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Amador A, Salord S, Xiol X, Garcia-Guix M, Cachero A, Rota R, Hernandez Aretxabaleta N, Baliellas C, Castellote J. Improvement of quality of care provided to outpatients with hepatic cirrhosis after an educational intervention. Eur J Gastroenterol Hepatol 2024; 36:941-944. [PMID: 38625820 DOI: 10.1097/meg.0000000000002778] [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: 04/18/2024]
Abstract
OBJECTIVE A set of indicators has been reported to measure the quality of care for cirrhotic patients, and previously published studies report variable adherence rates to these indicators. This study aimed to assess the quality of care provided to cirrhotic outpatients before and after an educational intervention by determining its impact on adherence to quality indicators. METHODS We conducted a quasi-experimental, cross-sectional study including 324 cirrhotic patients seen in 2017 and 2019 at a tertiary teaching hospital in Spain. Quality indicators were assessed in five domains: documentation of cirrhosis etiology, disease severity assessment, hepatocellular carcinoma (HCC) screening, variceal bleeding prophylaxis, and vaccination. After identifying areas for improvement, an educational intervention was implemented. A second evaluation was performed after the intervention to assess changes in adherence rates. RESULTS Before the intervention, adherence rates were excellent (>90%) for indicators related to variceal bleeding prophylaxis and documentation of cirrhosis etiology, acceptable (60-80%) for HCC screening and disease severity assessment, and poor (<50%) for vaccinations. After the educational intervention, there was a statistically significant improvement in adherence rates for eight indicators related to HCC screening (70-90%), disease severity assessment (90%), variceal bleeding prophylaxis (>90%), and vaccinations (60-90%). CONCLUSION Our study demonstrates a significant improvement in the quality of care provided to cirrhotic outpatients after an educational intervention. The findings highlight the importance of targeted educational interventions to enhance adherence to quality indicators in the management of cirrhosis.
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Affiliation(s)
- Alberto Amador
- Hepatology Unit, Gastroenterology Department, Hospital Universitari de Bellvitge, Institut Català de la Salut, Hepatobiliary and Pancreatic Diseases Research Group, IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
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Nugraha YK, Maimunah U. Perioperative management of constrictive pericarditis with cardiac cirrhosis: A case report. Int J Surg Case Rep 2024; 120:109843. [PMID: 38848659 DOI: 10.1016/j.ijscr.2024.109843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/26/2024] [Accepted: 05/30/2024] [Indexed: 06/09/2024] Open
Abstract
INTRODUCTION The interactions between the heart and liver have been known for a long time, pericarditis constrictive could cause congestive hepatopathy via right-sided heart failure. Liver cirrhosis correlates with a high risk of mortality so perioperative management greatly influences outcomes. CASE PRESENTATION An Indonesian man, 50 years old, complained of breath shortness. The patient had a history of pulmonary tuberculosis and was declared cured 30 years ago. The patient began experiencing fatigue 14 years ago, and the patient was diagnosed with constrictive pericarditis 5 years ago. Currently, the patient has an increased jugular venous pressure of 9 cmH2O and abnormal laboratory indicators, including a platelet count of 121,000/μL, albumin count of 3.41 g/L, direct bilirubin count of 0.7 mg/dL, total bilirubin count of 1.4 mg/dL, and INR of 1.4. Echocardiography revealed left ventricle hypertrophy, diastolic dysfunction, and right ventricle failure. Cardiac CT scan showed pericardial calcification. Abdominal ultrasound showed liver congestive and splenomegaly. Transient elastography showed severe fibrosis in liver and stiffness in spleen. The patient underwent pericardiectomy with CTP score of 6 and MELD of 12. The surgery was successful, and the complaint was reduced. The patient experienced an improvement in his condition and able to carry out activities well after 2 years post-surgery. DISCUSSION The patient has no contraindications to pericardiectomy, CTP class A (5-6) and MELD score <13.5 has a low risk of mortality. CONCLUSION CTP and MELD scores predict life expectancy in post-surgery cardiac cirrhosis patients.
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Affiliation(s)
- Yudha Klahan Nugraha
- Study Program of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Ummi Maimunah
- Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Academic Hospital, Surabaya, Indonesia.
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Borhani A, Luu H, Mohseni A, Xu Z, Shaghaghi M, Tolosa C, Attari MMA, Madani SP, Shahbazian H, Khoshpouri P, Afyouni S, Zandieh G, Kamel IR, Kim AK. Screening for exclusion of high-risk bleeding features of esophageal varices in cirrhosis through CT and MRI. Clin Imaging 2024; 110:110168. [PMID: 38703476 DOI: 10.1016/j.clinimag.2024.110168] [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: 11/16/2023] [Revised: 04/14/2024] [Accepted: 04/18/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND & AIM Esophageal varices (EV) screening guidelines have evolved with improved risk stratification to avoid unnecessary esophagogastroduodenoscopy (EGD) in individuals with low bleeding risks. However, uncertainties persist in the recommendations for certain patient groups, particularly those with hepatocellular carcinoma (HCC) and/or receiving non-selective beta-blockers (NSBB) without prior endoscopy. This study assessed the efficacy of imaging in ruling out EVs and their high-risk features associated with bleeding in patients with cirrhosis and with HCC. We also evaluated the impact of NSBB on the detection of these characteristics. METHODS A total of 119 patients undergoing EGD with CT and/or MRI within 90 days of the procedure were included. 87 patients had HCC. A new imaging grading system was developed utilizing the size of EVs and the extent of their protrusion into the esophagus lumen. The negative predictive value (NPV) of EVimaging(-) versus EVimaging (+) (grades 1-3) in ruling out the presence of EV and/or high-risk features by EGD was calculated. The predictive performance of imaging was determined by logistic regression. RESULTS The NPV of imaging for detecting EV and high-risk features was 81 % and 92 %, respectively. Among HCC patients, the NPV for EV and high-risk features was 80 % and 64 %, respectively. Being on NSBB didn't statistically impact the imaging detection of EV. Imaging was a better predictor of high-risk EGD findings than Child-Turcotte-Pugh scores. CONCLUSIONS Our results suggest that imaging can effectively rule out the presence of EV and high-risk features during EGD, even in patients with HCC and/or receiving NSBB.
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Affiliation(s)
- Ali Borhani
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Harry Luu
- Department of Medicine, Gastroenterology and Hepatology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Alireza Mohseni
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ziyi Xu
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Mohammadreza Shaghaghi
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Celestina Tolosa
- Department of Medicine, Gastroenterology and Hepatology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Seyedeh Panid Madani
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Haneyeh Shahbazian
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Pegah Khoshpouri
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Shadi Afyouni
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ghazal Zandieh
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ihab R Kamel
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - Amy K Kim
- Department of Medicine, Gastroenterology and Hepatology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Jothimani D, Rela M, Kamath PS. Management of Portal Hypertension in the Older Patient. Curr Gastroenterol Rep 2024:10.1007/s11894-024-00930-y. [PMID: 38780678 DOI: 10.1007/s11894-024-00930-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE OF THIS REVIEW Aging is a process of physiological slowing, reduced regenerative capacity and inability to maintain cellular homeostasis. World Health Organisation declared the commencement of population aging globally, largely attributed to improvement in the healthcare system with early diagnosis and effective clinical management. Liver ages similar to other organs, with reduction in size and blood flow. In this review we aim to evaluate the effect of aging in liver disease. RECENT FINDINGS Aging causes dysregulation of major carbohydrate, fat and protein metabolism in the liver. Age is a major risk factor for liver fibrosis accelerated by sinusoidal endothelial dysfunction and immunological disharmony. Age plays a major role in patients with liver cirrhosis and influence outcomes in patients with portal hypertension. Transient elastography may be an useful tool in the assessment of portal hypertension. Hepatic structural distortion, increased vascular resistance, state of chronic inflammation, associated comorbidities, lack of physiological reserve in the older population may aggravate portal hypertension in patients with liver cirrhosis and may result in pronounced variceal bleed. Cut-offs for other non-invasive markers of fibrosis may differ in the elderly population. Non-selective beta blockers initiated at lower dose followed by escalation are the first line of therapy in elderly patients with cirrhosis and portal hypertension, unless contraindicated. Acute variceal bleed in the elderly cirrhotic patients can be life threatening and may cause rapid exsanguination due to poor reserve and associated comorbidities. Vasoactive drugs may be associated with more adverse reactions. Early endoscopy may be warranted in the elderly patients with acute variceal bleed. Role of TIPS in the elderly cirrhotics discussed. Management of portal hypertension in the older population may pose significant challenges to the treating clinician.
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Affiliation(s)
- Dinesh Jothimani
- Institute of Liver disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, India.
| | - Mohamed Rela
- Institute of Liver disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, India
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, 55906, USA
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Menichelli D, Gazzaniga G, Del Sole F, Pani A, Pignatelli P, Pastori D. Acute upper and lower gastrointestinal bleeding management in older people taking or not taking anticoagulants: a literature review. Front Med (Lausanne) 2024; 11:1399429. [PMID: 38765253 PMCID: PMC11099229 DOI: 10.3389/fmed.2024.1399429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 04/11/2024] [Indexed: 05/21/2024] Open
Abstract
Acute upper and lower gastrointestinal (GI) bleeding may be a potentially life-threatening event that requires prompt recognition and an early effective management, being responsible for a considerable number of hospital admissions. Methods. We perform a clinical review to summarize the recent international guidelines, helping the physician in clinical practice. Older people are a vulnerable subgroup of patients more prone to developing GI bleeding because of several comorbidities and polypharmacy, especially related to an increased use of antiplatelet and anticoagulant drugs. In addition, older patients may have higher peri-procedural risk that should be evaluated. The recent introduction of reversal strategies may help the management of GI bleeding in this subgroup of patients. In this review, we aimed to (1) summarize the epidemiology and risk factors for upper and lower GI bleeding, (2) describe treatment options with a focus on pharmacodynamics and pharmacokinetics of different proton pump inhibitors, and (3) provide an overview of the clinical management with flowcharts for risk stratification and treatment. In conclusion, GI is common in older patients and an early effective management may be helpful in the reduction of several complications.
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Affiliation(s)
- Danilo Menichelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
- Department of General Surgery and Surgical Specialty Paride Stefanini, Sapienza University of Rome, Rome, Italy
| | - Gianluca Gazzaniga
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Francesco Del Sole
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Arianna Pani
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milan, Italy
| | - Pasquale Pignatelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Daniele Pastori
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
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Daneti D, Senthamizhselvan K, Chandra MR, Mohan P, Kate V. Clinical Outcomes and Their Determinants in Patients With Gastric Variceal Bleed Undergoing Endoscopic Cyanoacrylate Injection: An Observational Study. J Clin Exp Hepatol 2024; 14:101315. [PMID: 38283706 PMCID: PMC10821593 DOI: 10.1016/j.jceh.2023.101315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/06/2023] [Indexed: 01/30/2024] Open
Abstract
Background and aims Gastric variceal bleeding (GVB), compared to esophageal varices, is rare but often massive and associated with high mortality. Endoscopic cyanoacrylate glue injection (ECGI) is the first-line treatment for GVB. Hence, we conducted this study to assess the clinical outcomes and the determinants of ECGI for gastric variceal bleeding. Methods This was a prospective observational study of patients with ECGI for GVB between June 2019 and February 2023. The demographic characteristics, etiology and severity of cirrhosis, size, type of gastric varices, volume of cyanoacrylate used, number of sessions required, technical success, rebleeding rate, and survival at three months were studied. Results A total of 135 patients underwent ECGI for GVB. Their mean (SD) age was 44.9 (13.6) years, with a male preponderance (n = 23, 68.1 %). Eighty-two patients (60.7 %) had cirrhosis. Their mean model for end-stage liver disease (MELD) score was 14.3 (7.3). Gastric varices were gastroesophageal varices (GOV)1 in 42 (31.1 %), GOV2 in 73 (54.1 %), and isolated gastric varices (IGV)1 in 20 (14.8 %) patients. Varices were large in 35 (25.9 %) and had F1 morphology in 89 (65.9 %) patients. The success rate of initial hemostasis was 98.5 %. The median sessions required were 1 (1-2), and the median volume of cyanoacrylate per session was 2 (1-2) ml. The procedure was associated with minor complications like transient abdominal pain in 11 (8.1 %) and fever in 2 (2.7 %) patients. Rebleeding was observed in 23 (17 %) patients. GOV2, F1 morphology, and a high MELD score were significantly associated with rebleeding. Five (3.7 %) patients died during the study; 2 (1.5 %) were due to failure to control bleeding. Conclusion In conclusion, our study demonstrated ECGI to be very safe and effective for GVB. The technical success was high and could be achieved in fewer sessions with a smaller volume of cyanoacrylate during each session.
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Affiliation(s)
- Dharanesh Daneti
- Department of Medical Gastroenterology, JIPMER, Puducherry, India
| | | | | | - Pazhanivel Mohan
- Department of Medical Gastroenterology, JIPMER, Puducherry, India
| | - Vikram Kate
- Department of Surgery, JIPMER, Puducherry, India
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Lo GH, Yeh JH, Tseng CH, Chen TH, Tai CM, Wang WL, Lin HC. A Noninferiority Trial Comparing 2 Days vs 5 Days of Terlipressin and Ceftriaxone in Terms of 5-Day Rebleeding for Patients With Acute Gastroesophageal Variceal Hemorrhage. Am J Gastroenterol 2024:00000434-990000000-01085. [PMID: 38526204 DOI: 10.14309/ajg.0000000000002776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 02/26/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION This trial was to shorten the duration of both vasoconstrictors and prophylactic antibiotics to only 2 days in the therapy of acute gastroesophageal variceal hemorrhage. METHODS After successful endoscopic hemostasis of gastroesophageal variceal hemorrhage, eligible patients were randomized to receive terlipressin infusion 1 mg per 6 hours and ceftriaxone 1 g daily for 5 days (group A) or a similar regimen for 2 days (group B). Primary end points were very early rebleeding at 5 days, and secondary end points included 48-hour hemostasis, 42-day rebleeding, and hospitalization days. RESULTS Group A comprised 48 patients, and group B comprised 52 patients. Both groups were comparable in the severity of liver disease. Forty-eight-hour initial hemostasis was 95.8% in group A and 100% in group B ( P = 0.13). Very early rebleeding between 3 and 5 days occurred in 1 patient (2.1%) in group A and 2 patients (3.8%) in group B ( P = 0.60). The difference was 1.8% and the 95% confidence interval was -1.31% to 2.08%, which demonstrated noninferiority. Forty-two-day rebleeding occurred in 5 patients (10.4%) in group A and 4 patients (7.7%) in group B ( P = 0.63). The median hospitalization days were 8.5 ± 3.8 days in group A vs 5.6 ± 2.6 days in group B ( P < 0.001). DISCUSSION After successful endoscopic hemostasis of acute variceal bleeding, combination of 2-day terlipressin infusion and ceftriaxone therapy was not inferior to the 5-day regimen in terms of very early rebleeding, with the advantage of shortening hospitalization stay.
