value of fMRI in monitoring renal function remains unclear in patients with cirrhosis undergoing acute variceal bleeding. METHODS This is a multicenter, randomized controlled trial (RCT). Participants will be 1:1 assigned randomly into either terlipressin or octreotide groups. Sixty participants with clinically and/or pathologically diagnosed cirrhosis and active gastroesophageal variceal bleeding (GVB) will be recruited in several sites in China. Participants will receive either the treatment of terlipressin or octreotide after assigned into each group. The primary end point for the trial is the renal function. The secondary end points are (I) renal perfusion; (II) renal blood oxygenation; (III) failure to control bleeding; (IV) intra-hospital rebleeding; (V) intra-hospital mortality; (VI) adverse events (AE); (VII) overall survival. Statistical analysis including multivariate Cox regression, Kaplan-Meier analysis with log-rank test, etc. will be conducted. DISCUSSION The study will provide new insight into the protection of renal function in the process of the treatment of variceal bleeding in patients with cirrhosis. TRIAL REGISTRATION NUMBER NCT04028323.
Collapse
Affiliation(s)
- Xinwen Yan
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou 730000, China
- Department of Hepatology Unit and Infectious Diseases, The First School of Clinical Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Ruoyang Shao
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou 730000, China
- Department of Hepatology Unit and Infectious Diseases, The First School of Clinical Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Yuancheng Wang
- Department of Radiology, Zhongda Hospital, Medical School of Southeast University, Nanjing 210009, China
| | - Xiaorong Mao
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou 730000, China
| | - Junqiang Lei
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou 730000, China
| | - Liting Zhang
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou 730000, China
| | - Jianjun Zheng
- Department of Radiology, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo 315010, China
| | - Aimin Liu
- Department of Gastroenterology, Fuling Central Hospital of Chongqing City, Chongqing 404000, China
| | - Huimin Zhao
- CHESS Working Party, Xingtai People’s Hospital, Xingtai 054031, China
| | - Fengxiao Gao
- CHESS Working Party, Xingtai People’s Hospital, Xingtai 054031, China
| | - Jitao Wang
- CHESS Working Party, Xingtai People’s Hospital, Xingtai 054031, China
| | - Ping Li
- CHESS Working Party, Tianjin Second People’s Hospital, Tianjin 300192, China
| | - Shengjuan Yao
- CHESS Working Party, Tianjin Second People’s Hospital, Tianjin 300192, China
| | - Ming Xu
- Department of Gastroenterology, Guangdong Second Provincial General Hospital, Guangzhou 510317, China
| | - Jian Xu
- Department of Hepatology & Translation Medicine, Fuling Center Hospital of Chongqing City, Chongqing 404000, China
| | - Dengxiang Liu
- CHESS Working Party, Xingtai People’s Hospital, Xingtai 054031, China
| | - Yuqiang Mi
- CHESS Working Party, Tianjin Second People’s Hospital, Tianjin 300192, China
| | - Xijun Gong
- Department of Radiology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China
| | - Jun Ye
- Department of Hepatology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China
| | - Mingming Deng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China
| | - Tong Dang
- Inner Mongolia Institute of Digestive Diseases, The Second Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Baotou 014040, China
| | - Jiansong Ji
- Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Affiliated Lishui Hospital of Zhejiang University, The Central Hospital of Zhejiang Lishui, Lishui 323000, China
| | - Chuxiao Shao
- Department of Hepatobiliary and Pancreatic Surgery, The Fifth Affiliated Hospital of Wenzhou Medical University, Affiliated Lishui Hospital of Zhejiang University, The Central Hospital of Zhejiang Lishui, Lishui 323000, China
| | - Chao Liu
- CHESS Working Party, Hospital of Chengdu Office, People’s Government of Tibet Autonomous Region, Chengdu 610041, China
| | - Ye Gu
- Department of Gastroenterology, The Sixth Peoples Hospital of Shenyang, Shenyang 110006, China
| | - Yunhong Wu
- CHESS Working Party, Hospital of Chengdu Office, People’s Government of Tibet Autonomous Region, Chengdu 610041, China
| | - Fengmei Wang
- CHESS Working Party, Tianjin Second People’s Hospital, Tianjin 300192, China
| | - Gaojun Teng
- Department of Interventional Radiology, Zhongda Hospital, Medical School of Southeast University, Nanjing 210009, China
| | - Xun Li
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou 730000, China
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110000, China
| | - Shenghong Ju
- Department of Radiology, Zhongda Hospital, Medical School of Southeast University, Nanjing 210009, China
| | - Xiaolong Qi
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou 730000, China
| |
Collapse
|
|
9
|
Abstract
Hepatorenal syndrome is a severe complication of end-stage cirrhosis characterized by increased splanchnic blood flow, hyperdynamic state, a state of decreased central volume, activation of vasoconstrictor systems, and extreme kidney vasoconstriction leading to decreased GFR. The contribution of systemic inflammation, a key feature of cirrhosis, in the development of hepatorenal syndrome has been highlighted in recent years. The mechanisms by which systemic inflammation precipitates kidney circulatory changes during hepatorenal syndrome need to be clarified. Early diagnosis is central in the management and recent changes in the definition of hepatorenal syndrome help identify patients at an earlier stage. Vasoconstrictive agents (terlipressin in particular) and albumin are the first-line treatment option. Several controlled studies proved that terlipressin is effective at reversing hepatorenal syndrome and may improve short-term survival. Not all patients are responders, and even in responders, early mortality rates are very high in the absence of liver transplantation. Liver transplantation is the only curative treatment of hepatorenal syndrome. In the long term, patients transplanted with hepatorenal syndrome tend to have lower GFR compared with patients without hepatorenal syndrome. Differentiating hepatorenal syndrome from acute tubular necrosis (ATN) is often a challenging yet important step because vasoconstrictors are not justified for the treatment of ATN. Hepatorenal syndrome and ATN may be considered as a continuum rather than distinct entities. Emerging biomarkers may help differentiate these two conditions and provide prognostic information on kidney recovery after liver transplantation, and potentially affect the decision for simultaneous liver-kidney transplantation.
