U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients

These updated guidelines on the management of variceal haemorrhage have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the liver section of the BSG. The original guidelines which this document supersedes were written in 2000 and have undergone extensive revision by 13 members of the Guidelines Development Group (GDG). The GDG comprises elected members of the BSG liver section, representation from British Association for the Study of the Liver (BASL) and Liver QuEST, a nursing representative and a patient representative. The quality of evidence and grading of recommendations was appraised using the AGREE II tool.The nature of variceal haemorrhage in cirrhotic patients with its complex range of complications makes rigid guidelines inappropriate. These guidelines deal specifically with the management of varices in patients with cirrhosis under the following subheadings: (1) primary prophylaxis; (2) acute variceal haemorrhage; (3) secondary prophylaxis of variceal haemorrhage; and (4) gastric varices. They are not designed to deal with (1) the management of the underlying liver disease; (2) the management of variceal haemorrhage in children; or (3) variceal haemorrhage from other aetiological conditions.

Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension

These guidelines on transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the management of portal hypertension have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the Liver Section of the BSG. The guidelines are new and have been produced in collaboration with the British Society of Interventional Radiology (BSIR) and British Association of the Study of the Liver (BASL). The guidelines development group comprises elected members of the BSG Liver Section, representation from BASL, a nursing representative and two patient representatives. The quality of evidence and grading of recommendations was appraised using the GRADE system. These guidelines are aimed at healthcare professionals considering referring a patient for a TIPSS. They comprise the following subheadings: indications; patient selection; procedural details; complications; and research agenda. They are not designed to address: the management of the underlying liver disease; the role of TIPSS in children; or complex technical and procedural aspects of TIPSS.

Randomized controlled trial of carvedilol versus variceal band ligation for the prevention of the first variceal bleed

Current therapy for preventing the first variceal bleed includes beta-blocker and variceal band ligation (VBL). VBL has lower bleeding rates, with no differences in survival, whereas beta-blocker therapy can be limited by side effects. Carvedilol, a non-cardioselective vasodilating beta-blocker, is more effective in reducing portal pressure than propranolol; however, there have been no clinical studies assessing the efficacy of carvedilol in primary prophylaxis. The goal of this study was to compare carvedilol and VBL for the prevention of the first variceal bleed in a randomized controlled multicenter trial. One hundred fifty-two cirrhotic patients from five different centers with grade II or larger esophageal varices were randomized to either carvedilol 12.5 mg once daily or VBL performed every 2 weeks until eradication using a multibander device. Seventy-seven patients were randomized to carvedilol and 75 to VBL. Baseline characteristics did not differ between the groups (alcoholic liver disease, 73%; median Child-Pugh score, 8; median age, 54 years; median follow-up, 20 months). On intention-to-treat analysis, carvedilol had lower rates of the first variceal bleed (10% versus 23%; relative hazard 0.41; 95% confidence interval 0.19-0.96 [P = 0.04]), with no significant differences in overall mortality (35% versus 37%, P = 0.71), and bleeding-related mortality (3% versus 1%, P = 0.26). Six patients in the VBL group bled as a result of banding ulcers. Per-protocol analysis revealed no significant differences in the outcomes.

CONCLUSION

Carvedilol is effective in preventing the first variceal bleed. Carvedilol is an option for primary prophylaxis in patients with high-risk esophageal varices.

The role of the transjugular intrahepatic portosystemic stent shunt (TIPSS) in the management of bleeding gastric varices: clinical and haemodynamic correlations

BACKGROUND

The transjugular intrahepatic portosystemic stent shunt (TIPSS) is effective in the management of both oesophageal and gastric variceal bleeding. Although it has been reported that gastric varices can bleed at pressures of < or = 12 mm Hg, this phenomenon has been little studied in the clinical setting.

AIMS

To assess the efficacy of TIPSS on rebleeding and mortality following gastric and oesophageal variceal bleeding, and the importance of portal pressure in both groups.

METHODS

Forty eligible patients who had bled from gastric varices and 232 from oesophageal varices were studied. Patients were also subdivided into those whose portal pressure gradients (PPG) prior to TIPSS were < or = 12 mm Hg (group 1) and >12 mm Hg (group 2).

RESULTS

There was no difference in Child-Pugh score, age, sex, or alcohol related disease between patients bleeding from gastric or oesophageal varices. Patients who bled from gastric varices had a lower PPG pre-TIPSS (15.8 (0.8) v 21.44 (0.4) mm Hg; p<0.001). There was no difference in the rebleeding rate (20.0% v 14.7%; NS). There was a significant difference (p<0.05) in favour of the gastric varices group in the one year mortality (30.7% v 38.7%) and five year mortality (49.5% v 74.9%), particularly in those patients in group 2. Gastric variceal bleeding accounted for significantly more cases in group 1 than in group 2 (36.8% v 10.2%; p<0.001). Most patients in group 2 who rebled had a PPG post-TIPSS of >7 mm Hg.

CONCLUSIONS

TIPSS is equally effective in the prevention of rebleeding following gastric and oesophageal variceal bleeding. A significant proportion of gastric varices bleed at a PPG < or = 12 mm Hg. The improved mortality in patients with gastric variceal bleeding is seen only in those that bleed at a PPG >12 mm Hg, and warrants further study.