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Affiliation(s)
- Gin-Ho Lo
- Division of Gastroenterology, Department of Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Jen-Hao Yeh
- Division of Gastroenterology, Department of Medicine, E-Da Dachang Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Cheng-Hao Tseng
- Division of Gastroenterology, Department of Medicine, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Tzu-Haw Chen
- Division of Gastroenterology, Department of Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Chi-Ming Tai
- Division of Gastroenterology, Department of Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Wen-Lun Wang
- Division of Gastroenterology, Department of Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Hui-Chen Lin
- Division of Gastroenterology, Department of Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
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Patel VC, McPhail MJ, Uddin R, Jafari H, Lawrence V, Le Boutillier C, Shearer J, Yaziji N, Cape A, Ahmed H, Ward C, Walsh P, Besly K, Zamalloa A, Kelly J, Carter B. Beta-blockers or Placebo for Primary Prophylaxis (BOPPP) of oesophageal varices: study protocol for a randomised controlled trial. Trials 2024; 25:265. [PMID: 38627804 PMCID: PMC11022376 DOI: 10.1186/s13063-024-08063-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/18/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Liver disease is within the top five causes of premature death in adults. Deaths caused by complications of cirrhosis continue to rise, whilst deaths related to other non-liver disease areas are declining. Portal hypertension is the primary sequelae of cirrhosis and is associated with the development of variceal haemorrhage, ascites, hepatic encephalopathy and infection, collectively termed hepatic decompensation, which leads to hospitalisation and mortality. It remains uncertain whether administering a non-selective beta-blocker (NSBB), specifically carvedilol, at an earlier stage, i.e. when oesophageal varices are small, can prevent VH and reduce all-cause decompensation (ACD). METHODS/DESIGN The BOPPP trial is a pragmatic, multicentre, placebo-controlled, triple-blinded, randomised controlled trial (RCT) in England, Scotland, Wales and Northern Ireland. Patients aged 18 years or older with cirrhosis and small oesophageal varices that have never bled will be recruited, subject to exclusion criteria. The trial aims to enrol 740 patients across 55 hospitals in the UK. Patients are allocated randomly on a 1:1 ratio to receive either carvedilol 6.25 mg (a NSBB) or a matched placebo, once or twice daily, for 36 months, to attain adequate power to determine the effectiveness of carvedilol in preventing or reducing ACD. The primary outcome is the time to first decompensating event. It is a composite primary outcome made up of variceal haemorrhage (VH, new or worsening ascites, new or worsening hepatic encephalopathy (HE), spontaneous bacterial peritonitis (SBP), hepatorenal syndrome, an increase in Child-Pugh grade by 1 grade or MELD score by 5 points, and liver-related mortality. Secondary outcomes include progression to medium or large oesophageal varices, development of gastric, duodenal, or ectopic varices, participant quality of life, healthcare costs and transplant-free survival. DISCUSSION The BOPPP trial aims to investigate the clinical and cost-effectiveness of carvedilol in patients with cirrhosis and small oesophageal varices to determine whether this non-selective beta-blocker can prevent or reduce hepatic decompensation. There is clinical equipoise on whether intervening in cirrhosis, at an earlier stage of portal hypertension, with NSBB therapy is beneficial. Should the trial yield a positive result, we anticipate that the administration and use of carvedilol will become widespread with pathways developed to standardise the administration of the medication in primary care. ETHICS AND DISSEMINATION The trial has been approved by the National Health Service (NHS) Research Ethics Committee (REC) (reference number: 19/YH/0015). The results of the trial will be submitted for publication in a peer-reviewed scientific journal. Participants will be informed of the results via the BOPPP website ( www.boppp-trial.org ) and partners in the British Liver Trust (BLT) organisation. TRIAL REGISTRATION EUDRACT reference number: 2018-002509-78. ISRCTN reference number: ISRCTN10324656. Registered on April 24 2019.
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Affiliation(s)
- Vishal C Patel
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK.
- Institute of Liver Studies, Faculty of Life Sciences and Medicine, School of Immunology and Microbial Sciences, King's College London, London, UK.
- The Roger Williams Institute of Hepatology, Foundation for Liver Research, 111 Coldharbour Lane, London, SE5 9NT, UK.
| | - Mark J McPhail
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
- Institute of Liver Studies, Faculty of Life Sciences and Medicine, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Ruhama Uddin
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Hassan Jafari
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- King's Clinical Trials Unit, Institute of Psychiatry, Psychology & Neuroscience,, King's College London, London, UK
| | - Vanessa Lawrence
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Clair Le Boutillier
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Division of Methodologies, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - James Shearer
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Nahel Yaziji
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Angela Cape
- King's Clinical Trials Unit, Institute of Psychiatry, Psychology & Neuroscience,, King's College London, London, UK
| | - Haroon Ahmed
- Cardiff University, Division of Population Medicine, Cardiff, UK
| | | | - Peter Walsh
- British Liver Trust, Venta Court, Winchester, UK
| | - Kevin Besly
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Ane Zamalloa
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Joanna Kelly
- King's Clinical Trials Unit, Institute of Psychiatry, Psychology & Neuroscience,, King's College London, London, UK
| | - Ben Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- King's Clinical Trials Unit, Institute of Psychiatry, Psychology & Neuroscience,, King's College London, London, UK
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Melandro F, Parisse S, Ginanni Corradini S, Cardinale V, Ferri F, Merli M, Alvaro D, Pugliese F, Rossi M, Mennini G, Lai Q. Transjugular Intrahepatic Portosystemic Shunt as a Bridge to Abdominal Surgery in Cirrhosis. J Clin Med 2024; 13:2213. [PMID: 38673486 PMCID: PMC11050968 DOI: 10.3390/jcm13082213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/01/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
Abdominal surgery is associated with high postoperative mortality and morbidity in cirrhotic patients. Despite improvements in surgical techniques, clinical management, and intensive care, the outcome could be influenced by the degree of portal hypertension, the severity of hepatopathy, or the type of surgery. Preoperative transjugular intrahepatic portosystemic shunt (TIPS) placement, in addition to medical therapy, plays an important role in managing the complications of portal hypertension such as ascites, hepatic encephalopathy, variceal bleeding or portal vein thrombosis. To date, the improvement of post-surgery outcomes in cirrhotic patients after TIPS placement remains unclear. Only observational data existing in the literature and prospective studies are urgently needed to evaluate the efficacy and safety of TIPS in this setting. This review aims to outline the role of TIPS as a tool in postoperative complications reduction in cirrhotic patients, both in the setting of emergency and elective surgery.
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Affiliation(s)
- Fabio Melandro
- Department of General and Specialist Surgery, Sapienza University of Rome, 00185 Rome, Italy; (F.P.); (M.R.); (G.M.); (Q.L.)
| | - Simona Parisse
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.P.); (S.G.C.); (V.C.); (F.F.); (M.M.); (D.A.)
| | - Stefano Ginanni Corradini
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.P.); (S.G.C.); (V.C.); (F.F.); (M.M.); (D.A.)
| | - Vincenzo Cardinale
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.P.); (S.G.C.); (V.C.); (F.F.); (M.M.); (D.A.)
| | - Flaminia Ferri
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.P.); (S.G.C.); (V.C.); (F.F.); (M.M.); (D.A.)
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.P.); (S.G.C.); (V.C.); (F.F.); (M.M.); (D.A.)
| | - Domenico Alvaro
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.P.); (S.G.C.); (V.C.); (F.F.); (M.M.); (D.A.)
| | - Francesco Pugliese
- Department of General and Specialist Surgery, Sapienza University of Rome, 00185 Rome, Italy; (F.P.); (M.R.); (G.M.); (Q.L.)
| | - Massimo Rossi
- Department of General and Specialist Surgery, Sapienza University of Rome, 00185 Rome, Italy; (F.P.); (M.R.); (G.M.); (Q.L.)
| | - Gianluca Mennini
- Department of General and Specialist Surgery, Sapienza University of Rome, 00185 Rome, Italy; (F.P.); (M.R.); (G.M.); (Q.L.)
| | - Quirino Lai
- Department of General and Specialist Surgery, Sapienza University of Rome, 00185 Rome, Italy; (F.P.); (M.R.); (G.M.); (Q.L.)
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Abramowitz BR, Meier RR, Chen M, Graham-Hill S. Ultrarapid Development of Ruptured Esophageal Varices in a Patient With a History of Heller Myotomy. Cureus 2024; 16:e58954. [PMID: 38800322 PMCID: PMC11126783 DOI: 10.7759/cureus.58954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2024] [Indexed: 05/29/2024] Open
Abstract
Esophageal varices commonly affect cirrhotic patients as a result of elevated portal system resistance. Blood pools within esophageal portosystemic collateral vessels, which can eventually rupture, leading to life-threatening hemorrhage. To prevent this, cirrhotic patients without a history of varices undergo endoscopic surveillance for varices every 2-3 years. We present an unusual case of variceal hemorrhage in a patient who was seen to have no varices on endoscopic evaluation only a month earlier.
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Affiliation(s)
- Binyamin R Abramowitz
- Internal Medicine, State University of New York Downstate Health Sciences University, Brooklyn, USA
| | | | - Michelle Chen
- Internal Medicine, State University of New York Downstate Health Sciences University, Brooklyn, USA
| | - Suzette Graham-Hill
- Cardiology, State University of New York Downstate Health Sciences University, Brooklyn, USA
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11
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Zhu J, Xia Y, Liu X, Zhang C. Preventing variceal rebleeding in cirrhotic patients with portal vein thrombosis: A systematic review and meta-analysis. J Gastroenterol Hepatol 2024; 39:642-648. [PMID: 38233086 DOI: 10.1111/jgh.16489] [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: 08/11/2023] [Revised: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 01/19/2024]
Abstract
BACKGROUND AND AIM Preventing rebleeding is crucial, but the best prevention technique for patients with cirrhosis and portal vein thrombosis (PVT) remains debatable. Therefore, this systematic review and meta-analysis compared a transjugular intrahepatic portosystemic shunt (TIPS) with endoscopic therapy (ET) plus nonselective beta-blockers (NSBBs) for preventing variceal rebleeding in this patient population. METHODS The PubMed, Embase, Cochrane Library, and Web of Science databases were searched from their inception until May 18, 2023. The studies were screened using predetermined criteria, relevant data were extracted, and pooled analyses were performed using the Reviewer Manager 5.4.1 software. RESULTS We retrieved 1032 studies, of which 5 studies comprising a total of 272 patients were included. The postoperative variceal rebleeding rate was significantly lower in the TIPS group than in the ET + NSBBs group (odds ratio [OR] = 0.19, 95% confidence interval [CI] = 0.11-0.35, P < 0.05, I2 = 0%), but the portal vein recanalization rate was higher (OR = 7.92, 95% CI = 3.04-20.67, P < 0.05, I2 = 0%). The rates of hepatic encephalopathy (HE) and mortality did not differ between the groups. CONCLUSIONS Our results suggest that TIPS prevents variceal rebleeding without increasing the hepatic encephalopathy risk more effectively than ET plus NSBBs, but this benefit did not translate into improved survival. Thus, it may be preferable to ET plus NSBBs for preventing variceal rebleeding in patients with cirrhosis and PVT. However, more large-scale and multicenter randomized controlled trials involving other patient populations are required to verify the clinical efficacy of both these treatments and ensure generalizability.
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Affiliation(s)
- Junyuan Zhu
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yifu Xia
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Xiao Liu
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, China
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12
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Jiang JJ, Gao C, Mao JF, Yang GY, Huang J, Yu XH, Tan Y, Zhang JC, Zheng XF. Effect of endoscopic therapy and drug therapy on prognosis and rebleeding in patients with esophagogastric variceal bleeding. Sci Rep 2024; 14:7364. [PMID: 38548903 PMCID: PMC10978843 DOI: 10.1038/s41598-024-57791-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 03/21/2024] [Indexed: 04/01/2024] Open
Abstract
Esophagogastric variceal bleeding (EVB) is one of the common digestive system emergencies with poor prognosis and high rate of rebleeding after treatment. To explore the effects of endoscopic therapy and drug therapy on the prognosis and rebleeding of patients with EVB, and then select better treatment methods to effectively improve the prognosis. From January 2013 to December 2022, 965 patients with EVB who were hospitalized in gastroenterology Department of the 940 Hospital of Joint Logistic Support Forces of PLA were retrospectively analyzed. Patients were divided into endoscopic treatment group (ET, n = 586) and drug treatment group (DT, n = 379). Propensity score matching (PSM) analysis was performed in both groups, and the general information, efficacy and length of hospital stay were recorded. The patients were followed up for 3 months after bleeding control to determine whether rebleeding occurred. There were 286 cases in each group after PSM. Compared with DT group, ET had higher treatment success rate (P < 0.001), lower rebleeding rate (P < 0.001), lower mortality rate within 3 months, and no significant difference in total hospital stay (P > 0.05). Compared with drug therapy, endoscopic treatment of EVB has short-term efficacy advantages, and can effectively reduce the incidence of rebleeding and mortality within 3 months.
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Affiliation(s)
- Jing-Jing Jiang
- Department of Gastroenterology, The 940 Hospital of Joint Logistic Support Forces of PLA, Qilihe District, 333Rd Binhenan Road, Lanzhou, 730050, Gansu, China
- The First School of Clinical Medical, Gansu University of Chinese Medicine, Lanzhou, 730000, Gansu, China
| | - Chun Gao
- Department of Gastroenterology, The 940 Hospital of Joint Logistic Support Forces of PLA, Qilihe District, 333Rd Binhenan Road, Lanzhou, 730050, Gansu, China
- The First School of Clinical Medical, Gansu University of Chinese Medicine, Lanzhou, 730000, Gansu, China
| | - Jun-Feng Mao
- Department of Nuclear Medicine, The 940 Hospital of Joint Logistic Support Forces of PLA, Lanzhou, 730050, Gansu, China
| | - Guo-Yuan Yang
- The First School of Clinical Medical, Gansu University of Chinese Medicine, Lanzhou, 730000, Gansu, China
| | - Jun Huang
- Department of Gastroenterology, The 940 Hospital of Joint Logistic Support Forces of PLA, Qilihe District, 333Rd Binhenan Road, Lanzhou, 730050, Gansu, China
- The First School of Clinical Medical, Gansu University of Chinese Medicine, Lanzhou, 730000, Gansu, China
| | - Xiao-Hui Yu
- Department of Gastroenterology, The 940 Hospital of Joint Logistic Support Forces of PLA, Qilihe District, 333Rd Binhenan Road, Lanzhou, 730050, Gansu, China
| | - Yong Tan
- Department of Gastroenterology, The 940 Hospital of Joint Logistic Support Forces of PLA, Qilihe District, 333Rd Binhenan Road, Lanzhou, 730050, Gansu, China
| | - Jiu-Cong Zhang
- Department of Gastroenterology, The 940 Hospital of Joint Logistic Support Forces of PLA, Qilihe District, 333Rd Binhenan Road, Lanzhou, 730050, Gansu, China.
| | - Xiao-Feng Zheng
- Department of Gastroenterology, The Second Hospital of Lanzhou University, Lanzhou, 730030, Gansu, China.
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13
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Tripathi D, Patch D, Mehrzad H, Yu D, Aspinall RJ, Armstrong MJ, Stanley A, Ireland H, Travis S, Hayes P, Lomax M, Roslund N, Lam E, Slinn G, Jowett S, Moakes C, Maher A, Brettell E, Sehmi S. Study protocol for a Randomised controlled trial of EArly transjugular intrahepatiC porTosystemic stent-shunt in Acute Variceal Bleeding (REACT-AVB trial). BMJ Open Gastroenterol 2024; 11:e001314. [PMID: 38519049 DOI: 10.1136/bmjgast-2023-001314] [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: 12/02/2023] [Accepted: 02/16/2024] [Indexed: 03/24/2024] Open
Abstract
INTRODUCTION In liver cirrhosis, acute variceal bleeding (AVB) is associated with a 1-year mortality rate of up to 40%. Data on early or pre-emptive transjugular intrahepatic portosystemic stent-shunt (TIPSS) in AVB is inconclusive and may not reflect current management strategies. Randomised controlled trial of EArly transjugular intrahepatiC porTosystemic stent-shunt in AVB (REACT-AVB) aims to investigate the clinical and cost-effectiveness of early TIPSS in patients with cirrhosis and AVB after initial bleeding control. METHODS AND ANALYSIS REACT-AVB is a multicentre, randomised controlled, open-label, superiority, two-arm, parallel-group trial with an internal pilot. The two interventions allocated randomly 1:1 are early TIPSS within 4 days of diagnostic endoscopy or secondary prophylaxis with endoscopic therapy in combination with non-selective beta blockers. Patients aged ≥18 years with cirrhosis and Child-Pugh Score 7-13 presenting with AVB with endoscopic haemostasis are eligible for inclusion. The primary outcome is transplant-free survival at 1 year post randomisation. Secondary endpoints include transplant-free survival at 6 weeks, rebleeding, serious adverse events, other complications of cirrhosis, Child-Pugh and Model For End-Stage Liver Disease (MELD) scores at 6 and 12 months, health-related quality of life, use of healthcare resources, cost-effectiveness and use of cross-over therapies. The sample size is 294 patients over a 4-year recruitment period, across 30 hospitals in the UK. ETHICS AND DISSEMINATION Research ethics committee of National Health Service has approved REACT-AVB (reference number: 23/WM/0085). The results will be submitted for publication in a peer-reviewed journal. A lay summary will also be emailed or posted to participants before publication. TRIAL REGISTRATION NUMBER ISRCTN85274829; protocol version 3.0, 1 July 2023.