Collapse
Affiliation(s)
- Claire Francoz
- Hepatology and Liver Intensive Care Unit, Hospital Beaujon, Clichy, France
- INSERM U1149, University Paris Diderot, Paris, France; and
| | - François Durand
- Hepatology and Liver Intensive Care Unit, Hospital Beaujon, Clichy, France
- INSERM U1149, University Paris Diderot, Paris, France; and
| | - Jeffrey A Kahn
- Division of Gastrointestinal and Liver Disease, Department of Medicine
| | - Yuri S Genyk
- Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplant, Department of Surgery, and
| | - Mitra K Nadim
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| |
Collapse
|
|
10
|
Wang X, Liu Y, Zhao J, Zhang J. Clinical efficacy of octreotide acetate combined with thrombin in the treatment of liver cirrhosis complicated with gastrointestinal hemorrhage. Exp Ther Med 2019; 17:3417-3422. [PMID: 30988720 PMCID: PMC6447786 DOI: 10.3892/etm.2019.7345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 02/11/2019] [Indexed: 12/10/2022] Open
Abstract
Clinical efficacy of octreotide acetate combined with thrombin in the treatment of liver cirrhosis complicated with gastrointestinal hemorrhage was investigated. A retrospective analysis of 157 patients with liver cirrhosis and gastrointestinal hemorrhage admitted to Weifang People's Hospital from March 2012 to September 2014 was performed. Among them, 74 patients treated with octreotide acetate were enrolled into the octreotide group, and 83 patients treated with octreotide acetate combined with thrombin were enrolled into the combination group. Comparison between the two groups was made in terms of the average hemostasis time, the hospitalization time, the amount of blood transfusion during hospitalization, the efficacy of hemostasis and visual analog scale (VAS) scores. The mean hemostasis time of the octreotide group was higher than that of the combination group, with a statistically significant difference between the two groups (P<0.05); the hospitalization time of the octreotide group was significantly longer than that of the combination group (P<0.05); the blood transfusion volume of patients in the octreotide group was significantly higher than that of the combination group (P<0.05); the overall effective rate of the combination group after treatment was higher than the overall effective rate of the octreotide group (89.19%) (P<0.05). The VAS scores of the combination group at 24 and 72 h after treatment were lower than those of the octreotide group (P<0.05); the VAS scores of both the octreotide and the combination group at 24 and 72 h after treatment were significantly lower than those before treatment (P<0.05). In conclusion, the combination of octreotide acetate and thrombin is worthy of clinical promotion as it could reduce the average hemostasis time, the bleeding volume, and the hospitalization time of patients with liver cirrhosis combined with gastrointestinal hemorrhage, with better efficacy than the use of octreotide acetate alone.
Collapse
Affiliation(s)
- Xiaoyan Wang
- Department of Hepatological Surgery, Weifang People's Hospital, Weifang, Shandong 261041, P.R. China
| | - Yanyan Liu
- Department of Hepatological Surgery, Weifang People's Hospital, Weifang, Shandong 261041, P.R. China
| | - Jingjing Zhao
- Department of Hepatological Surgery, Weifang People's Hospital, Weifang, Shandong 261041, P.R. China
| | - Jinmei Zhang
- Department of Hepatological Surgery, Weifang People's Hospital, Weifang, Shandong 261041, P.R. China
| |
Collapse
|
|
11
|
Lo GH. The Use of Vasoconstrictors in Acute Variceal Bleeding: How Long Is Enough? Clin Endosc 2019; 52:36-39. [PMID: 30665290 PMCID: PMC6370929 DOI: 10.5946/ce.2018.084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 06/07/2018] [Indexed: 12/15/2022] Open
Abstract
Vasoconstrictors are often used as the first line therapy for acute esophageal variceal hemorrhage. They might also be used for a few days after endoscopic therapy to prevent early rebleeding. International guidelines recommend the use of vasoconstrictor therapy when acute esophageal variceal hemorrhage is suspected and continuation of the therapy until 3 to 5 days after endoscopic treatment. However, the duration of use of vasoconstrictors after endoscopic therapy is not clear. This review shows that if variceal bleeding is successfully controlled by endoscopic variceal ligation, the combination of vasoconstrictors can be reduced to less than 1 day.
Collapse
Affiliation(s)
- Gin-Ho Lo
- Division of Gastroenterology, Department of Medical Research, E-DA Hospital, Kaohsiung, Taiwan
| |
Collapse
|
|
12
|
Heidet M, Amathieu R, Audureau E, Augusto O, Nicolazo de Barmon V, Rialland A, Schmitz D, Pierrang F, Marty J, Chollet-Xémard C, Thirion O, Jacob L. Efficacy and tolerance of early administration of tranexamic acid in patients with cirrhosis presenting with acute upper gastrointestinal bleeding: a study protocol for a multicentre, randomised, double-blind, placebo-controlled trial (the EXARHOSE study). BMJ Open 2018; 8:e021943. [PMID: 30099397 PMCID: PMC6089293 DOI: 10.1136/bmjopen-2018-021943] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION The management of acute upper gastrointestinal bleeding (UGIB) is challenging in patients with cirrhosis, as it is responsible for severe complications and high mortality rates. Tranexamic acid (TXA) may help control the bleeding by counterbalancing cirrhosis-related hyperfibrinolysis. Still, there is a lack of unbiased data to conclude on its efficacy. The aim of this study is to evaluate the efficacy of TXA in the early treatment of acute UGIB in patients with cirrhosis. METHODS AND ANALYSIS This study is a multicentre, randomised, double-blind, placebo-controlled trial, for adult patients with cirrhosis presenting with an acute UGIB and allocated to one of two arms: TXA or placebo (saline). Physicians from emergency mobile services, emergency departments (EDs) or intensive care units (ICUs) can include patients. Besides study intervention, standard care for UGIB will be performed as recommended. Intervention will consist an intravenous infusion of 10 mL of TXA (1 g) or saline, immediately followed by three identical intravenous infusions over 8 hours each (total dose of 4 g of TXA or 40 mL of placebo over 24 hours). Main analyses will be conducted in intention to treat on every patient included, then in modified intention to treat on patients with underlying lesion of portal hypertension visualised by endoscopy. The main objective is to show efficacy of TXA until day 5 on a composite criterion (bleeding control, rebleeding episodes and mortality). Secondary objectives aim at showing the efficacy of TXA on each individual component of the main outcome measure and others at 6 weeks and later (transjugular intrahepatic portosystemic shunt procedure, cirrhosis-specific complications, length of stay in ICU and in hospital, safety and tolerance of TXA, liver transplantation). Included patients will be followed up to 1 year after inclusion.500 patients will be necessary to show a reduction in the prevalence of the primary outcome from 30% to 18% with a bilateral alpha risk of 5% and a power of 80%. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Comité de Protection des Personnes Ile-de-France 1 (CPP-IDF1). Results will be disseminated via publications in peer-review medical journals and scientific forums. PROTOCOL VERSION This protocol is based on the latest version, as established on 11 October 2017 and validated by the IRB CPP Ile-de-France 1. TRIAL REGISTRATION NUMBER NCT03023189.
Collapse
Affiliation(s)
- Matthieu Heidet
- Groupe Hospitalo-Universitaire Henri Mondor, SAMU 94, Assistance Publique - Hôpitaux de Paris, Créteil, France
- EA-4390 (Analysis of Risk in Complex Health Systems), Université Paris-Est Créteil, Créteil, France
| | - Roland Amathieu
- Hôpital Universitaire Jean Verdier, Service de Réanimation, Assistance Publique - Hôpitaux de Paris, Bondy, France
- UMR 7244, Centre national de la recherche scientifique (CNRS), Université Paris 13, Bobigny, France
| | - Etienne Audureau
- EA 7376 (Clinical Epidemiology and Ageing, CEpiA), Université Paris-Est Créteil, Créteil, France
- Groupe Hospitalo-Universitaire Henri Mondor, Département de Santé Publique, Assistance Publique - Hôpitaux de Paris, Créteil, France
| | - Oriane Augusto
- Groupe Hospitalo-Universitaire Henri Mondor, Unité de Recherche Clinique, Assistance Publique - Hôpitaux de Paris, Créteil, France
| | - Violaine Nicolazo de Barmon
- Groupe Hospitalo-Universitaire Henri Mondor, Unité de Recherche Clinique, Assistance Publique - Hôpitaux de Paris, Créteil, France
| | - Amandine Rialland
- Groupe Hospitalo-Universitaire Henri Mondor, Unité de Recherche Clinique, Assistance Publique - Hôpitaux de Paris, Créteil, France
| | - David Schmitz
- Groupe Hospitalo-Universitaire Henri Mondor, Unité de Recherche Clinique, Assistance Publique - Hôpitaux de Paris, Créteil, France
| | - François Pierrang
- Groupe Hospitalo-Universitaire Henri Mondor, Unité de Recherche Clinique, Assistance Publique - Hôpitaux de Paris, Créteil, France
| | - Jean Marty
- Groupe Hospitalo-Universitaire Henri Mondor, SAMU 94, Assistance Publique - Hôpitaux de Paris, Créteil, France
- EA-4390 (Analysis of Risk in Complex Health Systems), Université Paris-Est Créteil, Créteil, France
| | - Charlotte Chollet-Xémard
- Groupe Hospitalo-Universitaire Henri Mondor, SAMU 94, Assistance Publique - Hôpitaux de Paris, Créteil, France
| | - Olivier Thirion
- Groupe Hospitalo-Universitaire Henri Mondor, Pharmacie Centrale, Assistance Publique - Hôpitaux de Paris, Créteil, France
| | - Line Jacob
- Département de Médecine d’urgence et SAMU-SMUR, Hôpital Marc Jacquet, Melun, France
| |
Collapse
|
|
13
|
|
|
14
|
Papaluca T, Gow P. Terlipressin: Current and emerging indications in chronic liver disease. J Gastroenterol Hepatol 2018; 33:591-598. [PMID: 28981166 DOI: 10.1111/jgh.14009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 09/21/2017] [Accepted: 09/26/2017] [Indexed: 12/12/2022]
Abstract
Terlipressin is an analogue of vasopressin that has potent vasoactive properties and has been available for use in most countries for nearly two decades. It has both established roles and emerging indications in the management of complications of decompensated chronic liver disease. We explore historic and emerging literature regarding the use of terlipressin for a range of indications including hepatorenal syndrome, portal hypertensive bleeding, and disruptions in sodium homeostasis. Novel methods of infusion-based terlipressin administration including the beneficial effect in reduction of adverse events are explored, in addition to new indications for the use of terlipressin in decompensated cirrhosis in an outpatient setting.