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Affiliation(s)
- Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - David Patch
- Hepatology and Liver Transplantation, Royal Free Hampstead NHS Trust, London, UK
| | - Homoyon Mehrzad
- Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Dominic Yu
- Department of Radiology, Royal Free London NHS Foundation Trust, London, UK
| | - Richard J Aspinall
- Gastroenterology and Hepatology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Matthew J Armstrong
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | | | - Hamish Ireland
- Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Simon Travis
- Department of Radiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Peter Hayes
- Hepatology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | - Emily Lam
- GI and Liver PPI Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Gemma Slinn
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
| | - Sue Jowett
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
| | - Catherine Moakes
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
| | - Alisha Maher
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
| | - Elizabeth Brettell
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
| | - Sukhwant Sehmi
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
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14
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Ichita C, Goto T, Okada Y, Uojima H, Iwagami M, Sasaki A, Shimizu S. Development and validation of a scoring system for in-hospital mortality following band ligation in esophageal variceal bleeding. Dig Endosc 2024. [PMID: 38462957 DOI: 10.1111/den.14773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/29/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVES We aimed to develop and validate a simple scoring system to predict in-hospital mortality after endoscopic variceal ligation (EVL) for esophageal variceal bleeding. METHODS Data from a 13-year study involving 46 Japanese institutions were split into development (initial 7 years) and validation (last 6 years) cohorts. The study subjects were patients hospitalized for esophageal variceal bleeding and treated with EVL. Variable selection was performed using least absolute shrinkage and selection operator regression, targeting in-hospital all-cause mortality as the outcome. We developed the Hospital Outcome Prediction following Endoscopic Variceal Ligation (HOPE-EVL) score from β coefficients of multivariate logistic regression and assessed its discrimination and calibration. RESULTS The study included 980 patients: 536 in the development cohort and 444 in the validation cohort. In-hospital mortality was 13.6% and 10.1% for the respective cohorts. The scoring system used five variables: systolic blood pressure (<80 mmHg: 2 points), Glasgow Coma Scale (≤12: 1 point), total bilirubin (≥5 mg/dL: 1 point), creatinine (≥1.5 mg/dL: 1 point), and albumin (<2.8 g/dL: 1 point). The risk groups (low: 0-1, middle: 2-3, high: ≥4) in the validation cohort corresponded to observed and predicted mortality probabilities of 2.0% and 2.5%, 19.0% and 22.9%, and 57.6% and 71.9%, respectively. In this cohort, the HOPE-EVL score demonstrated excellent discrimination ability (area under the curve [AUC] 0.890; 95% confidence interval [CI] 0.850-0.930) compared with the Model for End-stage Liver Disease score (AUC 0.853; 95% CI 0.794-0.912) and the Child-Pugh score (AUC 0.798; 95% CI 0.727-0.869). CONCLUSIONS The HOPE-EVL score practically and effectively predicts in-hospital mortality. This score could facilitate the appropriate allocation of resources and effective communication with patients and their families.
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Affiliation(s)
- Chikamasa Ichita
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kanagawa, Japan
- Department of Health Data Science, Yokohama City University, Kanagawa, Japan
| | - Tadahiro Goto
- Department of Health Data Science, Yokohama City University, Kanagawa, Japan
- TXP Research, TXP Medical Co., Ltd, Tokyo, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Yohei Okada
- Department of Preventive Services, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Health Services and Systems Research, Duke-NUS Medical School, Singapore City, Singapore
| | - Haruki Uojima
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kanagawa, Japan
- Department of Genome Medical Sciences Project, Research Institute, National Center for Global Health and Medicine, Chiba, Japan
| | - Masao Iwagami
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Chiba, Japan
| | - Akiko Sasaki
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Sayuri Shimizu
- Department of Health Data Science, Yokohama City University, Kanagawa, Japan
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15
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Dalbeni A, Cattazzo F, De Marco L, Bevilacqua M, Zoncapè M, Lombardi R, Stupia R, Mantovani A, Sacerdoti D. Bacterial infections as a risk factor for non-neoplastic portal vein thrombosis development in cirrhotic patients. Dig Liver Dis 2024; 56:477-483. [PMID: 37778894 DOI: 10.1016/j.dld.2023.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/23/2023] [Accepted: 09/07/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Portal vein thrombosis (PVT) and sepsis are common complications in patients with liver cirrhosis. Factors that lead to PVT are not completely understood. This study aimed to investigate the possible association between bacterial infections and the development of PVT in cirrhotic patients. PATIENTS AND METHODS 202 consecutive cirrhotic patients without previous infections, followed at the Liver Unit in Verona Hospital, were enrolled from 2017 to 2021 (median follow-up 3.3 years). During the follow-up period, PVT was diagnosed by ultrasound, CT and/or MRI, and episodes of bacterial infections requiring hospitalization were recorded. Malignant PVT was an exclusion criterion. RESULTS Of the 202 patients enrolled (68.3 % males, mean age 63.8 ± 11 years), 22 (10.8 %) developed PVT during the follow up. In patients with PVT, the prevalence of previous bacterial infections was significantly higher compared to patients without PVT (63.6% vs 31.1 %; p = 0.02). Cox regression analysis revealed that a history of bacterial infection was the only variable that demonstrated a significant association with the risk of de novo PVT occurrence (HR 4.04, 95 % CI: 1.68-9.65). CONCLUSION in patients with liver cirrhosis bacterial infections are a predisposing factor for the following development of PVT. Further studies are needed to confirm this evidence.
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Affiliation(s)
- Andrea Dalbeni
- Division of General Medicine C, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, University of Verona, Verona, Italy; Liver Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, University of Verona, Verona, Italy.
| | - Filippo Cattazzo
- Division of General Medicine C, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, University of Verona, Verona, Italy; Liver Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, University of Verona, Verona, Italy
| | - Leonardo De Marco
- Division of General Medicine C, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, University of Verona, Verona, Italy; Liver Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, University of Verona, Verona, Italy
| | - Michele Bevilacqua
- Division of General Medicine C, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, University of Verona, Verona, Italy; Liver Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, University of Verona, Verona, Italy
| | - Mirko Zoncapè
- Division of General Medicine C, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, University of Verona, Verona, Italy; Liver Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, University of Verona, Verona, Italy
| | - Rosa Lombardi
- Department of Pathophysiology and Transplantation, Unit of Metabolic and Internal Medicine, University of Milan, Italy
| | - Roberta Stupia
- Division of General Medicine C, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, University of Verona, Verona, Italy; Liver Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, University of Verona, Verona, Italy
| | - Anna Mantovani
- Division of General Medicine C, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, University of Verona, Verona, Italy; Liver Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, University of Verona, Verona, Italy.
| | - David Sacerdoti
- Liver Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, University of Verona, Verona, Italy
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16
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Murillo Pineda MI, Siu Xiao T, Sanabria Herrera EJ, Ayala Aguilar A, Arriaga Escamilla D, Aleman Reyes AM, Rojas Marron AD, Fabila Lievano RR, de Jesús Correa Gomez JJ, Martinez Ramirez M. The Prediction and Treatment of Bleeding Esophageal Varices in the Artificial Intelligence Era: A Review. Cureus 2024; 16:e55786. [PMID: 38586705 PMCID: PMC10999134 DOI: 10.7759/cureus.55786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 04/09/2024] Open
Abstract
Esophageal varices (EVs), a significant complication of cirrhosis, present a considerable challenge in clinical practice due to their high risk of bleeding and associated morbidity and mortality. This manuscript explores the transformative role of artificial intelligence (AI) in the management of EV, particularly in enhancing diagnostic accuracy and predicting bleeding risks. It underscores the potential of AI in offering noninvasive, efficient alternatives to traditional diagnostic methods such as esophagogastroduodenoscopy (EGD). The complexity of EV management is highlighted, necessitating a multidisciplinary approach that includes pharmacological therapy, endoscopic interventions, and, in some cases, surgical options tailored to individual patient profiles. Additionally, the paper emphasizes the importance of integrating AI into medical education and practice, preparing healthcare professionals for the evolving landscape of medical technology. It projects a future where AI significantly influences the management of gastrointestinal bleeding, improving clinical decision-making, patient outcomes, and overall healthcare efficiency. The study advocates for a patient-centered approach in healthcare, balancing the incorporation of innovative technologies with ethical principles and the diverse needs of patients to optimize treatment efficacy and enhance healthcare accessibility.
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Affiliation(s)
| | - Tania Siu Xiao
- Radiology, Thomas Jefferson University Hospital, Philadelphia, USA
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17
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Berengy MS, Abd El-Hamid Hassan EM, Ibrahim AH, Mohamed EF. Safety and efficacy of transjugular intrahepatic portosystemic shunts vs endoscopic band ligation plus propranolol in patients with cirrhosis with portal vein thrombosis: a systematic review and meta-analysis. J Gastrointest Surg 2024; 28:316-326. [PMID: 38445926 DOI: 10.1016/j.gassur.2023.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/20/2023] [Accepted: 12/30/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND This systematic review and meta-analysis aimed to assess the efficacy and safety of transjugular intrahepatic portosystemic shunts (TIPS) against the combined treatment of endoscopic band ligation (EBL) and propranolol in managing patients with cirrhosis diagnosed with portal vein thrombosis (PVT). METHODS A literature search from inception to September 2023 was performed using MEDLINE, the Cochrane Library, Web of Science, and Scopus. Independent screening, data extraction, and quality assessment were performed. The main measured outcomes were the incidence and recurrence of variceal bleeding (VB), hepatic encephalopathy, and overall survival. RESULTS A total of 5 studies were included. For variceal eradication, there was initially no significant difference between the groups; however, after sensitivity analysis, a significant effect emerged (risk ratio [RR], 1.55; P < .0001). TIPS was associated with a significant decrease in the incidence of VB (RR, 0.34; P < .0001) and a higher probability of remaining free of VB in the first 2 years after the procedure (first year: RR, 1.41; P < .0001; second year: RR, 1.58; P < .0001). TIPS significantly reduced the incidence of death due to acute GI bleeding compared with EBL + propranolol (RR, 0.37; P = .05). CONCLUSION TIPS offers a comprehensive therapeutic advantage over the combined EBL and propranolol regimen, especially for patients with cirrhosis with PVT. Its efficacy in variceal eradication, reducing rebleeding, and mitigating death risks due to acute GI bleeding is evident.
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Affiliation(s)
- Mahmoud Saad Berengy
- Department of Internal Medicine, Damietta Faculty of Medicine, Al-Azhar University, Damietta, Egypt.
| | | | - Amal H Ibrahim
- Department of Internal Medicine, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
| | - Eman F Mohamed
- Department of Internal Medicine, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
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18
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Wong YJ, Teng M, Sim A, Thet HM, Teoh X, De Roza MA, Sen Kew G, Koh JH, Loi PL, Lim K, Kang G, Kuang J, Low EXS, Ho JL, Cher LYG, Sze K, Wong GW, Kwek BYA, Yang WL, Abraldes JG, Chang J. Full adherence to cirrhosis quality indicators is associated with lower mortality in acute variceal bleeding: Nationwide audit. Hepatology 2024:01515467-990000000-00764. [PMID: 38381716 DOI: 10.1097/hep.0000000000000793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/23/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND AND AIMS Acute variceal bleeding (AVB) is a major complication in patients with cirrhosis. Using a nationwide AVB audit, we performed a nested cohort study to determine whether full adherence to the AVB quality indicator (QI) improves clinical outcomes in patients with cirrhosis and AVB. APPROACH AND RESULTS We assessed real-world adherence to AVB QI among patients with cirrhosis admitted for AVB in all public hospitals in Singapore between January 2015 and December 2020. Full adherence was considered when all 5 QIs were fulfilled: prophylactic antibiotics, vasoactive agents, timely endoscopy, endoscopic hemostasis during index endoscopy, and nonselective beta-blockers after AVB. We compare 6-week mortality between the full adherence and suboptimal adherence groups using a propensity-matched cohort.A total of 989 patients with AVB were included. Full adherence to all AVB QI was suboptimal (56.5%). Analysis of the propensity-matched cohort with comparable baseline characteristics showed that full adherence was associated with a lower risk of early infection (20.0% vs. 26.9%), early rebleeding (5.2% vs. 10.2%), and mortality at 6 weeks (8.2% vs. 19.7%) and 1 year (21.3% vs. 35.4%) ( p <0.05 for all). While full adherence was associated with a lower 6-week mortality regardless of the MELD score, nonadherence was associated with a higher 6-week mortality despite a lower predicted risk of 6-week mortality. Despite high adherence to the recommended process measures, patients with CTP-C remain at a higher risk of rebleeding, 6-week and 1-year mortality. CONCLUSIONS Full adherence to the AVB QI should be the target for quality improvement in patients with cirrhosis.
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Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore
- Duke-NUS Academic Clinical Program, SingHealth, Singapore
- Liver unit, Division of Gastroenterology & Hepatology, University of Alberta, Canada
| | - Margaret Teng
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore
| | - Alyssa Sim
- Department of Gastroenterology & Hepatology, Tan Tock Seng General Hospital, Singapore
| | - Htay Myat Thet
- Department of Medicine, Division of Gastroenterology & Hepatology, Ng Teng Fong Hospital, Singapore
| | - Xuhui Teoh
- Department of General Medicine, Division of Gastroenterology, Khoo Teck Puat Hospital, Singapore
| | | | - Guan Sen Kew
- Department of Medicine, Woodlands Health, Singapore
| | - Jia Hong Koh
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore
| | - Pooi Ling Loi
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Kai Lim
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Garrett Kang
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore
| | - Jonathan Kuang
- Department of Gastroenterology & Hepatology, Tan Tock Seng General Hospital, Singapore
| | - En Xian Sarah Low
- Department of Medicine, Division of Gastroenterology & Hepatology, Ng Teng Fong Hospital, Singapore
| | | | - Liu Yuan Gabriel Cher
- Department of General Medicine, Division of Gastroenterology, Khoo Teck Puat Hospital, Singapore
| | - Kenny Sze
- Department of General Medicine, Division of Gastroenterology, Khoo Teck Puat Hospital, Singapore
| | - Guan Wee Wong
- Department of Medicine, Division of Gastroenterology & Hepatology, Ng Teng Fong Hospital, Singapore
| | - Boon Yew Andrew Kwek
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore
- Duke-NUS Academic Clinical Program, SingHealth, Singapore
| | - Wei Lyn Yang
- Department of Gastroenterology & Hepatology, Tan Tock Seng General Hospital, Singapore
| | - Juan G Abraldes
- Liver unit, Division of Gastroenterology & Hepatology, University of Alberta, Canada
| | - Jason Chang
- Duke-NUS Academic Clinical Program, SingHealth, Singapore
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
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Li Z, LingHu E, Li W, Zhou L. Guiding role of esophageal variceal diameter in treatment of endoscopic ligation: an animal experimental study. Sci Rep 2024; 14:3929. [PMID: 38365842 PMCID: PMC10873287 DOI: 10.1038/s41598-024-53752-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 02/05/2024] [Indexed: 02/18/2024] Open
Abstract
In this study, according to the Location, Diameter, Risk factor (LDRf) classification principle, the influence and effect of esophageal varices diameter on the degree of complete ligation of multicyclic ligator were investigated. Methods. The esophageal veins of healthy piglets were filled with methylene blue solution, and the in vitro pig esophageal varices model was made, which were divided into three groups according to the diameter of esophageal varices: D1, 0.4-1.0 cm; D2, 1.1-1.5 cm; and D3, 1.6-2.0 cm. Finally, the ligation effect of each group was analyzed statistically. A total of 407 ligations were performed on the simulated esophageal variceal model. There were 103 ligations in the D1 group and 98 were complete (95.15%, 98/103); 151 ligations in the D2 group and 47 were complete (31.13%, 47/151); and 153 ligations in the D3 group but none were complete (0%, 0/153). There was significant difference in the degree of complete ligation between the two groups (χ2 = 38.0014, P ≤ 0.001). In the varicose ligation model, the complete ligation effect was the most complete and robust when the varicose diameter was 0.4-1.0 cm. This study showed that the varicose vein diameter in LDRf classification was reasonable and feasible to guide endoscopic varicose vein ligation.
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Affiliation(s)
- Zhiqun Li
- Department of Gastroenterology, Chinese PLA General Hospital, Beijing, 100853, China.
- Department of Gastroenterology, Chinese PLA 984 Hospital, Beijing, 100094, China.
| | - Enqiang LingHu
- Department of Gastroenterology, Chinese PLA General Hospital, Beijing, 100853, China.
| | - Weimin Li
- Beijing Friendship Hospital Pinggu Campus, Capital Medical University, Beijing, 101200, China
| | - Licai Zhou
- Beijing Friendship Hospital Pinggu Campus, Capital Medical University, Beijing, 101200, China
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Deng Y, Jiang Y, Jiang T, Chen L, Mou HJ, Tuo BG, Shi GQ. Evaluation of the efficacy and safety of endoscopic band ligation in the treatment of bleeding from mild to moderate gastric varices type 1. World J Gastroenterol 2024; 30:440-449. [PMID: 38414583 PMCID: PMC10895593 DOI: 10.3748/wjg.v30.i5.440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/15/2023] [Accepted: 01/11/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND According to practice guidelines, endoscopic band ligation (EBL) and endoscopic tissue adhesive injection (TAI) are recommended for treating bleeding from esophagogastric varices. However, EBL and TAI are known to cause serious complications, such as hemorrhage from dislodged ligature rings caused by EBL and hemorrhage from operation-related ulcers resulting from TAI. However, the optimal therapy for mild to moderate type 1 gastric variceal hemorrhage (GOV1) has not been determined. Therefore, the aim of this study was to discover an individualized treatment for mild to moderate GOV1. AIM To compare the efficacy, safety and costs of EBL and TAI for the treatment of mild and moderate GOV1. METHODS A clinical analysis of the data retrieved from patients with mild or moderate GOV1 gastric varices who were treated under endoscopy was also conducted. Patients were allocated to an EBL group or an endoscopic TAI group. The differences in the incidence of varicose relief, operative time, operation success rate, mortality rate within 6 wk, rebleeding rate, 6-wk operation-related ulcer healing rate, complication rate and average operation cost were compared between the two groups of patients. RESULTS The total effective rate of the two treatments was similar, but the efficacy of EBL (66.7%) was markedly better than that of TAI (39.2%) (P < 0.05). The operation success rate in both groups was 100%, and the 6-wk mortality rate in both groups was 0%. The average operative time (26 min) in the EBL group was significantly shorter than that in the TAI group (46 min) (P < 0.01). The rate of delayed postoperative rebleeding in the EBL group was significantly lower than that in the TAI group (11.8% vs 45.1%) (P < 0.01). At 6 wk after the operation, the healing rate of operation-related ulcers in the EBL group was 80.4%, which was significantly greater than that in the TAI group (35.3%) (P < 0.01). The incidence of postoperative complications in the two groups was similar. The average cost and other related economic factors were greater for the EBL than for the TAI (P < 0.01). CONCLUSION For mild to moderate GOV1, patients with EBL had a greater one-time varix eradication rate, a greater 6-wk operation-related ulcer healing rate, a lower delayed rebleeding rate and a lower cost than patients with TAI.
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Affiliation(s)
- Yue Deng
- Department of Gastroenterology, Digestive Disease Hospital, The Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
- Department of Gastroenterology, Guizhou Hospital of the First Affiliated Hospital, Sun Yat-sen University, Guiyang 550000, Guizhou Province, China
| | - Ya Jiang
- Department of Gastroenterology, Yinjiang Autonomous County People’s Hospital, Tongren 554300, Guizhou Province, China
| | - Tong Jiang
- Department of Gastroenterology, Digestive Disease Hospital, The Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Ling Chen
- Department of Gastroenterology, Digestive Disease Hospital, The Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Hai-Jun Mou
- Department of Gastroenterology, Digestive Disease Hospital, The Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Bi-Guang Tuo
- Department of Gastroenterology, Digestive Disease Hospital, The Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Guo-Qing Shi
- Department of Gastroenterology, Digestive Disease Hospital, The Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
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21
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Chen WC, Yang TC, Lee PC, Wang YP, Hou MC, Lee FY. A Randomized Controlled Trial of Propranolol Use During Ligation Program for Secondary Prophylaxis of Esophageal Variceal Bleeding. Am J Gastroenterol 2024; 119:278-286. [PMID: 37543755 DOI: 10.14309/ajg.0000000000002457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 07/14/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Endoscopic variceal ligation (EVL) plus nonselective β-blockers (NSBB) is the standard of care for secondary prophylaxis of esophageal variceal bleeding (EVB). This trial aimed to compare the rebleeding rates between EVL plus NSBB till eradication of esophageal varices (EEV) and EVL plus long-term NSBB. METHODS After control of acute EVB, patients with cirrhosis were randomized into 2 groups, with group A patients receiving EVL plus propranolol till EEV, while group B patients received standard of care with continuation of propranolol. Recurrent varices were ligated at follow-up endoscopy in both groups. RESULTS The median follow-up period was 23.0 months in group A (n = 106) and 23.6 months in group B (n = 106). Twelve patients (11.3%) in group A and 11 (10.4%) in group B had recurrent EVB. The difference in rebleeding rates and the 95% confidence interval (CI) was 0.9% (-7.5% to 9.3%). The upper 95% CI bound of the difference was within the margin of 13.2%, and the noninferiority of group A to group B was established. Thirty-eight patients (35.8%) in group A and 40 (37.7%) in group B had further decompensation, with the difference (95% CI) of -1.9% (-14.9% to 11.1%). Twenty-four patients (22.6%) in group A and 26 (24.5%) in group B expired, with the difference (95% CI) in mortality rates of -1.9% (-13.3% to 9.5%). DISCUSSION EVL plus propranolol till EEV was noninferior to EVL plus continuing propranolol in secondary prophylaxis of EVB, but the impact on further decompensation and transplantation-free survival deserved further investigation.
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Affiliation(s)
- Wen-Chi Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Post-Baccalaureate Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Tsung-Chieh Yang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Pei-Chang Lee
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yen-Po Wang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Chih Hou
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Fa-Yauh Lee
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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22
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Ichita C, Shimizu S, Goto T, Haruki U, Itoh N, Iwagami M, Sasaki A. Effectiveness of antibiotic prophylaxis for acute esophageal variceal bleeding in patients with band ligation: A large observational study. World J Gastroenterol 2024; 30:238-251. [PMID: 38314133 PMCID: PMC10835525 DOI: 10.3748/wjg.v30.i3.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/12/2023] [Accepted: 01/03/2024] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Esophageal variceal bleeding is a severe complication associated with liver cirrhosis and typically necessitates endoscopic hemostasis. The current standard treatment is endoscopic variceal ligation (EVL), and Western guidelines recommend antibiotic prophylaxis following hemostasis. However, given the improvements in prognosis for variceal bleeding due to advancements in the management of bleeding and treatments of liver cirrhosis and the global concerns regarding the emergence of multidrug-resistant bacteria, there is a need to reassess the use of routine antibiotic prophylaxis after hemostasis. AIM To evaluate the effectiveness of antibiotic prophylaxis in patients treated for EVL. METHODS We conducted a 13-year observational study using the Tokushukai medical database across 46 hospitals. Patients were divided into the prophylaxis group (received antibiotics on admission or the next day) and the non-prophylaxis group (did not receive antibiotics within one day of admission). The primary outcome was composed of 6-wk mortality, 4-wk rebleeding, and 4-wk spontaneous bacterial peritonitis (SBP). The secondary outcomes were each individual result and in-hospital mortality. A logistic regression with inverse probability of treatment weighting was used. A subgroup analysis was conducted based on the Child-Pugh classification to determine its influence on the primary outcome measures, while sensitivity analyses for antibiotic type and duration were also performed. RESULTS Among 980 patients, 790 were included (prophylaxis: 232, non-prophylaxis: 558). Most patients were males under the age of 65 years with a median Child-Pugh score of 8. The composite primary outcomes occurred in 11.2% of patients in the prophylaxis group and 9.5% in the non-prophylaxis group. No significant differences in outcomes were observed between the groups (adjusted odds ratio, 1.11; 95% confidence interval, 0.61-1.99; P = 0.74). Individual outcomes such as 6-wk mortality, 4-wk rebleeding, 4-wk onset of SBP, and in-hospital mortality were not significantly different between the groups. The primary outcome did not differ between the Child-Pugh subgroups. Similar results were observed in the sensitivity analyses. CONCLUSION No significant benefit to antibiotic prophylaxis for esophageal variceal bleeding treated with EVL was detected in this study. Global reassessment of routine antibiotic prophylaxis is imperative.
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Affiliation(s)
- Chikamasa Ichita
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura 247-8533, Kanagawa, Japan
- Department of Health Data Science, Yokohama City University, Yokohama 236-0027, Kanagawa, Japan
| | - Sayuri Shimizu
- Department of Health Data Science, Yokohama City University, Yokohama 236-0027, Kanagawa, Japan
| | - Tadahiro Goto
- Department of Health Data Science, Yokohama City University, Yokohama 236-0027, Kanagawa, Japan
- TXP Research, TXP Medical Co., Ltd., Chiyoda-ku 101-0042, Tokyo, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku 113-0033, Tokyo, Japan
| | - Uojima Haruki
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura 247-8533, Kanagawa, Japan
- Department of Genome Medical Sciences Project, Research Institute, National Center for Global Health and Medicine, Ichikawa 272-8516, Chiba, Japan
| | - Naoya Itoh
- Division of Infectious Diseases, Aichi Cancer Center, Nagoya 464-8681, Aichi, Japan
| | - Masao Iwagami
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Tsukuba 305-8575, Ibaraki, Japan
| | - Akiko Sasaki
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura 247-8533, Kanagawa, Japan
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Asenov K, Dimov R, Kraeva M, Basheva-Kraeva Y. EUS-Guided Combined Injection Therapy as a Secondary Prophylaxis of Gastric Variceal Bleeding in a Patient Contraindicated for TIPS: Case Report. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:116. [PMID: 38256377 PMCID: PMC10820955 DOI: 10.3390/medicina60010116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 12/31/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024]
Abstract
Background: Although bleeding from gastric varices is less observed than esophageal variceal bleeding (VB) (25% vs. 64%), it is associated with an exceedingly high mortality rate of up to 45%. Current guidelines suggest that endoscopic cyanoacrylate injection therapy (ECI) is the first-line treatment for gastric variceal bleeding (GVB). A major concern, however, is the possibility of embolic incidents, which are clinically evident in approximately 1% of cases. There are no guidelines for secondary prophylaxis of GVB. Radiological treatments using a transjugular intrahepatic portosystemic shunt (TIPS) or balloon occlusive transvenous obliteration (BRTO) are considered viable. However, they are not universally inapplicable; for instance, in the setting of pulmonary hypertension (TIPS). EUS-guided combined injection therapy (EUS-CIT) (embolization coils + cyanoacrylate) is an emerging procedure with a perceived reduced risk of systemic embolization. Case presentation: A patient with alcoholic liver cirrhosis was subjected to EUS-CIT as a secondary prophylaxis for GVB. He had three VB episodes of prior presentation treated by endoscopic band ligation (EBL) and ECI. Due to recurrent episodes of bleeding, he was referred to TIPS, but was considered contraindicated due to severe pulmonary hypertension. EUS-CIT was conducted with two embolization coils inserted into the varix, followed by an injection of 1.5 mL of cyanoacrylate glue. A 19 Ga needle, 0.035″ 14/70 mm coils, non-diluted n-butyl-caynoacrylate, and a transgastric approach were utilized. There were no immediate complications. Complete obliteration of the GV was observed in a follow-up endoscopy on day 30. Subsequent endoscopies in months three and six showed no progression of gastric varices. Conclusions: Our initial experience with EUS-CIT suggests that it can be successfully used as secondary prophylaxis for recurrent GVB.
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Affiliation(s)
- Krasimir Asenov
- Section “Gastroenterology”, Second Department of Internal Diseases, Medical Faculty, Medical University—Plovdiv, 4000 Plovdiv, Bulgaria;
- Gastroenterology Clinic, University Hospital “Kaspela”, 4000 Plovdiv, Bulgaria
| | - Rosen Dimov
- Department of Special Surgery, Medical Faculty, Medical University—Plovdiv, 4000 Plovdiv, Bulgaria;
- Surgical Department, University Hospital “Kaspela”, 4000 Plovdiv, Bulgaria
| | - Maria Kraeva
- Department of Otorhynolaryngology, Medical Faculty, Medical University—Plovdiv, 4000 Plovdiv, Bulgaria
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Hui RWH, Abbas N, Dunne P, Tripathi D. Predicting and optimising risks for non-hepatic surgery in patients with cirrhosis: insights from the #FGDebate. Frontline Gastroenterol 2024; 15:86-87. [PMID: 38487556 PMCID: PMC10935529 DOI: 10.1136/flgastro-2023-102510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/04/2023] [Indexed: 03/17/2024] Open
Affiliation(s)
- Rex Wan-Hin Hui
- Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Nadir Abbas
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Philip Dunne
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Dhiraj Tripathi
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- The Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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25
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Liu S, Ma J, Chen P, Liu S, Guo Y, Tan M, Guo X, Feng Y, Wang Q, Li W, Yang C, Gao B, Hua Y, Liu N, Song H, He R, Wang R, Gao Q, Liu C, Qi X. Novel serum biomarker of Golgi protein 73 for the diagnosis of clinically significant portal hypertension in patients with compensated cirrhosis. J Med Virol 2024; 96:e29380. [PMID: 38235849 DOI: 10.1002/jmv.29380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 12/17/2023] [Accepted: 12/28/2023] [Indexed: 01/19/2024]
Abstract
Hepatic venous pressure gradient (HVPG) is the gold standard for evaluating clinically significant portal hypertension (CSPH). However, reliable noninvasive methods are limited. Our study aims to investigate the diagnostic value of serum Golgi protein 73 (GP73) for CSPH in patients with compensated cirrhosis. The study enrolled 262 consecutive patients with compensated cirrhosis from three centers in China from February 2021 to September 2023, who underwent both serum GP73 tests and HVPG measurements. CSPH was defined as HVPG ≥ 10 mmHg. Diagnostic accuracy was evaluated using the areas under the receiver operating characteristic curve (AUC). The prevalence of CSPH was 56.9% (n = 149). There were significant differences between the CSPH and non-CSPH groups in the median serum GP73 level (126.8 vs. 73.1 ng/mL, p < 0.001). GP73 level showed a significant positive linear correlation with HVPG (r = 0.459, p < 0.001). The AUC for the diagnosis of CSPH using serum GP73 alone was 0.75 (95% confidence interval [CI] 0.68-0.81). Multivariate logistic regression analysis determined that the levels of GP73, platelets and international normalized ratio were independently associated with CSPH. The combination of these three markers was termed "IP73" score with an AUC value of 0.85 (95% CI 0.80-0.89) for CSPH. Using 0 as a cut-off value, the specificity and sensitivity of IP73 score were 77.9% and 81.9%, respectively. The IP73 score offers a novel, simple and noninvasive method of assessing CSPH in patients with compensated cirrhosis. A cut-off value of the IP73 score at 0 can distinguish patients with or without CSPH.