Collapse
Affiliation(s)
| | - Paul Gow
- Austin Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
|
15
|
Baseline Renal Function Predicts Hyponatremia in Liver Cirrhosis Patients Treated with Terlipressin for Variceal Bleeding. Gastroenterol Res Pract 2017; 2017:7610374. [PMID: 29075291 PMCID: PMC5623796 DOI: 10.1155/2017/7610374] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 07/05/2017] [Accepted: 07/30/2017] [Indexed: 12/19/2022] Open
Abstract
Objectives Terlipressin is safely used for acute variceal bleeding. However, side effects, such as hyponatremia, although very rare, can occur. We investigated the development of hyponatremia in cirrhotic patients who had acute variceal bleeding treated with terlipressin and the identification of the risk factors associated with the development of hyponatremia. Design and Methods This retrospective, case-control study investigated 88 cirrhotic patients who developed hyponatremia and 176 controls that did not develop hyponatremia and were matched in terms of age and gender during the same period following terlipressin administration. Results The overall change in serum sodium concentration and the mean lowest serum sodium concentration were 3.44 ± 9.55 and 132.44 ± 8.78 mEq/L during treatment, respectively. Multivariate analysis revealed that baseline serum sodium was an independent positive predictor, and the presence of baseline serum creatinine, HBV, DM, creatinine, and shock on admission was independent negative predictors of hyponatremia (P < 0.05). Conclusion The presence of HBV, DM, the baseline serum sodium, shock on admission, and especially baseline creatinine may be predictive of the development of hyponatremia after terlipressin treatment. Therefore, physicians conduct vigilant monitoring associated with severe hyponatremia when cirrhotic patients with preserved renal function are treated with terlipressin for variceal bleeding.
Collapse
|
|
16
|
|
|
17
|
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.
Collapse
|
|
18
|
|
|
19
|
Iannone A, Principi M, Barone M, Losurdo G, Ierardi E, Di Leo A. Gastrointestinal bleeding from vascular malformations: Is octreotide effective to rescue difficult-to-treat patients? Clin Res Hepatol Gastroenterol 2016; 40:373-7. [PMID: 27595456 DOI: 10.1016/j.clinre.2016.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 01/15/2016] [Accepted: 02/09/2016] [Indexed: 02/07/2023]
Abstract
Gastrointestinal vascular malformations are responsible for 2-8% of all cases of bleeding and 30-40% of all obscure hemorrhages, being the most frequent cause of occult bleeding in older people. The aim of this review was to provide an up-to-date report about the use of octreotide in bleeding from both hereditary and acquired vascular malformations of the gastrointestinal tract. A systematic literature search was performed, using the keywords "gastrointestinal vascular malformation", "octreotide", "angiodysplasia", "portal hypertensive gastropathy", "gastric antral vascular ectasia", and "hereditary vascular malformations". The first line therapy of acute/chronic bleeding from digestive vascular malformations is endoscopy, followed by angiographic embolization and surgical resection when this is unsuccessful. In the setting of difficult-to-treat patients, octreotide has been proposed as an alternative therapeutic strategy. Studies reported in the literature show a high efficacy and safety of octreotide, but described only a small number of enrolled patients, heterogeneous therapeutic schedules and short-term follow-up, with the exception of acute bleeding from esophageal varices. As a consequence, the use of octreotide is not approved in this setting and it is currently still prescribed as an off-label drug. Studies in larger populations are needed to confirm the promising results observed in the small case series reports, so as to provide physicians with a treatment option for patients without available alternatives. Octreotide could also determine a strong decrease in the management costs of these clinical conditions, and especially, could dramatically reduce hospital admission costs.
Collapse
Affiliation(s)
- Andrea Iannone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Mariabeatrice Principi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Michele Barone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Giuseppe Losurdo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Enzo Ierardi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy.
| | - Alfredo Di Leo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| |
Collapse
|
|
20
|
Laine L. Deflating balloon tamponade: Should we expand the use of stents for severe refractory esophageal variceal bleeding? Hepatology 2016; 63:1768-70. [PMID: 27205898 DOI: 10.1002/hep.28439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 12/25/2015] [Indexed: 12/25/2022]
Affiliation(s)
- Loren Laine
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT
| |
Collapse
|
|
21
|
Hung TH, Tsai CC, Tseng KC, Hsieh YH, Tseng CW. No mortality difference following treatment with terlipressin or somatostatin in cirrhotic patients with gastric variceal hemorrhage. Saudi J Gastroenterol 2016; 22:220-5. [PMID: 27184641 PMCID: PMC4898092 DOI: 10.4103/1319-3767.182458] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND/AIMS The aim of this study was to compare the efficacy of terlipressin versus somatostatin as adjuvants to endoscopic treatment in cirrhotic patients with gastric variceal bleeding. PATIENTS AND METHODS The National Health Insurance Database, derived from the Taiwan National Health Insurance Program, was used to enroll patients who were discharged with International Classification of Diseases, 9th Revision, Clinical Modification diagnoses of cirrhosis and who underwent gastric variceal sclerotherapy for gastric variceal bleeding between January 1, 2007, and December 31, 2007. We observed treatment outcomes and identified clinical factors associated with mortality. RESULTS In total, we enrolled 311 cirrhosis patients who underwent sclerotherapy for active gastric variceal bleeding. Among them, 218 patients received terlipressin, and 93 patients received somatostatin. The overall 30 day mortality rate was 13.2% (41/311). A total of 78 (25.1%) patients underwent second-look endoscopy, but only 12 (7%) needed a second course of gastric variceal sclerotherapy. The overall 30-day mortality rates for patients treated with terlipressin and somatostatin were 13.3% and 12.9%, respectively, showing no statistically significant differences between outcomes in the two treatment groups (P = 0.672). The risk of 30-day mortality was significantly higher in patients with hepatocellular carcinoma (HR: 3.257, 95% CI: 1.640-6.469, P= 0.001), acute renal failure (HR: 6.261, 95% CI: 2.376-16.499, P< 0.001), or hepatic encephalopathy (HR: 3.091, 95% CI: 1.430-6.680, P= 0.004). CONCLUSIONS Mortality rates did not differ significantly between cirrhosis patients with acute gastric variceal bleeding who received somatostatin or terlipressin as adjuvants to endoscopy.