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Affiliation(s)
- Shanghao Liu
- Center of Portal Hypertension, Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
- Basic Medicine Research and Innovation Center of Ministry of Education, Zhongda Hospital, Southeast University, Nanjing, China
| | - Jianzhong Ma
- Department of General Surgery, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Ping Chen
- Department of infectious diseases, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, China
| | - Shirong Liu
- Department of Infectious Diseases, Qufu People's Hospital, Qufu, China
| | - Ying Guo
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Mingjie Tan
- Department of Gastrointestinal and Hepatology, Beijing You'An Hospital, Capital Medical University, Beijing, China
| | - Xiaoqing Guo
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Yinong Feng
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Qinghui Wang
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Wenhua Li
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Chengchen Yang
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Bo Gao
- Medical Laboratory, Qufu People's Hospital, Qufu, China
| | - Yongli Hua
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Ning Liu
- Department of Infectious Diseases, Qufu People's Hospital, Qufu, China
| | - Haolin Song
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Ruiling He
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Ruiying Wang
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Qi Gao
- Beijing Key Laboratory of POCT for Bioemergency and Clinic (No. BZ0329); Beijing Hotgen Biotechnology Inc., Beijing, China
| | - Chuan Liu
- Center of Portal Hypertension, Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
- Basic Medicine Research and Innovation Center of Ministry of Education, Zhongda Hospital, Southeast University, Nanjing, China
| | - Xiaolong Qi
- Center of Portal Hypertension, Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
- Basic Medicine Research and Innovation Center of Ministry of Education, Zhongda Hospital, Southeast University, Nanjing, China
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26
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Cao J, Yao Z, Huo G, Liu Z, Tang Y, Huang J, Chen M, Ding R, Shen L, Zhou D. Analysis of transjugular intrahepatic portosystemic shunt by hemodynamic simulation. Biomed Mater Eng 2024; 35:27-37. [PMID: 37482973 DOI: 10.3233/bme-230020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS), which artificially creates a portocaval shunt to reduce portal venous pressure, has gradually become the primary treatment for portal hypertension (PH). However, there is no prefect shunting scheme in TIPS to balance the occurrence of postoperative complications and effective haemostasis. OBJECTIVE To construct cirrhotic PH models and compare different shunting schemes in TIPS. METHODS Three cases of cirrhotic PH with different liver volumes were selected for enhanced computed tomography scanning. The models for different shunting schemes were created using Mimics software, and following FLUENT calculation, all the models were imported into the software computational fluid dynamic-post for processing. In each shunting scheme, the differences in portal vein pressure, hepatic blood perfusion and blood flow from the superior mesenteric vein in the shunt tract were compared. The coefficient G was adapted to evaluate the advantages and disadvantages. RESULTS (1) Concerning the precise location of the shunt tract, the wider the diameter of the shunt tract, the lower the pressure of the portal vein and the lesser the hepatic blood perfusion. Meanwhile, the pressure drop objective was not achieved with the 6 mm-diameter shunting scheme. (2) The 8 mm-diameter shunting scheme through the left portal vein (LPV) had the highest coefficient G. CONCLUSION The 8 mm-diameter shunting scheme through the LPV may demonstrate a superior effect and prognosis in TIPS procedures.
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Affiliation(s)
- Junjie Cao
- Department of Vascular Surgery, Gusu School of Nanjing Medical University, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital (HQ), Suzhou, China
| | - Zhichao Yao
- Department of Vascular Surgery, Gusu School of Nanjing Medical University, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital (HQ), Suzhou, China
| | - Guijun Huo
- Department of Vascular Surgery, Gusu School of Nanjing Medical University, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital (HQ), Suzhou, China
| | - Zhanao Liu
- Department of Vascular Surgery, Gusu School of Nanjing Medical University, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital (HQ), Suzhou, China
| | - Yao Tang
- Department of Vascular Surgery, Gusu School of Nanjing Medical University, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital (HQ), Suzhou, China
| | - Jian Huang
- Department of Vascular Surgery, Gusu School of Nanjing Medical University, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital (HQ), Suzhou, China
| | - Minxin Chen
- Department of Mathematics, Soochow University, Suzhou, China
| | - Rui Ding
- Department of Mathematics, Soochow University, Suzhou, China
| | - Liming Shen
- Department of Vascular Surgery, Gusu School of Nanjing Medical University, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital (HQ), Suzhou, China
| | - Dayong Zhou
- Department of Vascular Surgery, Gusu School of Nanjing Medical University, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital (HQ), Suzhou, China
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27
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Xu X, Tang C, Linghu E, Ding H. Guidelines for the Management of Esophagogastric Variceal Bleeding in Cirrhotic Portal Hypertension. J Clin Transl Hepatol 2023; 11:1565-1579. [PMID: 38161497 PMCID: PMC10752807 DOI: 10.14218/jcth.2023.00061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 07/11/2023] [Accepted: 09/07/2023] [Indexed: 01/03/2024] Open
Abstract
To standardize the diagnosis, treatment, and management of esophagogastric variceal bleeding (EVB) in patients with cirrhotic portal hypertension, the Chinese Society of Hepatology, the Chinese Society of Gastroenterology, and the Chinese Society of Digestive Endoscopy of the Chinese Medical Association brought together relevant experts, reviewed the latest national and international progress in clinical research on EVB in cirrhotic portal hypertension, and followed evidence-based medicine to update the Guidelines on the Management of EVB in Cirrhotic Portal Hypertension. The guidelines provide recommendations for the diagnosis, treatment, and management of EVB in cirrhotic portal hypertension and with the aim to improve the level of clinical treatment of EVB in patients with cirrhotic portal hypertension.
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Affiliation(s)
- Xiaoyuan Xu
- Department of Gastroenterology, Peking University First Hospital, Beijing, China
| | - Chengwei Tang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Enqiang Linghu
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Huiguo Ding
- Department of Gastroenterology and Hepatology, Beijing You’an Hospital Affiliated to Capital Medical University, Beijing, China
| | - Chinese Society of Hepatology, Chinese Medical Association; Chinese Society of Gastroenterology, Chinese Medical Association; Chinese Society of Digestive Endoscopy, Chinese Medical Association
- Department of Gastroenterology, Peking University First Hospital, Beijing, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Gastroenterology and Hepatology, Beijing You’an Hospital Affiliated to Capital Medical University, Beijing, China
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Aggeletopoulou I, Tsounis EP, Kalafateli M, Michailidou M, Tsami M, Zisimopoulos K, Mandellou M, Diamantopoulou G, Kouskoura M, Michalaki M, Markopoulou CK, Thomopoulos K, Triantos C. Low Urinary Free Cortisol as a Risk Factor for Patients with Variceal Bleeding. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2112. [PMID: 38138215 PMCID: PMC10744924 DOI: 10.3390/medicina59122112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023]
Abstract
Background and Objectives: Specificity and reliability issues of the current cortisol assessment methods lead to limitations on the accurate assessment of relative adrenal insufficiency. Although free cortisol provides a more accurate evaluation of adrenal cortisol production, the expense and time-consuming nature of these assays make them impractical for routine use. Research has, thus, focused on alternative methods, such as indirectly measuring free cortisol using Coolens' equation or directly assessing salivary cortisol concentration, which is considered a more favorable approach despite associated challenges like sampling issues and infection risks. The aim of this study was to explore correlations between 24 h urinary free cortisol (UFC), free plasma cortisol, serum total cortisol, and salivary cortisol as potential reliable indices of free cortisol in the setting of variceal bleeding. Additionally, we assessed the predictive value of UFC for 6-week mortality and 5-day treatment failure in patients with liver cirrhosis and variceal bleeding. Materials and Methods: A total of 40 outpatients with liver cirrhosis and variceal bleeding were enrolled. Free cortisol levels in serum, saliva, and urine were assessed using the electrochemiluminescence immunoassay method. For the measurement of plasma-free cortisol, a single quadrupole mass spectrometer was employed. The quantification of free cortisol was fulfilled by analyzing the signal response in the negative ESI-MS mode. Results: UFC was significantly correlated to free plasma cortisol. Negative correlations were demonstrated between UFC, the Child-Pugh (CP) score, and C reactive protein (CRP) levels. In the multivariate analysis, CP stage C was associated with 6-week mortality risk and portal vein thrombosis with 5-day treatment failure using Cox regression and binary logistic regression analyses, respectively. Patients who experienced rebleeding, infection, or death (or any combination of these events) presented with lower levels of UFC. Conclusions: This study suggests that low levels of UFC may impose a risk factor for patients with liver cirrhosis and variceal bleeding. The use of UFC as an index of adrenal cortisol production in variceal bleeding warrants further investigation.
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Affiliation(s)
- Ioanna Aggeletopoulou
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
| | - Efthymios P. Tsounis
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
| | - Maria Kalafateli
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
| | - Maria Michailidou
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
| | - Maria Tsami
- Laboratory of Pharmaceutical Analysis, Department of Pharmaceutical Technology, School of Pharmacy, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (M.T.); (M.K.); (C.K.M.)
| | - Konstantinos Zisimopoulos
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
| | - Martha Mandellou
- Department of Biochemistry, University Hospital of Patras, 26504 Patras, Greece;
| | - Georgia Diamantopoulou
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
| | - Maria Kouskoura
- Laboratory of Pharmaceutical Analysis, Department of Pharmaceutical Technology, School of Pharmacy, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (M.T.); (M.K.); (C.K.M.)
| | - Marina Michalaki
- Division of Endocrinology, Diabetes and Metabolic Diseases, Department of Internal Medicine, University of Patras, 26504 Patras, Greece;
| | - Catherine K. Markopoulou
- Laboratory of Pharmaceutical Analysis, Department of Pharmaceutical Technology, School of Pharmacy, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (M.T.); (M.K.); (C.K.M.)
| | - Konstantinos Thomopoulos
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
| | - Christos Triantos
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
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Gao H, Sun B, Li X, Bai T, Du L, Song Y, Zheng C, Kan X, Liu F. Risk factors for portal vein system thrombosis after partial splenic embolisation in cirrhotic patients with hypersplenism. Clin Radiol 2023; 78:919-927. [PMID: 37634989 DOI: 10.1016/j.crad.2023.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/18/2023] [Accepted: 07/26/2023] [Indexed: 08/29/2023]
Abstract
AIM To determine risk factors for portal venous system thrombosis (PVST) after partial splenic artery embolisation (PSAE) in cirrhotic patients with hypersplenism. MATERIALS AND METHODS Between March 2014 and February 2022, 428 cirrhotic patients with hypersplenism underwent partial splenic artery embolisation and from these patients 208 were enrolled and 220 were excluded. Medical records of enrolled patients were collected. Computed tomography (CT) images were reviewed by two blinded, independent radiologists. Statistical analyses were performed by using SPSS. RESULTS Progressive PVST was observed in 18.75% (39/208) of cirrhotic patients after PSAE. No significant differences in peripheral blood counts, liver function biomarkers, and renal function were observed between the patients with progressive PVST and the patients without progressive PVST. The imaging data showed significant differences in PVST, the diameters of the portal, splenic, and superior mesenteric veins between the progressive PVST group and non-progressive PVST group. Univariate and multivariate analysis demonstrated portal vein thrombosis, spleen infarction percentage, and the diameter of the splenic vein were independent risk factors for progressive PVST. Seventeen of 173 (9.83%) patients showed new PVST; the growth of PVST was observed in 62.86% (22/35) of the patients with pre-existing PVST. Spleen infarction percentage and the diameter of the splenic vein were independent risk factors for new PVST after PSAE. CONCLUSION The present study demonstrated portal vein thrombosis, spleen infarction percentage, and the diameter of the splenic vein were independent risk factors for PVST after PSAE in cirrhotic patients with hypersplenism.
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Affiliation(s)
- H Gao
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - B Sun
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - X Li
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - T Bai
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - L Du
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Y Song
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - C Zheng
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - X Kan
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
| | - F Liu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
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Li Y, Gao J, Zheng X, Nie G, Qin J, Wang H, He T, Wheelock Å, Li CX, Cheng L, Li X. Diagnostic Prediction of portal vein thrombosis in chronic cirrhosis patients using data-driven precision medicine model. Brief Bioinform 2023; 25:bbad478. [PMID: 38221905 PMCID: PMC10788706 DOI: 10.1093/bib/bbad478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/16/2023] [Accepted: 12/01/2023] [Indexed: 01/16/2024] Open
Abstract
BACKGROUND Portal vein thrombosis (PVT) is a significant issue in cirrhotic patients, necessitating early detection. This study aims to develop a data-driven predictive model for PVT diagnosis in chronic hepatitis liver cirrhosis patients. METHODS We employed data from a total of 816 chronic cirrhosis patients with PVT, divided into the Lanzhou cohort (n = 468) for training and the Jilin cohort (n = 348) for validation. This dataset encompassed a wide range of variables, including general characteristics, blood parameters, ultrasonography findings and cirrhosis grading. To build our predictive model, we employed a sophisticated stacking approach, which included Support Vector Machine (SVM), Naïve Bayes and Quadratic Discriminant Analysis (QDA). RESULTS In the Lanzhou cohort, SVM and Naïve Bayes classifiers effectively classified PVT cases from non-PVT cases, among the top features of which seven were shared: Portal Velocity (PV), Prothrombin Time (PT), Portal Vein Diameter (PVD), Prothrombin Time Activity (PTA), Activated Partial Thromboplastin Time (APTT), age and Child-Pugh score (CPS). The QDA model, trained based on the seven shared features on the Lanzhou cohort and validated on the Jilin cohort, demonstrated significant differentiation between PVT and non-PVT cases (AUROC = 0.73 and AUROC = 0.86, respectively). Subsequently, comparative analysis showed that our QDA model outperformed several other machine learning methods. CONCLUSION Our study presents a comprehensive data-driven model for PVT diagnosis in cirrhotic patients, enhancing clinical decision-making. The SVM-Naïve Bayes-QDA model offers a precise approach to managing PVT in this population.
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Affiliation(s)
- Ying Li
- The First Hospital of Lanzhou University, Lanzhou, China
| | - Jing Gao
- Respiratory Medicine Unit, Department of Medicine & Centre for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Xubin Zheng
- School of Computing and Information Technology, Great Bay University, Guangdong, China
| | - Guole Nie
- The First Hospital of Lanzhou University, Lanzhou, China
| | - Jican Qin
- School of Computing and Information Technology, Great Bay University, Guangdong, China
| | - Haiping Wang
- The First Hospital of Lanzhou University, Lanzhou, China
| | - Tao He
- Jilin Hepato-Biliary Diseases Hospital, Changchun, China
| | - Åsa Wheelock
- Respiratory Medicine Unit, Department of Medicine & Centre for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital, Stockholm, Sweden
| | - Chuan-Xing Li
- Respiratory Medicine Unit, Department of Medicine & Centre for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lixin Cheng
- Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, The Second Clinical Medical College of Jinan University, Shenzhen, China
| | - Xun Li
- The First Hospital of Lanzhou University, Lanzhou, China
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Wei M, Chen Y, Wang M, Li J, Zeng Y, Sun X, Zhang A, Liu X, Zhou T, Gao Y. Partial splenic embolization combined with endoscopic therapies and vasoconstrictive drugs reduces rebleeding in cirrhosis patients with acute variceal bleeding and hypersplenism: a multicenter randomized controlled trial. J Gastroenterol 2023; 58:1144-1153. [PMID: 37486372 DOI: 10.1007/s00535-023-02027-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/14/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND This study aimed to compare the efficacy of partial splenic embolization (PSE) combined with endoscopic therapy and endoscopic therapy alone in cirrhosis patients with acute variceal bleeding (AVB) and hypersplenism. METHODS Cirrhosis patients with AVB who visited three hospitals from June 2016 to June 2022 were prospectively enrolled and randomly allocated to either the endoscopic therapy combined with PSE group (EP group) or the endoscopic intervention group (E group) in a 1:1 ratio. The primary endpoint of the study was re-bleeding of varices during follow-up, and the secondary endpoints were the recurrence of varices, death, and adverse events. RESULTS One hundred and fourteen patients were prospectively included, of whom 110 completed the trial. The risk of variceal re-bleeding (19.3% vs. 40.4% (23/57), p = 0.013) and variceal recurrence (28.1% vs. 63.2%, p < 0.001) five years after treatment was significantly lower in the EP group than in the E group, and the EP treatment was the only significant independent risk factor affecting variceal re-bleeding and variceal recurrence in patients. The mortality rate was comparable between the EP and E groups. Peripheral blood counts and liver function all improved significantly in the EP group compared to the E group during the follow-up (p < 0.05). CONCLUSIONS The rates of variceal re-bleeding and recurrence were significantly lower in cirrhosis patients with AVB and hypersplenism after combined endoscopic and PSE treatment compared to those who were provided endoscopic treatment only. The peripheral blood counts and liver function were also improved significantly in EP group (NCT02778425).
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Affiliation(s)
- Min Wei
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Yong Chen
- Department of Gastroenterology, Shandong Provincial Hospital, Jinan, Shandong, China
| | - Minghui Wang
- Department of Gastroenterology, The 960th Hospital of the Chinese People's Liberation Army, Jinan, Shandong, China
| | - Jinhou Li
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Department of Gastroenterology, Taian City Central Hospital, Taian, Shandong, China
| | - Yunqing Zeng
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Xin Sun
- Department of Gastroenterology, Central Hospital Affiliated of Shandong First Medical University, Jinan, Shandong, China
| | - Anzhong Zhang
- Department of Gastroenterology, Shandong Provincial Hospital, Jinan, Shandong, China
| | - Xiaofeng Liu
- Department of Gastroenterology, The 960th Hospital of the Chinese People's Liberation Army, Jinan, Shandong, China
| | - Tao Zhou
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Jinan, Shandong, China.
- Key Laboratory of Cardiovascular Proteomics of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China.
| | - Yanjing Gao
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong, China.
- The Institute of Portal Hypertension, Shandong University, Jinan, Shandong, China.
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Iqbal Janjua F, Ahmad M, Javed S, Zia MQ, Abbas G, Aslam N, Farooq K, Shafqat MN. Endoscopic Therapy of Gastric Varices: Safety and Efficacy of N-Butyl-2-Cyanoacrylate Injection. Cureus 2023; 15:e49539. [PMID: 38156146 PMCID: PMC10753266 DOI: 10.7759/cureus.49539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 12/30/2023] Open
Abstract
Background Upper gastrointestinal bleeding (UGIB) is a common medical emergency that results in significant morbidity, mortality, and socioeconomic burden. Both types of cardio-fundal varices, gastro-esophageal varix 2 (GOV2) and isolated gastric varices type 1 (IGV1), can cause massive bleeding and often are difficult to treat compared to the other types of gastric varices. Endoscopic variceal band ligation (EVBL) is a less effective treatment modality for gastric varices than esophageal varices and is associated with high re-bleeding rates. N-butyl-2-cyanoacrylate (Histoacryl) injection is an effective and potential treatment option for fundal varices. This study aims to evaluate the safety and efficacy of n-butyl-2-cyanoacrylate injection therapy in cardio-fundal varices. Objective To assess the efficacy and safety of n-butyl-2-cyanoacrylate injection therapy for fundal varices. Methods This retrospective observational cohort study was conducted at the Department of Gastroenterology, Allied Teaching Hospital, Gujranwala, over one year. All patients, irrespective of age and gender, presenting with UGIB and in whom fundal varices were diagnosed on gastroscopy followed by n-butyl 2-cyanoacrylate injection therapy were included in this study. The efficacy and safety of Histoacryl therapy were assessed by analyzing successful hemostasis, frequency of re-bleeding, obliteration, and regression of fundal varices on repeat endoscopy. Adverse events such as re-bleeding and mortality related to fundal variceal treatment were documented. Results A total of 60 patients were included in the study. Of these, 70% had IGV1, while the remaining 30% had GOV2. Hemostasis was achieved in 100% of patients following n-butyl-2-cyanoacrylate injection. Successful obliteration with regression of varices was observed in 91.3% of patients. Various adverse events were observed, with abdominal pain being the most common observed complication in 18.3% of participants. However, only 8.3% of participants developed re-bleeding due to ulcer formation at the injection site, and no death occurred directly due to fundal variceal treatment. Conclusion N-butyl-2-cyanoacrylate injection therapy is a lifesaving, effective, and safe intervention for controlling bleeding from cardio-fundal varices, leading to improved health status and a consequent decrease in episodes of recurrent bleeding. Its side effects are few and infrequent. However, larger-scale studies are needed to further evaluate the safety and effectiveness of n-butyl-2-cyanoacrylate injection therapy. These studies will be crucial in establishing comprehensive guidelines for the management of fundal varices.
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Affiliation(s)
- Fawad Iqbal Janjua
- Department of Gastroenterology and Hepatology, Allied Teaching Hospital, Gujranwala, Gujranwala, PAK
| | - Mahmood Ahmad
- Department of Gastroenterology and Hepatology, Amna Inayat Medical College, Lahore, PAK
| | - Salman Javed
- Department of Gastroenterology and Hepatology, Services Institute of Medical Sciences, Lahore, PAK
| | - Muhammad Qasim Zia
- Department of Gastroenterology and Hepatology, Khawaja Muhammad Safdar Medical College, Sialkot, PAK
| | - Ghulam Abbas
- Department of Gastroenterology and Hepatology, Allama Iqbal Medical College, Lahore, PAK
| | - Naveed Aslam
- Department of Gastroenterology and Hepatology, Allied Teaching Hospital, Gujranwala, Gujranwala, PAK
| | - Kamran Farooq
- Department of Gastroenterology and Hepatology, Sheikh Khalifa Medical City, Abu Dhabi, ARE
| | - Muhammad Nabeel Shafqat
- Department of Gastroenterology and Hepatology, Allied Teaching Hospital, Gujranwala, Gujranwala, PAK
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Jhajharia A, Ashdhir P, Dhaked G, Sharma H. Endoscopic Glue Injection Versus Endoscopic Human Thrombin Injection for Bleeding Gastric Varices-A Randomized Controlled Trial. J Clin Gastroenterol 2023:00004836-990000000-00222. [PMID: 37983812 DOI: 10.1097/mcg.0000000000001933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/12/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Acute gastric variceal bleeding (AGVB) is a potentially fatal consequence of portal hypertension, accounting for 10% to 30% of all variceal bleeding. Although endoscopic cyanoacrylate glue injection is a common treatment for acute hemostasis, it has been linked to significant side effects. In the treatment of AGVB, there is limited evidence of the efficacy and relative safety of endoscopic human thrombin injection over glue injection. MATERIALS AND METHODS A total of 52 AGVB patients were randomized to receive either thrombin injection (25 patients) or glue injection (27 patients). The primary outcome was the incidence of any glue or thrombin injection-related post-therapy complications. Initial hemostasis, rebleeding, and mortality were all secondary end goals. RESULTS Both groups had comparable baseline data. Hemostasis of active bleeding at endoscopy was 100.0% (10/10) in the thrombin group and 87.5% (7/8) in the glue group (P=0.44). Treatment failure after 5 days occurred in 2 patients (6.1%) in the glue group compared with none in the thrombin group (P=0.165). Between 6 and 42 days after index bleeding, rebleeding occurred in 4 patients in the thrombin group compared with 6 patients in the glue group (P=0.728). In the thrombin group, none of the patients had post-treatment ulcers on gastric varices compared with 14.81% (4/27) that occurred in the glue group (P=0.045), a statistically significant observation. Overall, complications occurred in 4 (20%) and 11 (40.7%) patients in the thrombin and glue groups, respectively (P=0.105). Two patients in the glue group died. CONCLUSION To achieve successful AGVB hemostasis, endoscopic thrombin injection has been proven efficacious. However, glue injection may be linked to a higher rate of rebleeding and post-therapy gastric variceal ulceration compared with thrombin.
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Affiliation(s)
- Ashok Jhajharia
- Department of Gastroenterology, SMS Medical College and Hospital, Jaipur, Rajasthan, India
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Mei X, Zhang Q, Zhang F, Jin J, Zeng Z, Kong D. Balloon-occluded Esophageal Varices Obliteration Versus Ligation for the Management of F2 Esophageal Varices: A Randomized Controlled Trial. Surg Laparosc Endosc Percutan Tech 2023; 33:456-462. [PMID: 37523518 DOI: 10.1097/sle.0000000000001209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 05/17/2023] [Indexed: 08/02/2023]
Abstract
AIM To compare balloon-occluded esophageal varices obliteration (BEVO) with esophageal variceal ligation (EVL) in the management of cirrhotic patients with type F2 esophageal varices (F2-EVs). MATERIALS AND METHODS A total of 157 patients with F2-EVs were randomly assigned to either BEVO (n=79) or EVL (n=78) group in the prospective study between July 2021 and December 2021. Primary outcomes included recurrence and eradication rates. Secondary outcomes included rebleeding rate, and procedural complications. RESULTS The recurrence rate of EVs was notably lower in the BEVO group than in the EVL group (3.80% vs. 21.79%; P =0.001). The rate of complete eradication in the BEVO group was significantly higher than that of the EVL group (96.20% vs. 74.36%; P <0.001). The incidence of rebleeding in the BEVO group was markedly lower than that of the EVL group (7.59% vs. 20.51%; P =0.02). There was a higher incidence of transient dysphagia in the EVL group than in the BEVO group (10.26% vs. 1.27%; P =0.015). CONCLUSIONS BEVO exerted an effective treatment option for F2-EVs.
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Affiliation(s)
- Xuecan Mei
- Department of Gastroenterology, the First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Hefei, Anhui, China
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Hassan M, Merza N, Nawras Y, Bahbah EI, Al-Hillan A, Ahmed Z, ElSheref SEDM, Dahiya DS, Dar S, Al Azzawi M, Kobeissy A. Continuous vs. intermittent terlipressin infusion for portal hypertension: a systematic review and meta-analysis. Ann Med Surg (Lond) 2023; 85:5001-5010. [PMID: 37811089 PMCID: PMC10553058 DOI: 10.1097/ms9.0000000000001261] [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: 05/27/2023] [Accepted: 08/23/2023] [Indexed: 10/10/2023] Open
Abstract
Background Portal hypertension, a major complication of chronic liver disease, often leads to life-threatening variceal bleeding, managed effectively with vasoactive drugs like terlipressin. However, the most optimal method of terlipressin administration, continuous versus intermittent infusion, remains a subject of debate, necessitating this systematic review and meta-analysis for evidence-based decision-making in managing this critical condition. Methods This systematic review and meta-analysis adhered to the PRISMA standards and explored multiple databases until 6 April 2023, such as MEDLINE through PubMed, Scopus, Web of Science, and CENTRAL. Independent reviewers selected randomized controlled trials (RCTs) that met specific inclusion criteria. After assessing study quality and extracting necessary data, statistical analysis was performed using Review Manager (RevMan), with results presented as risk ratios (RR) or mean differences. Results Five RCTs (n=395 patients) were included. The continuous terlipressin group had a significantly lower risk of rebleeding (RR=0.43, P=0.0004) and treatment failure (RR=0.22, P=0.02) and fewer total adverse effects (RR=0.52, P<0.00001) compared to the intermittent group. However, there were no significant differences between the two groups in mean arterial pressure (P=0.26), length of hospital stays (P=0.78), and mortality rates (P=0.65). Conclusion This study provides robust evidence suggesting that continuous terlipressin infusion may be superior to intermittent infusions in reducing the risk of rebleeding, treatment failure, and adverse effects in patients with portal hypertension. However, further large-scale, high-quality RCTs are required to confirm these findings and to investigate the potential benefits of continuous terlipressin infusion on mortality and hospital stays.
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Affiliation(s)
| | | | - Yusuf Nawras
- The University of Toledo, College of Medicine and Life Sciences, Toledo, Ohio
| | - Eshak I. Bahbah
- Department of Internal Medicine, Al Azhar University, New Damietta, Egypt
| | - Alsadiq Al-Hillan
- Gastroenterology Department, Corewell health/Willam Beaumont University Hospital, Michigan
| | | | | | - Dushyant S. Dahiya
- Division of Gastroenterology, University of Kansas School of Medicine, Kansas City
| | - Sophia Dar
- Gastroenterology Department, Southern Illinois University, Springfield, Illinois, USA
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Lv Y, Bai W, Zhu X, Xue H, Zhao J, Zhuge Y, Sun J, Zhang C, Ding P, Jiang Z, Zhu X, Ren W, LiZhang YK, Zhang W, Li K, Wang Z, Luo B, Li X, Yuan J, Yang Z, Guo W, Xia D, Xie H, Yang C, Pan Y, Yin Z, Fan D, Han G. Association of nonmalignant portal vein thrombosis and clinical outcomes in patients with cirrhosis and acute variceal bleeding: a multicenter observational study. Hepatol Int 2023; 17:1192-1204. [PMID: 37258989 DOI: 10.1007/s12072-023-10493-1] [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: 11/02/2022] [Accepted: 01/20/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND AND AIM Baveno VII workshop recommends management of acute variceal bleeding (AVB) in cirrhotic patients with nonmalignant portal vein thrombosis (PVT) should be performed according to the guidelines for patients without PVT. Nevertheless, whether PVT affects the outcome of patients with cirrhosis and AVB remains unclear. The aim of this study was to assess the clinical impact of PVT on the outcomes in the pre-emptive TIPSS eligible patients with cirrhosis and AVB. METHODS From December 2010 to June 2016, 1219 consecutive cirrhotic patients admitted due to AVB with (n = 151; 12.4%) or without PVT (n = 1068; 87.6%), who received drug plus endoscopic treatment (a combination of vasoactive drugs, antibiotics, and endoscopic ligation for AVB, followed by beta-blockers plus variceal ligation for prevention of rebleeding) were retrospectively included. Fine and Gray competing risk regression models were taken to evaluate the impact of PVT on clinical outcomes after adjusting for potential confounders. RESULTS During follow-up, 211 patients (17.3%) died, 490 (40.2%) experienced further bleeding, and 78 (6.4%) experienced new or worsening ascites within 1 year. Compared with those without PVT, patients with PVT had a similar risk of mortality (PVT vs no-PVT: 19.9% vs 16.7% at 1 year; adjusted HR 0.88, 95%CI 0.51-1.52, p = 0.653), further bleeding (47.0% vs 39.2% at 1 year, adjusted HR 1.19, 95% CI 0.92-1.53, p = 183), and new or worsening ascites (7.9% vs 9.6%, adjusted HR 0.70, 95% CI 0.39-1.28, p = 0.253) after adjusting for confounders in multivariable models. These findings were consistent across different relevant subgroups and confirmed by propensity score matching analysis. CONCLUSIONS Our study showed no evidence that the PVT was associated with an improved or worsened outcome among cirrhotic patients with AVB who received standard treatment.
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Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Military Medical Innovation Center, Fourth Military Medical University, Xi'an, China
| | - Wei Bai
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Xuan Zhu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hui Xue
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jianbo Zhao
- Department of Interventional Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yuzheng Zhuge
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Junhui Sun
- Division of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Hepatobiliary and Pancreatic Intervention Center, Zhejiang University, Hangzhou, China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Pengxu Ding
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zaibo Jiang
- Department of Interventional Radiology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xiaoli Zhu
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Weixin Ren
- Department of Interventional Radiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yingchun Kewei LiZhang
- Department of Interventional Radiology, Second Affiliated Hospital of Kunming Medical University, Kunming, China
- Department of Vascular Surgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - Wenguang Zhang
- Department of Interventional Radiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Kai Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhengyu Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Bohan Luo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Xiaomei Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Jie Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Zhiping Yang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Wengang Guo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Dongdong Xia
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Huahong Xie
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Changbing Yang
- Military Medical Innovation Center, Fourth Military Medical University, Xi'an, China
| | - Yanglin Pan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China.
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China.