Collapse
Affiliation(s)
- Tsung-Hsing Hung
- Department of Internal Medicine, Division of Gastroenterology, Taipei, Taiwan,Department of Clinical Medicine, School of Medicine, Tzuchi University, Hualien, Taipei, Taiwan
| | - Chen-Chi Tsai
- Department of Clinical Medicine, School of Medicine, Tzuchi University, Hualien, Taipei, Taiwan,Department of Medicine, Division of Infectious Disease, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi, Taipei, Taiwan
| | - Kuo-Chih Tseng
- Department of Internal Medicine, Division of Gastroenterology, Taipei, Taiwan,Department of Clinical Medicine, School of Medicine, Tzuchi University, Hualien, Taipei, Taiwan
| | - Yu-Hsi Hsieh
- Department of Internal Medicine, Division of Gastroenterology, Taipei, Taiwan,Department of Clinical Medicine, School of Medicine, Tzuchi University, Hualien, Taipei, Taiwan
| | - Chih-Wei Tseng
- Department of Internal Medicine, Division of Gastroenterology, Taipei, Taiwan,Department of Clinical Medicine, School of Medicine, Tzuchi University, Hualien, Taipei, Taiwan,Department of Medicine, Division of Gastroenterology, Taipei Veterans General Hospital, Taipei, Taiwan,Department of Internal Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan,Address for correspondence: Dr. Chih-Wei Tseng, Department of Internal Medicine, Division of Gastroenterology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No 2, Ming-Shen Road, Dalin Town, Chia-Yi County 622, Taiwan. E-mail:
| |
Collapse
|
|
22
|
Belletti A, Castro ML, Silvetti S, Greco T, Biondi-Zoccai G, Pasin L, Zangrillo A, Landoni G. The Effect of inotropes and vasopressors on mortality: a meta-analysis of randomized clinical trials. Br J Anaesth 2015; 115:656-75. [PMID: 26475799 DOI: 10.1093/bja/aev284] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- A Belletti
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, via Olgettina 60, Milan 20132, Italy
| | - M L Castro
- Anaesthesiology Department, Centro Hospitalar Lisboa Central, EPE - Hospital de Santa Marta, Rua de Santa Marta 50, Lisbon 1169-024, Portugal
| | - S Silvetti
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, via Olgettina 60, Milan 20132, Italy
| | - T Greco
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, via Olgettina 60, Milan 20132, Italy Laboratorio di Statistica Medica, Biometria ed Epidemiologia "G. A. Maccacaro", Dipartimento di Scienze Cliniche e di Comunità, University of Milan, Via Festa del Perdono 7, Milan 20122, Italy
| | - G Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, Latina 04100, Italy
| | - L Pasin
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, via Olgettina 60, Milan 20132, Italy
| | - A Zangrillo
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, via Olgettina 60, Milan 20132, Italy Vita-Salute San Raffaele University, via Olgettina 58, Milan 20132, Italy
| | - G Landoni
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, via Olgettina 60, Milan 20132, Italy Vita-Salute San Raffaele University, via Olgettina 58, Milan 20132, Italy
| |
Collapse
|
|
23
|
Seo YS, Jung CH, Kim TH, Yim SY, Um SH. Reply: To PMID 24415445. Hepatology 2015; 62:653-4. [PMID: 25482652 DOI: 10.1002/hep.27646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 12/04/2014] [Indexed: 12/07/2022]
Affiliation(s)
- Yeon Seok Seo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Chang Ho Jung
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Tae Hyung Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sun Young Yim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Soon Ho Um
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| |
Collapse
|
|
24
|
Lo GH. Lack of difference among vasoconstrictors: Similar effectiveness or similar ineffectiveness? Hepatology 2015; 62:653. [PMID: 25482959 DOI: 10.1002/hep.27648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2014] [Indexed: 12/07/2022]
Affiliation(s)
- Gin-Ho Lo
- Department of Medical Research , Digestive Center, E-DA Hospital and School of Medicine for International Students, I-Shou University, Kaohsiung, Taiwan
| |
Collapse
|
|
25
|
Bloom S, Kemp W, Lubel J. Portal hypertension: pathophysiology, diagnosis and management. Intern Med J 2015; 45:16-26. [DOI: 10.1111/imj.12590] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 08/27/2014] [Indexed: 12/19/2022]
Affiliation(s)
- S. Bloom
- Gastroenterology and Hepatology; Eastern Health; Melbourne Victoria Australia
| | - W. Kemp
- Gastroenterology and Hepatology; Alfred Health; Melbourne Victoria Australia
| | - J. Lubel
- Gastroenterology and Hepatology; Eastern Health; Melbourne Victoria Australia
| |
Collapse
|
|
26
|
DellaVolpe JD, Garavaglia JM, Huang DT. Management of Complications of End-Stage Liver Disease in the Intensive Care Unit. J Intensive Care Med 2014; 31:94-103. [PMID: 25223828 DOI: 10.1177/0885066614551144] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 07/14/2014] [Indexed: 12/19/2022]
Abstract
The management of critically ill patients with end-stage liver disease can be challenging due to the vulnerability of this population and the wide-ranging complications of the disease. This review proposes an approach based on the major organ systems affected, to provide a framework for managing the most common complications. Although considerable practice variation exists, a focus on the evidence behind the most common practices will ensure the development of the optimal skillset to appropriately manage this disease.
Collapse
Affiliation(s)
- Jeffrey D DellaVolpe
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeffrey M Garavaglia
- Department of Pharmacy & Therapeutics, Transplant Intensive Care Unit, UPMC Presbyterian Shadyside, Pittsburgh, PA, USA
| | - David T Huang
- Department of Critical Care Medicine, Director Multidisciplinary Acute Care Research Organization, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| |
Collapse
|
|
27
|
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.
Collapse
Affiliation(s)
- Yeon Seok Seo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
28
|
External hemorrhage from a portacaval anastomosis in a patient with liver cirrhosis. Case Reports Hepatol 2014; 2014:523610. [PMID: 25374728 PMCID: PMC4207600 DOI: 10.1155/2014/523610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 07/01/2014] [Indexed: 11/20/2022] Open
Abstract
Variceal bleeding is the major complication of portal hypertension in patients with liver cirrhosis. Hemorrhage mainly occurs in gastrointestinal lumen. Extraluminal hemorrhages are quite rare, such as intraperitoneal hemorrhages. We aimed to present a variceal bleeding case from the anastomosis on the anterior abdominal wall, as an extraordinary bleeding location, in a patient with portal hypertension in whom there were no esophageal and gastric varices.
Collapse
|
|
29
|
Rahimi RS, Guntipalli P, Rockey DC. Worldwide practices for pharmacologic therapy in esophageal variceal hemorrhage. Scand J Gastroenterol 2014; 49:131-7. [PMID: 24295524 DOI: 10.3109/00365521.2013.850736] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Pharmacologic therapy (PT) for patients with esophageal variceal hemorrhage (EVH) may improve outcomes. The aim of this article is to assess the current and potential future use of PT in cirrhotic patients with EVH. MATERIAL AND METHODS We validated a 13-question survey about PT and physician preferences for specific therapies in cirrhotics with EVH; 2349 randomly selected Gastroenterology and Hepatology physicians worldwide were surveyed. The survey addressed institutional location, octreotide or terlipressin use and preference, PT prior to endoscopy, and future plans for terlipressin use, if not already instituted. RESULTS Of those surveyed, 337 (14%) email addresses were nonfunctioning. Of the remaining 2012 surveyed, 371 (18%) responses were collected. Nearly two-thirds of physicians preferred to use PT prior to endoscopic intervention (p < 0.001). Nearly 70% of respondents only had octreotide available, while 6% had only terlipressin. Of the 24% having both octreotide and terlipressin available, 55% preferred terlipressin compared to 38% who preferred octreotide (p < 0.001). Of those physicians currently not using terlipressin because of its unavailability, 93% would be willing to use it if it were readily available. CONCLUSIONS Of physicians with both terlipressin and octreotide available for treatment of EVH in cirrhotics, most prefer terlipressin, even if currently unavailable.
Collapse
Affiliation(s)
- Robert S Rahimi
- University of Texas Southwestern Medical Center, Division of Digestive and Liver Disease and the Department of Internal Medicine , Dallas, Texas 75390 , USA
| | | | | |
Collapse
|
|
30
|
|
|
31
|
Zhang Y, Liu Z, Liu X, Han X, Zhou Y, Cao Y, Zhang X. Prediction of octreotide efficacy by electrogastrography in the treatment of patients with esophageal variceal hemorrhage. Physiol Meas 2013; 34:799-812. [PMID: 23780564 DOI: 10.1088/0967-3334/34/7/799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Our aim is to investigate the significance of electrogastrography in the treatment of esophageal variceal hemorrhage with octreotide. Electrogastrography was performed in patients with esophageal variceal hemorrhage before and during the treatment consisting of various doses of octreotide (25 ug h(-1) group and 50 ug h(-1) group). The dominant power of electrogastrography and its relationship with the hemostatic efficacy of octreotide treatment were evaluated. Dominant power of electrogastrography decreased significantly during treatment with octreotide (P < 0.05). The reduction in the amplitude of dominant power in the 50 ug h(-1) group was significantly larger than in the 25 ug h(-1) group (P < 0.05), and it was correlated with hemostatic efficacy of octreotide treatment. We conclude that octreotide treatment in patients with esophageal variceal hemorrhage can result in a significant decrease of dominant power, which correlates with the hemostatic efficacy of octreotide, so the change of dominant power could be used as a predictor of evaluating the treatment efficacy of octreotide in esophageal variceal hemorrhage patients.