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Canillas L, Pelegrina A, Colominas-González E, Salis A, Enríquez-Rodríguez CJ, Duran X, Caro A, Álvarez J, Carrión JA. Comparison of Surgical Risk Scores in a European Cohort of Patients with Advanced Chronic Liver Disease. J Clin Med 2023; 12:6100. [PMID: 37763038 PMCID: PMC10531688 DOI: 10.3390/jcm12186100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023] Open
Abstract
Patients with advanced chronic liver disease (ACLD) or cirrhosis undergoing surgery have an increased risk of morbidity and mortality in contrast to the general population. This is a retrospective, observational study to evaluate the predictive capacity of surgical risk scores in European patients with ACLD. Cirrhosis was defined by the presence of thrombocytopenia with <150,000/uL and splenomegaly, and AST-to-Platelet Ratio Index >2, a nodular liver edge seen via ultrasound, transient elastography of >15 kPa, and/or signs of portal hypertension. We assessed variables related to 90-day mortality and the discrimination and calibration of current surgical scores (Child-Pugh, MELD-Na, MRS, NSQIP, and VOCAL-Penn). Only patients with ACLD and major surgeries included in VOCAL-Penn were considered (n = 512). The mortality rate at 90 days after surgery was 9.8%. Baseline disparities between the H. Mar and VOCAL-Penn cohorts were identified. Etiology, obesity, and platelet count were not associated with mortality. The VOCAL-Penn showed the best discrimination (C-statistic90D = 0.876) and overall predictive capacity (Brier90D = 0.054), but calibration was not excellent in our cohort. VOCAL-Penn was suboptimal in patients with diabetes (C-statistic30D = 0.770), without signs of portal hypertension (C-statistic30D = 0.555), or with abdominal wall (C-statistic30D = 0.608) or urgent (C-statistic180D = 0.692) surgeries. Our European cohort has shown a mortality rate after surgery similar to those described in American studies. However, some variables included in the VOCAL-Penn score were not associated with mortality, and VOCAL-Penn's discriminative ability decreases in patients with diabetes, without signs of portal hypertension, and with abdominal wall or urgent surgeries. These results should be validated in larger multicenter and prospective studies.
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Affiliation(s)
- Lidia Canillas
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain; (L.C.); (A.P.); (E.C.-G.); (A.S.); (C.J.E.-R.)
- Liver Section, Gastroenterology Department, Hospital del Mar, 08003 Barcelona, Spain;
- Hospital del Mar Medical Research Institute, 08003 Barcelona, Spain;
| | - Amalia Pelegrina
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain; (L.C.); (A.P.); (E.C.-G.); (A.S.); (C.J.E.-R.)
- Hospital del Mar Medical Research Institute, 08003 Barcelona, Spain;
- Department of General Surgery, Hospital del Mar, 08003 Barcelona, Spain
| | - Elena Colominas-González
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain; (L.C.); (A.P.); (E.C.-G.); (A.S.); (C.J.E.-R.)
- Pharmacy Department, Hospital del Mar, 08003 Barcelona, Spain
| | - Aina Salis
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain; (L.C.); (A.P.); (E.C.-G.); (A.S.); (C.J.E.-R.)
- Department of Medicine, Universitat Autònoma de Barcelona, 08003 Barcelona, Spain
| | - César J. Enríquez-Rodríguez
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain; (L.C.); (A.P.); (E.C.-G.); (A.S.); (C.J.E.-R.)
- Hospital del Mar Medical Research Institute, 08003 Barcelona, Spain;
| | - Xavier Duran
- Biostatistics Unit, Hospital del Mar Research Institute, 08003 Barcelona, Spain;
| | - Antonia Caro
- Liver Section, Gastroenterology Department, Hospital del Mar, 08003 Barcelona, Spain;
| | - Juan Álvarez
- Hospital del Mar Medical Research Institute, 08003 Barcelona, Spain;
- Anesthesia Department, Hospital del Mar, 08003 Barcelona, Spain
| | - José A. Carrión
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain; (L.C.); (A.P.); (E.C.-G.); (A.S.); (C.J.E.-R.)
- Liver Section, Gastroenterology Department, Hospital del Mar, 08003 Barcelona, Spain;
- Hospital del Mar Medical Research Institute, 08003 Barcelona, Spain;
- Department of Medicine, Universitat Autònoma de Barcelona, 08003 Barcelona, Spain
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38
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Swarna A, Ramamoorthy M, Kini R, Annasamy C, Kalyanasundaram M, Immaneni S. Platelet-albumin-bilirubin score - a risk stratification scoring system to predict outcome of acute variceal bleeding in patients with cirrhosis. Eur J Gastroenterol Hepatol 2023; 35:1044-1048. [PMID: 37395183 DOI: 10.1097/meg.0000000000002600] [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: 07/04/2023]
Abstract
BACKGROUND Acute variceal bleed is a common complication of cirrhosis of liver. Up to 25% of patients with newly diagnosed varices will experience bleeding within 2 years. Of patients who have stopped bleeding, approximately one-third will rebleed within the next 6 weeks. Though scores like Child-Turcotte-Pugh (CTP) and Model of End-stage Liver Disease (MELD) predict the survival of upper gastrointestinal bleed, they have certain limitations in this regard. So, there is a need for reliable scoring system to assess the outcome of patients who had acute variceal bleed. AIM To evaluate the platelet-albumin-bilirubin (PALBI) score in predicting outcome of acute variceal bleeding in patients with cirrhosis. METHODS A total of 130 patients who presented to our institute with acute variceal bleed over a period of 1 year were analyzed. CTP, MELD Na and PALBI scores were calculated for these patients on admission and the outcome was compared in the form of 90-day rebleeding rates. The areas under the receiver operating characteristic curves (AUROC) were calculated for this purpose. RESULTS Mean age was 56 years; 80 were male (61.5%), 50 were female (38.5%), 62 CTP-A (47.7%), 53 CTP-B (40.8%), 15 CTP-C (11.5%); 63 PALBI 1 (48.5%), 23 PALBI 2 (17.8%), and 44 PALBI 3 (33.8%). 1 patient died in the due course of the study. The AUROC for predicting rebleeding was 0.732, 0.71 and 0.803 for CTP, MELD Na and PALBI scores, respectively. CONCLUSION PALBI score on admission is a good predictor of outcomes in cirrhotics with acute variceal bleed.
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Affiliation(s)
- Anupama Swarna
- Institute of Medical Gastroenterology, Madras Medical College, Chennai, India
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39
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Durán M, Alfarah J, Hann A, Perera MTPR. Reconstruction for complex portal vein thrombosis - Anatomical if possible. J Hepatol 2023; 79:e129-e131. [PMID: 37004838 DOI: 10.1016/j.jhep.2023.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 04/04/2023]
Affiliation(s)
- Manuel Durán
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, B15 2GW, United Kingdom; Unit of Liver Transplantation, Reina Sofía University Hospital, Córdoba, 14004, Spain
| | - Jameel Alfarah
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, B15 2GW, United Kingdom
| | - Angus Hann
- Unit of Liver Transplantation, Reina Sofía University Hospital, Córdoba, 14004, Spain
| | - M T P R Perera
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, B15 2GW, United Kingdom; Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TH, United Kingdom.
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40
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Gangwani MK, Aziz A, Priyanka F, Lee Smith W, Aziz M, Hassan M. Optimizing Antibiotic Duration for Spontaneous Bacterial Peritonitis Prophylaxis: Time to Rethink. Am J Ther 2023; 30:e492-e494. [PMID: 37713708 DOI: 10.1097/mjt.0000000000001570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Manesh K Gangwani
- Department of Medicine, University of Toledo Medical Center, Toledo, OH
| | - Abeer Aziz
- Department of Medicine, Aga Khan University, Karachi, Sindh, Pakistan
| | - Fnu Priyanka
- Department of Medicine, Shaheed Mohtarma Benazir Bhutto University, Larkana, Pakistan
| | - Wade Lee Smith
- University of Toledo Libraries, University of Toledo, Toledo, OH
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, University of Toledo Medical Center, Toledo, OH
| | - Mona Hassan
- Division of Gastroenterology and Hepatology, University of Toledo Medical Center, Toledo, OH
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Georgescu D, Ancusa OE, Azoulay D, Lascu A, Ionita I, Calamar-Popovici D, Ionita M, Rosca CI, Brează GM, Reisz D, Lighezan D. Portal Vein Thrombosis in Patients with Liver Cirrhosis: What Went Wrong? Int J Gen Med 2023; 16:3889-3906. [PMID: 37662503 PMCID: PMC10473422 DOI: 10.2147/ijgm.s413438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/10/2023] [Indexed: 09/05/2023] Open
Abstract
Purpose This study aimed to explore inflammatory biomarkers, stool's functional bacterial groups and their possible link to portal vein thrombosis (PVT) in patients with liver cirrhosis (LC). Materials and Methods An observational study of 300 participants: 200 inhospital cirrhotic patients, who met inclusion criteria, equally assigned into two groups, based on the presence or absence of PVT and 100 healthy controls was carried out. Results The PVT group displayed significant differences related to older age, cigarettes smoking history, emergency admission, higher Child-Pugh score, metabolic related disorders and nonalcoholic fatty liver disease, as well as non-obstructive aspects, with chronic thrombi. The PVT group exhibited significant differences related to biomarkers such as tumor necrosis factor (TNF)-alpha, C-reactive protein (CRP), D-dimers (D-D), as well as gut overall dysbiosis (DB) and alteration of different functional bacterial groups of the gut microbiota. Strong positive correlations were observed between PVT severity, and TNF-alpha, CRP, D-D as well as lipopolysaccharide (LPS) positive bacteria. Esophageal varices, age and abdominal pain were independent predictors for PVT severity as well as CRP, TNF-alpha and D-D. Conclusion Patients with LC and PVT displayed elevation of TNF-alpha, CRP, D-D alterations of the functional gut microbiota, as well as several morphological and clinical particularities. Although the LPS positive gut microbiota was linked to inflammatory biomarkers and PVT severity, it was not proven to be an independent predictor of the PVT severity like CRP, TNF-alpha and D-D.
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Affiliation(s)
- Doina Georgescu
- Center of Advanced Researches in Cardiovascular Diseases and Hemostaseology, Department of Internal Medicine I, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Oana-Elena Ancusa
- Center of Advanced Researches in Cardiovascular Diseases and Hemostaseology, Department of Internal Medicine I, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Daniel Azoulay
- Hepato-Biliary Center, Paul-Brousse Hospital, Paris-Saclay University, Villejuif, France
| | - Ana Lascu
- Department of Functional Sciences, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Ioana Ionita
- Center of Advanced Researches in Cardiovascular Diseases and Hemostaseology, Department of Internal Medicine I, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Despina Calamar-Popovici
- Center of Advanced Researches in Cardiovascular Diseases and Hemostaseology, Department of Internal Medicine I, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Mihai Ionita
- Center of Advanced Researches in Cardiovascular Diseases and Hemostaseology, Department of Internal Medicine I, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Ciprian Ilie Rosca
- Center of Advanced Researches in Cardiovascular Diseases and Hemostaseology, Department of Internal Medicine I, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Gelu-Mihai Brează
- Department IX of Surgery I, Compartment of Hepatic-Biliary-Pancreatic Surgery, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Daniela Reisz
- Department of Neurosciences, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Daniel Lighezan
- Center of Advanced Researches in Cardiovascular Diseases and Hemostaseology, Department of Internal Medicine I, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
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Zhong L, Ren TT, Shi L, Deng Q, Hong L, Yu C, Yun T, Chen XJ. Global research on portal vein thrombosis and liver transplantation: A bibliometric and visualized study. Medicine (Baltimore) 2023; 102:e34497. [PMID: 37565897 PMCID: PMC10419595 DOI: 10.1097/md.0000000000034497] [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: 05/31/2023] [Accepted: 07/05/2023] [Indexed: 08/12/2023] Open
Abstract
In recent years, the association between portal vein thrombosis and liver transplantation has extensive attention from physicians worldwide. However, there is no available literature on bibliometric analysis in this research area. Herein, we aimed to conduct a bibliometric analysis to identify the hotspots and frontiers of research related to portal vein thrombosis and liver transplantation. Documents published between 2002 and 2022 were retrieved and downloaded from the Web of Science Core Collection database. VOSviewer was utilized to generate a visualization network map of authors, nations, institutions, journals, and keyword co-occurrence/clustering. Additionaly, CiteSpace was used to analyze the keywords with the strongest bursts. A total of 1272 articles and reviews were extracted from the database. The author Marco Senzolo published the largest number of papers. The United States was the most prolific country, and Hope-Bochon (France) was the top productive institution. Liver Transplantation was the most prolific journal in the field. The most commonly identified keywords in the study were cirrhosis, risk factors, portal vein thrombosis, and management, as revealed by the keyword co-occurrence analysis. It is suggested that patients with cirrhosis, portal vein thrombosis prevention, and management measures for portal vein thrombosis have been prominet topics in recent years. Furthermore, an analysis of keywords with the strongest citation bursts highlighted pediatric liver transplantation, direct oral anticoagulants, and nonalcoholic fatty liver disease as current research trends. Research in portal vein thrombosis and liver transplantation exhibits a general upward trend. The latest hot topics within this area of study involve pediatric patients and nonalcoholic fatty liver disease.
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Affiliation(s)
- Ling Zhong
- Department of Nursing, Guizhou Medical University, Guiyang, China
| | - Ting-Ting Ren
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Lei Shi
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Qian Deng
- Department of Nursing, Guizhou Medical University, Guiyang, China
| | - Li Hong
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Chao Yu
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Tan Yun
- Department of Nursing, Guizhou Medical University, Guiyang, China
| | - Xi Jun Chen
- Department of Nursing, Guizhou Medical University, Guiyang, China
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Gieser P, Merle U, Junghanss T, Weber TF, Stojković M. Vascular pathology in patients with alveolar echinococcosis: framework for assessment and clinical management - a retrospective case series. BMJ Open Gastroenterol 2023; 10:e001181. [PMID: 37567730 PMCID: PMC10423801 DOI: 10.1136/bmjgast-2023-001181] [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: 04/24/2023] [Accepted: 07/31/2023] [Indexed: 08/13/2023] Open
Abstract
OBJECTIVE Alveolar echinococcosis (AE) is a parasitic liver disease with infiltrative growth similar to solid organ malignancies. Major vascular damage is frequent and often remains untreated until catastrophic events precipitate. Detailed clinical and radiological assessment is required to guide individualised treatment decisions. Standardised radiological reporting templates of malignancies with profiles resembling AE are candidates for adaptation. Our objectives are to describe vascular pathology in AE and establish a framework for structured evaluation as the basis for treatment decisions and monitoring. DESIGN Retrospective case series. RESULTS 69 patients (37.1%) had vascular involvement: portal vein (PV) 24.7%, hepatic vein (HV) 22.6% inferior vena cava (IVC) 13.4%. Significant stenosis/occlusion of vessels was present in 15.1% of PV, in 13.4% of HV and in 7.5% of IVC involvement. Vascular pathology needing specific treatment or monitoring was present in 8.6% of patients. The most frequent clinical presentation was high grade IVC stenosis or occlusion which was seen in 11 patients of the cohort. CONCLUSION Advanced AE requires early multidisciplinary assessment to prevent progressive impairment of liver function due to vascular damage. The focus at first presentation is on complete evaluation of vascular (and biliary) involvement. The focus in non-resectable AE is on prevention of vascular (and biliary) complications while suppressing growth of AE lesions by benzimidazole treatment to improve the quality of life of patients. We developed a framework for standardised vascular assessment and follow-up of patients with AE to recognise and treat complications early.