Collapse
Affiliation(s)
- Yixiong Zhang
- Emergency department of Hunan Provincial People's Hospital, Hunan Normal University, No. 61, Jie Fang xi road, Changsha, Hunan province 410005, People's Republic of China
| | | | | | | | | | | | | |
Collapse
|
|
32
|
Wells M, Chande N, Adams P, Beaton M, Levstik M, Boyce E, Mrkobrada M. Meta-analysis: vasoactive medications for the management of acute variceal bleeds. Aliment Pharmacol Ther 2012; 35:1267-78. [PMID: 22486630 DOI: 10.1111/j.1365-2036.2012.05088.x] [Citation(s) in RCA: 144] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2012] [Revised: 03/12/2012] [Accepted: 03/14/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Vasoactive medications such as vasopressin, somatostatin and their analogues (terlipressin, vapreotide and octreotide) are commonly used for the treatment of acute variceal bleeding. However, the risks and benefits of these interventions are not well understood. AIM To undertake a meta-analysis of the efficacy of vasoactive medications in patients having acute variceal bleeds. METHODS Randomised controlled trials (RCTs) of vasopressin, somatostatin and their analogues, administered to patients with acute variceal bleeds were identified based on systematic searches of nine electronic databases and multiple sources of grey literature. RESULTS The search identified 3011 citations, and 30 trials with a total of 3111 patients met eligibility criteria. The use of vasoactive agents was associated with a significantly lower risk of 7-day mortality (RR 0.74; 95% CI 0.57-0.95; P = 0.02; I(2) = 0%; moderate quality of evidence), and a significant improvement in haemostasis (RR 1.21, 95% CI 1.13-1.30; P < 0.001; I(2) = 28%; very low quality of evidence), lower transfusion requirements (pooled mean difference -0.70 units of blood transfused, 95% CI -1.01 to -0.38; P < 0.001; I(2) = 82%; moderate quality of evidence), and a shorter duration of hospitalisation (pooled mean difference -0.71 days; 95% CI -1.23 to -0.19; P = 0.007; I(2) = 0%; low quality of evidence). Studies comparing different vasoactive agents did not show a difference in efficacy, although the quality of evidence was very low. CONCLUSIONS The use of vasoactive agents was associated with a significantly lower risk of acute all-cause mortality and transfusion requirements, and improved control of bleeding and shorter hospital stay. Studies comparing different vasoactive medications failed to demonstrate a difference in efficacy.
Collapse
Affiliation(s)
- M Wells
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | | | | | | | | | | | | |
Collapse
|
|
33
|
Azam Z, Hamid S, Jafri W, Salih M, Abbas Z, Abid S, Shah H. Short course adjuvant terlipressin in acute variceal bleeding: a randomized double blind dummy controlled trial. J Hepatol 2012; 56:819-24. [PMID: 22178268 DOI: 10.1016/j.jhep.2011.11.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2011] [Revised: 11/03/2011] [Accepted: 11/03/2011] [Indexed: 12/29/2022]
Abstract
BACKGROUND & AIMS Terlipressin is recommended for 3-5 days as adjuvant to endoscopic variceal band ligation (EVBL) in esophageal variceal bleeding (EVB). We assessed whether terlipressin can be administered for a shorter period of time to patients with EVB. METHODS All eligible EVB patients received 24h of open label terlipressin at presentation. After successful EVBL, patients were randomized to receive active or dummy terlipressin for the next 48 h. We excluded patients with failure to achieve initial hemostasis, bleeding gastric varices, known hepatoma, and/or portal vein thrombosis, advanced cirrhosis (Child-Pugh score ≥12), and patients on a ventilator. The primary outcome was failure to control EVB. The secondary outcomes were 30-day mortality; re-bleeding and composite outcome of failure to control EVB. RESULTS A total of 130 eligible patients were randomized to receive terlipressin for a total of 24 (short course or SC) or 72 h (usual course or UC). Baseline patient characteristics were comparable; the majority of patients were HCV-infected and male. There was one failure to control EVB (1.5%) in UC and none in SC terlipressin (p=0.50). The 30-day re-bleeding rate was 1.5% and 3.1% in UC, and SC terlipressin, respectively (p=0.50). The 30-day mortality was 12, 6 (9.2%) patients in each group (p=0.50). The 30-day failure to control bleeding was observed in 14 patients; seven in each group (p=0.494). CONCLUSIONS In patients with esophageal variceal bleeding, a 24-h course of terlipressin is as effective as a 72-h course when used as an adjunctive therapy to successful EVBL.
Collapse
Affiliation(s)
- Zahid Azam
- Section of Gastroenterology, Department of Medicine, The Aga Khan University, Karachi, Pakistan
| | | | | | | | | | | | | |
Collapse
|
|
34
|
Impact of a bleeding care pathway in the management of acute upper gastrointestinal bleeding. Indian J Gastroenterol 2011; 30:72-7. [PMID: 21584777 DOI: 10.1007/s12664-011-0089-5] [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] [Received: 03/25/2010] [Accepted: 01/21/2011] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Upper gastrointestinal (UGI) bleeding carries high morbidity and mortality. The use of a bleeding care pathway (BCP) may improve outcomes, but the results are inconsistent in various studies. METHODS A BCP for patients with UGI bleed with admission in a bleeding care unit (BCU) has been in use at our hospital since 2005. Prior to this, a high dependency unit was used for management of all emergencies including UGI bleeding. We compared the length of stay in the bleeding care/high dependency unit, total hospital stay, time to UGI endoscopy after admission, and survival between pre-2005 and post-2005 patients. RESULTS Five hundred and fifty-one patients were admitted with acute UGI bleed in the last 5 years; 121 belonged to pre-BCP (2004) period and 430 after implementation of the pathway (2005-2008). The mean (SD) time to UGI endoscopy improved from 21.3 (7.4) hours in the pre-BCU era to 9.4 (9.9) hours in BCU, p < 0.001. BCU stay was shorter from 2.41 (1.4) days pre-BCP to 1.93 (1.32) days post-BCP, (p < 0.001). The total hospital stay in pre-BCU (4.0 [2.08] days) as compared to BCU (4.13 [2.62] days; p = 0.58) was similar; there was no impact of BCU on survival. CONCLUSION A BCU implementation showed improvement in time to UGI endoscopy, and did not reduce BCU stay or impact survival.
Collapse
|
|
35
|
Solà E, Lens S, Guevara M, Martín-Llahí M, Fagundes C, Pereira G, Pavesi M, Fernández J, González-Abraldes J, Escorsell A, Mas A, Bosch J, Arroyo V, Ginès P. Hyponatremia in patients treated with terlipressin for severe gastrointestinal bleeding due to portal hypertension. Hepatology 2010; 52:1783-90. [PMID: 20931555 DOI: 10.1002/hep.23893] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
UNLABELLED Terlipressin is frequently used in acute variceal bleeding due to its powerful effect on vasopressin V1 receptors. Although terlipressin is also a partial agonist of renal vasopressin V2 receptors, its effects on serum sodium concentration have not been specifically investigated. To examine the effects of terlipressin on serum sodium concentration in patients with acute portal-hypertensive bleeding, 58 consecutive patients with severe portal-hypertensive bleeding treated with terlipressin were investigated. In the whole population, serum sodium decreased from 134.9 ± 6.6 mEq/L to 130.5 ± 7.7 mEq/L (P = 0.002). Thirty-nine patients (67%) had a decrease in serum sodium ≥ 5 mEq/L during treatment: in 18 patients (31%), between 5 and 10 mEq/L and in 21 patients (36%), greater than 10 mEq/L. In this latter group, serum sodium decreased from 137.2 ± 5 to 120.5 ± 5 mEq/L (P < 0.001). In multivariate analysis, the reduction in serum sodium was related to baseline serum sodium and Model for End-Stage Liver Disease (MELD) score; patients with low MELD and normal or near-normal baseline serum sodium had the highest risk of hyponatremia. Serum sodium returned to baseline values in most patients shortly after cessation of therapy. Three of the 21 patients with marked reduction in serum sodium developed neurological manifestations, including osmotic demyelination syndrome in one patient due to a rapid recovery of serum sodium (serum sodium in these three patients decreased from 135, 130, and 136 to 117, 114, and 109 mEq/L, respectively). CONCLUSION An acute reduction in serum sodium concentration is common during treatment with terlipressin for severe portal-hypertensive bleeding. It develops rapidly after start of therapy, may be severe in some patients and is associated with neurological complications, and is usually reversible after terlipressin withdrawal.
Collapse
Affiliation(s)
- Elsa Solà
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Catalunya, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
36
|
Hussey S, Kelleher KT, Ling SC. Emergency Management of Major Upper Gastrointestinal Hemorrhage in Children. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2010. [DOI: 10.1016/j.cpem.2010.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
|
37
|
Herrlinger K. [Classification and management of upper gastrointestinal bleeding]. Internist (Berl) 2010; 51:1145-56; quiz 1157. [PMID: 20680239 DOI: 10.1007/s00108-010-2590-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The upper gastrointestinal bleeding remains the most frequent emergency in gastroenterology. Due to the different therapeutic approach a distinction between the variceal and the non-variceal bleeding has been established. A risk assessment for the individual patient is crucial for timing of the endoscopic procedure as well as for the estimation of prognosis. This review gives an overview on modern therapeutic techniques for both, variceal and non-variceal bleeding highlighting on success rates but also on potential complications of the different therapeutic interventions.
Collapse
Affiliation(s)
- K Herrlinger
- Abteilung für Gastroenterologie, Hepatologie und Endokrinologie, Robert-Bosch-Krankenhaus, Auerbachstraße 110, 70376 Stuttgart, Deutschland.
| |
Collapse
|
|
38
|
Factors determining the clinical outcome of acute variceal bleed in cirrhotic patients. Indian J Gastroenterol 2010; 28:93-5. [PMID: 19907958 DOI: 10.1007/s12664-009-0034-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Revised: 12/22/2008] [Accepted: 02/10/2009] [Indexed: 02/07/2023]
Abstract
Variceal bleed is a severe complication of portal hypertension. We studied the predictors of failure to control variceal bleed and re-bleed in patients with cirrhosis. We reviewed the case records of 382 consecutive patients admitted with variceal bleed from January 2001 to December 2005. Diagnosis of cirrhosis was made on clinical, laboratory, and radiological parameters. Acute variceal bleeding, failure to control bleed, and re-bleeding were defined according to Baveno III consensus report. Failure to control bleed was observed in 39 (10.2%) patients while in hospital re-bleed occurred in 49 (12.8%) patients. Thirty-four patients died. Diabetes was present in 148 (39%) patients. On multivariate logistic regression analysis, predictors of failure to control bleed were presence of diabetes mellitus and active bleeding at the time of endoscopy; predictors of in-hospital re-bleed were diabetes mellitus and serum bilirubin >3 mg/dL. Diabetes mellitus, active bleeding at endoscopy and bilirubin >3 mg/dL are bad prognostic factors for initial control of variceal bleed, and recurrent bleed in patients with cirrhosis.
Collapse
|
|
39
|
Response to Gin-Ho Lo. Am J Gastroenterol 2009. [DOI: 10.1038/ajg.2009.499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2025]
|
|
40
|
Combination of endoscopic band ligation with terlipressin is better than that with octreotide in shortening hospital stay? Am J Gastroenterol 2009; 104:2855; author reply 2855-6. [PMID: 19888245 DOI: 10.1038/ajg.2009.495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
|
41
|
Testro AG, Angus PW. Targeting circulatory dysfunction in cirrhosis: terlipressin and the hepatorenal syndrome. J Gastroenterol Hepatol 2009; 24:1707-9. [PMID: 20136956 DOI: 10.1111/j.1440-1746.2009.06034.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|
|
42
|
|
|
43
|
|