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Affiliation(s)
- Paula Gieser
- Infectious and Tropical Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Uta Merle
- Department of Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Junghanss
- Infectious and Tropical Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Tim F Weber
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Marija Stojković
- Infectious and Tropical Diseases, University Hospital Heidelberg, Heidelberg, Germany
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Attanasi ML, Bou Daher H, Rockey DC. Natural History and Outcomes of Cavernous Transformation of the Portal Vein in Cirrhosis. Dig Dis Sci 2023; 68:3458-3466. [PMID: 37349605 DOI: 10.1007/s10620-023-07993-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/30/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND AND AIMS Cavernous transformation of the portal vein can occur after portal vein thrombosis (PVT). In this study, we investigated clinical complications associated with cavernous transformation in the context of cirrhosis and PVT. METHODS In this retrospective cohort analysis, 204 patients with cirrhosis and PVT with or without cavernous transformation were identified using MUSC's Clinical Data Warehouse between January 1, 2013, through December 31, 2019. Complete demographic data, clinical history, and laboratory tests were abstracted from the electronic medical record. RESULTS Of 204 patients, 41 (20%) had cavernous transformation. MELD, Child-Pugh, and Charlson Comorbidity Index scores were similar among groups. There were no significant differences in the prevalence of esophageal varices (with or without bleeding), splenomegaly, or hepatic encephalopathy in patients with and without cavernous transformation, although ascites tended to be lower in patients with cavernous transformation (31/41 (76%) vs 142/163 (87%), p = 0.06). Patients with cavernous transformation were significantly less likely to have hepatocellular carcinoma (HCC) (13/41 (32%) vs 81/163 (50%), p < 0.05) and had significantly lower APRI (1.4 vs 2.0, p < 0.05) and Fib-4 (4.7 vs 6.5, p < 0.05). Patients with cavernous transformation had lower 5-year mortality (12/41 (29%) vs 81/163 (49%) died, p = 0.06). The 10-year mortality of patients with cavernous transformation without HCC was significantly lower than in those without cavernous transformation (8/28 (29%) vs 46/82 (56%), respectively, p < 0.05). CONCLUSIONS Patients with cavernous transformation appeared to have better outcomes than those without cavernous transformation.
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Affiliation(s)
- Michael L Attanasi
- Digestive Disease Research Center, Medical University of South Carolina, 96 Jonathan Lucas Street, Clinical Sciences Building, Suite 908, Charleston, SC, 29425, USA
| | - Halim Bou Daher
- Digestive Disease Research Center, Medical University of South Carolina, 96 Jonathan Lucas Street, Clinical Sciences Building, Suite 908, Charleston, SC, 29425, USA
| | - Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, 96 Jonathan Lucas Street, Clinical Sciences Building, Suite 908, Charleston, SC, 29425, USA.
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Todd A, Shekhar C, O'Rourke J, Forde C, Pallan A, Wadhwani SS, Tripathi D, Mahon BS. Technical and clinical outcomes following EUS-guided thrombin injection and coil implantation for parastomal varices. BMJ Open Gastroenterol 2023; 10:e000819. [PMID: 37562855 PMCID: PMC10423785 DOI: 10.1136/bmjgast-2021-000819] [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: 01/19/2022] [Accepted: 03/28/2022] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND AND AIMS Bleeding from parastomal varices causes significant morbidity and mortality. Treatment options are limited, particularly in high-risk patients with significant underlying liver disease and other comorbidities. The use of EUS-guided embolisation coils combined with thrombin injection in gastric varices has been shown to be safe and effective. Our institution has applied the same technique to the treatment of parastomal varices. METHODS A retrospective review was performed of 37 procedures on 24 patients to assess efficacy and safety of EUS-guided injection of thrombin, with or without embolisation coils for treatment of bleeding parastomal varices. All patients had been discussed in a multidisciplinary team meeting, and correction of portal hypertension was deemed to be contraindicated. Rebleeding was defined as stomal bleeding that required hospital admission or transfusion. RESULTS All patients had significant parastomal bleeding at the time of referral. 100% technical success rate was achieved. 70.8% of patients had no further significant bleeding in the follow-up period (median 26.2 months) following one procedure. 1-year rebleed-free survival was 80.8% following first procedure. 7 patients (29.1%) had repeat procedures. There was no significant difference in rebleed-free survival following repeat procedures. Higher age was associated with higher risk of rebleeding. No major procedure-related complications were identified. CONCLUSIONS EUS-guided thrombin injection, with or without embolisation coils, is a safe and effective technique for the treatment of bleeding parastomal varices, particularly for patients for whom correction of portal venous hypertension is contraindicated.
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Affiliation(s)
- Andrew Todd
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Chander Shekhar
- Department of Gastroenterology, Walsall Healthcare NHS Trust, Walsall, UK
| | - Joanne O'Rourke
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Colm Forde
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Arvind Pallan
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Immunulogy and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Brinder Singh Mahon
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Mansour D, Masson S, Hammond J, Leithead JA, Johnson J, Rahim MN, Douds AC, Corless L, Shawcross DL, Heneghan MA, Tripathi D, McPherson S, Bonner E, Botterill G, West R, Donnelly M, Grapes A, Hollywood C, Ross V. British Society of Gastroenterology Best Practice Guidance: outpatient management of cirrhosis - part 3: special circumstances. Frontline Gastroenterol 2023; 14:474-482. [PMID: 37862443 PMCID: PMC10579550 DOI: 10.1136/flgastro-2023-102432] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2023] Open
Abstract
The prevalence of cirrhosis has risen significantly over recent decades and is predicted to rise further. Widespread use of non-invasive testing means cirrhosis is increasingly diagnosed at an earlier stage. Despite this, there are significant variations in outcomes in patients with cirrhosis across the UK, and patients in areas with higher levels of deprivation are more likely to die from their liver disease. This three-part best practice guidance aims to address outpatient management of cirrhosis, in order to standardise care and to reduce the risk of progression, decompensation and mortality from liver disease. Part 1 addresses outpatient management of compensated cirrhosis: screening for hepatocellular cancer, varices and osteoporosis, vaccination and lifestyle measures. Part 2 concentrates on outpatient management of decompensated disease including management of ascites, encephalopathy, varices, nutrition as well as liver transplantation and palliative care. In this, the third part of the guidance, we focus on special circumstances encountered in managing people with cirrhosis, namely surgery, pregnancy, travel, managing bleeding risk for invasive procedures and portal vein thrombosis.
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Affiliation(s)
- Dina Mansour
- Gateshead Health NHS Foundation Trust, Gateshead, UK
- Newcastle University, Newcastle upon Tyne, UK
| | - Steven Masson
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - John Hammond
- Hepatopancreatobiliary Multidisciplinary team, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Joanna A Leithead
- Addenbrooke's Hospital, Cambridge, UK
- Forth Valley Royal Hospital, Larbert, UK
| | | | | | - Andrew C Douds
- Gastroenterology, Queen Elizabeth Hospital, Kings Lynn, UK
| | - Lynsey Corless
- Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | | | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Stuart McPherson
- Newcastle University, Newcastle upon Tyne, UK
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | | | | | | | | | | | - Coral Hollywood
- Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
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47
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Mansour D, Masson S, Shawcross DL, Douds AC, Bonner E, Corless L, Leithead JA, Hammond J, Heneghan MA, Rahim MN, Tripathi D, West R, Johnson J, Botterill G, Hollywood C, Ross V, Donnelly M, Compston JE, McPherson S, Grapes A. British Society of Gastroenterology Best Practice Guidance: outpatient management of cirrhosis - part 1: compensated cirrhosis. Frontline Gastroenterol 2023; 14:453-461. [PMID: 37862444 PMCID: PMC10579555 DOI: 10.1136/flgastro-2023-102430] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2023] Open
Abstract
The prevalence of cirrhosis has risen significantly over recent decades and is predicted to rise further. Widespread use of non-invasive testing means cirrhosis is increasingly diagnosed at an earlier stage. Despite this, there are significant variations in outcomes in patients with cirrhosis across the UK, and patients in areas with higher levels of deprivation are more likely to die from their liver disease. This three-part best practice guidance aims to address outpatient management of cirrhosis, in order to standardise care and to reduce the risk of progression, decompensation and mortality from liver disease. Here, in part one, we focus on outpatient management of compensated cirrhosis, encompassing hepatocellular cancer surveillance, screening for varices and osteoporosis, vaccination and lifestyle measures. We also introduce a compensated cirrhosis care bundle for use in the outpatient setting. Part two concentrates on outpatient management of decompensated disease including management of ascites, encephalopathy, varices, nutrition as well as liver transplantation and palliative care. The third part of the guidance covers special circumstances encountered in managing people with cirrhosis: surgery, pregnancy, travel, managing bleeding risk for invasive procedures and portal vein thrombosis.
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Affiliation(s)
- Dina Mansour
- Newcastle Medical School, Newcastle University, Newcastle upon Tyne, UK
- Gastroenterology and hepatology, Gateshead Health NHS Foundation Trust, Gateshead, UK
| | - Steven Masson
- Newcastle Medical School, Newcastle University, Newcastle upon Tyne, UK
- Hepatology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | | | - Andrew C Douds
- Gastroenterology, Queen Elizabeth Hospital, Kings Lynn, UK
| | - Emily Bonner
- Anaesthetics, Freeman Hospital, Newcastle upon Tyne, UK
| | - Lynsey Corless
- Gastroenterology, Hull Royal Infirmary, Hull, UK
- Hull York Medical School, Hull, UK
| | - Joanna A Leithead
- Gastroenterology and Hepatology, Forth Valley Royal Hospital, Larbert, UK
| | - John Hammond
- Hepatopancreatobiliary Multidisciplinary Team, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | | | - Jill Johnson
- Dietetics, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | - Coral Hollywood
- Hepatology, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
| | - Valerie Ross
- Pharmacy, Barts and The London NHS Trust, London, UK
| | | | - Juliet E Compston
- Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Stuart McPherson
- Newcastle Medical School, Newcastle University, Newcastle upon Tyne, UK
- Hepatology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Allison Grapes
- Gastroenterology and hepatology, Gateshead Health NHS Foundation Trust, Gateshead, UK
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Whitton TP, Healy WJ. Review of Thromboelastography (TEG): Medical and Surgical Applications. THERAPEUTIC ADVANCES IN PULMONARY AND CRITICAL CARE MEDICINE 2023; 18:29768675231208426. [PMID: 38107072 PMCID: PMC10725099 DOI: 10.1177/29768675231208426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 09/22/2023] [Indexed: 12/19/2023]
Abstract
Thromboelastography (TEG) is a laboratory assay utilized to evaluate hemostatic properties of blood, identify coagulopathy, and guide blood product administration. While the clinical use of TEG started in the care of surgical patients, the assay has now been incorporated more routinely in the care of the medical patient as well. In this review, we explore the evolution of TEG from the historical perspective of its inception to the current state of the art of the assay. The TEG procedure and its measurements are illustrated along with a table that summarizes recommendations from across the medical and surgical literature. After each section, we review salient learning points to provide the busy clinician with information that can be immediately integrated at the bedside. We conclude with a series of summary questions to check for comprehension and direct the reader to additional resources to improve their knowledge of TEG.
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Affiliation(s)
- TP Whitton
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - WJ Healy
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Medical College of Georgia at Augusta University, Augusta, GA, USA
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Peng M, Bai Z, Zou D, Xu S, Wang C, Başaranoğlu M, Philips CA, Guo X, Shao X, Qi X. Timing of endoscopy in patients with cirrhosis and acute variceal bleeding: a single-center retrospective study. BMC Gastroenterol 2023; 23:219. [PMID: 37365510 DOI: 10.1186/s12876-023-02766-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 04/15/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND The optimal timing of endoscopy in liver cirrhosis with acute variceal bleeding (AVB) remains controversial in current guidelines and studies. METHODS Consecutive patients with liver cirrhosis and AVB were screened. The timing of endoscopy was calculated from the last presentation of AVB or the admission to endoscopy. Early endoscopy was defined as the interval < 12 h, < 24 h, or < 48 h. A 1:1 propensity score matching (PSM) analysis was performed. Five-day failure to control bleeding and in-hospital mortality were evaluated. RESULTS Overall, 534 patients were included. When the timing of endoscopy was calculated from the last presentation of AVB, PSM analysis demonstrated that the rate of 5-day failure to control bleeding was significantly higher in early endoscopy group defined as < 48 h (9.7% versus 2.4%, P = 0.009), but not < 12 h (8.7% versus 6.5%, P = 1.000) or < 24 h (13.4% versus 6.2%, P = 0.091), and that the in-hospital mortality was not significantly different between early and delayed endoscopy groups (< 12 h: 6.5% versus 4.3%, P = 1.000; <24 h: 4.1% versus 3.1%, P = 1.000; <48 h: 3.0% versus 2.4%, P = 1.000). When the timing of endoscopy was calculated from the admission, PSM analyses did not demonstrate any significant difference in the rate of 5-day failure to control bleeding (< 12 h: 4.8% versus 12.7%, P = 0.205; <24 h: 5.2% versus 7.7%, P = 0.355; <48 h: 4.5% versus 6.0%, P = 0.501) or in-hospital mortality (< 12 h: 4.8% versus 4.8%, P = 1.000; <24 h: 3.9% versus 2.6%, P = 0.750; <48 h: 2.0% versus 2.5%, P = 1.000) between early and delayed endoscopy groups. CONCLUSION Our study could not support any significant association of timing of endoscopy with cirrhotic patients with AVB.
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Affiliation(s)
- Mengyuan Peng
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, Liaoning Province, 110840, China
- Postgraduate College, Jinzhou Medical University, Jinzhou, P.R. China
| | - Zhaohui Bai
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, Liaoning Province, 110840, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, P.R. China
| | - Deli Zou
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, Liaoning Province, 110840, China
| | - Shixue Xu
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, Liaoning Province, 110840, China
| | - Chunmei Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, Liaoning Province, 110840, China
| | - Metin Başaranoğlu
- Department of Internal Medicine, Bezmialem Vakıf University Faculty of Medicine, İstanbul, Turkey
| | - Cyriac Abby Philips
- Clinical and Translational Hepatology & Monarch Liver Laboratory, The Liver Institute, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, Liaoning Province, 110840, China
| | - Xiaodong Shao
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, Liaoning Province, 110840, China.
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, Liaoning Province, 110840, China.
- Postgraduate College, Jinzhou Medical University, Jinzhou, P.R. China.
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, P.R. China.
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50
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Creeper KJ, Stafford AC, Choudhuri S, Tumian R, Breen K, Cohen AT. Bleeding related hospitalizations and mortality in England 2014-2019. J Thromb Thrombolysis 2023:10.1007/s11239-023-02849-z. [PMID: 37338712 DOI: 10.1007/s11239-023-02849-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2023] [Indexed: 06/21/2023]
Abstract
Acute bleeding is common and associated with increased morbidity and mortality. Epidemiological studies evaluating trends in bleeding-related hospitalisations and mortality are important as they have potential to guide resource allocation and service provision, however, despite this literature evaluating the national burden and annual trends are lacking. Our objective was to report the national burden and incidence of bleeding-related hospitalisation and mortality.This was a population-based review of all people in England between 2014 and 2019 either admitted to an acute care ward of a National Health Service (NHS) English hospital, or who died. Admissions and deaths were required to have a primary diagnosis of significant bleeding.There was a total of 3,238,427 hospitalisations with a mean of 539,738 ± 6033 per year and 81,264 deaths with a mean of 13,544 ± 331 per year attributable to bleeding. The mean annual incident rate for bleeding-related hospitalisations was 975 per 100,000 patient years and for mortality was 24.45. Over the study period there was a significant 8.2% reduction in bleeding related deaths (χ2 test for trend 91.4, p < 0.001). A direct relationship between increasing age and incidence of bleeding-related hospitalisation and mortality was seen.Bleeding remains a common cause of hospitalisation and death. The reduction in bleeding related mortality requires further investigation. This data may serve to guide future interventions designed to reduce bleeding-related morbidity and mortality.
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Affiliation(s)
- Katherine J Creeper
- Department of Haematological Medicine, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE17EH, UK.
- Department of Haematology, Sir Charles Gairdner Hospital, Perth, Australia.
| | | | | | - Rafeah Tumian
- Department of Haematological Medicine, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE17EH, UK
- Haematology Unit, Dept of Medicine, UKM Medical Centre, Kuala Lumpur, 56000, Malaysia
| | - Karen Breen
- Department of Haematological Medicine, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE17EH, UK
| | - Alexander T Cohen
- Department of Haematological Medicine, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE17EH, UK
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