Good clinical outcomes following transjugular intrahepatic portosystemic stent-shunts in Budd-Chiari syndrome

BACKGROUND

There have been encouraging reports on transjugular intrahepatic portosystemic stent-shunt (TIPSS) for Budd-Chiari syndrome (BCS). Long-term data are lacking.

AIM

To assess long-term outcomes and validate prognostic scores following TIPSS for BCS.

METHODS

A single centre retrospective study. Patients underwent TIPSS using bare or polytertrafluoroethane (PTFE)-covered stents.

RESULTS

Sixty-seven patients received successful TIPSS between 1996 and 2012 using covered (n = 40) or bare (n = 27) stents. Patients included had a Male: Female ratio of 21:46, and were characterised (mean ± s.d.) by age 39.9 ± 14.3 years, Model of end stage liver disease (MELD) 16.1 ± 7.0 and Child's score 8.8 ± 2.0. Seventy-eight percent had haematological risk factors. Presenting symptoms were ascites (n = 61) and variceal bleeding (n = 6). Nine patients underwent hepatic vein dilatation or stenting prior to TIPSS. Mean follow-up was 82 months (range 0.5-184 months). Fifteen percent had post-TIPSS encephalopathy. Two have been transplanted. Primary patency rates (76% vs. 27%, P < 0.001) and shunt re-interventions (22% vs. 100%, P < 0.001) significantly favoured covered stents. Secondary patency was 99%. Six-, 12-, 24-, 60- and 120-month survival was 97%, 92%, 87%, 80% and 72% respectively. Six patients had liver related deaths. Two patients developed hepatocellular carcinoma. The BCS TIPS PI independently predicted mortality in the whole cohort, but no prognostic score was a significant predictor of mortality after subgroup validation.

CONCLUSIONS

Long-term outcomes following TIPSS for Budd-Chiari syndrome are very good. PTFE-covered stents have significantly better primary patency. The value of prognostic scores is controversial. TIPSS should be considered as first line therapy in symptomatic patients in whom hepatic vein patency cannot be restored.

Improved clinical outcome with transjugular intrahepatic portosystemic stent-shunt utilizing polytetrafluoroethylene-covered stents

BACKGROUND AND AIMS

Transjugular intrahepatic portosystemic stent-shunt (TIPSS) with standard uncovered stents has a 50% one-year primary patency rate, and is complicated by hepatic encephalopathy in 35% of patients. Newer covered stents appear to have improved patency. This large study aimed to assess the shunt function and clinical efficacy of polytetrafluoroethylene-covered stents in a single centre.

METHODS

A total of 316 patients with uncovered stents before the introduction of covered stents (group 1) and 157 patients with the Viatorr Gore polytetrafluoroethylene-covered stents at the time of TIPSS creation (group 2) were studied.

RESULTS

The mean follow-up was 22.8+/-25.4 and 13.1+/-12.5 months, respectively (P<0.01). Shunt insufficiency was greater in group 1 [54 versus 8% at 12 months; relative hazard (RH) 8.6; 95% confidence interval (CI) 4.8-15.5; P<0.001]. The incidence of variceal rebleeding was greater in group 1 (11 versus 6% at 12 months; RH 2.4; 95% CI 1.1-5.1; P<0.05). The incidence of hepatic encephalopathy was greater in group 1 (32 versus 22% at 12 months; RH 1.5; 95% CI 1.1-2.3; P<0.05). Mortality was similar in the two groups.

CONCLUSION

The Viatorr type of polytetrafluoroethylene-covered stent results in vastly improved patency compared with uncovered stents, with reduced rates of variceal rebleeding and hepatic encephalopathy. This type of covered stent has the potential for superior clinical efficacy compared with uncovered stents.

Ten years' follow-up of 472 patients following transjugular intrahepatic portosystemic stent-shunt insertion at a single centre

BACKGROUND

Transjugular intrahepatic portosystemic stent-shunt (TIPSS) is increasingly used for the management of portal hypertension. We report on 10 years' experience at a single centre.

METHODS

Data held in a dedicated database was retrieved on 497 patients referred for TIPSS. The efficacy of TIPSS and its complications were assessed.

RESULTS

Most patients were male (59.4%) with alcoholic liver disease (63.6%), and bleeding varices (86.8%). Technical success was achieved in 474 (95.4%) patients. A total of 13.4% of patients bled at portal pressure gradients < or = 12 mmHg, principally from gastric and ectopic varices. Procedure-related mortality was 1.2%. The mean follow-up period of surviving patients was 33.3 +/- 1.9 months. Primary shunt patency rates were 45.4% and 26.0% at 1 and 2 years, respectively, while the overall secondary assisted patency rate was 72.2%. Variceal rebleeding rate was 13.7%, with all episodes occurring within 2 years of TIPSS insertion, and almost all due to shunt dysfunction. The overall mortality rate was 60.4%, mainly resulting from end-stage liver failure (42.5%). Patients who bled from gastric varices had lower mortality than those from oesophageal varices (53.9% versus 61.5%, P < 0.01). The overall rate of hepatic encephalopathy was 29.9% (de novo encephalopathy was 11.5%), with pre-TIPSS encephalopathy being an independent predicting variable. Refractory ascites responded to TIPSS in 72% of cases, although the incidence of encephalopathy was high in this group (36.0%).

CONCLUSIONS

TIPSS is effective in the management of variceal bleeding, and has a low complication rate. With surveillance, good patency can be achieved. Careful selection of patients is needed to reduce the encephalopathy rate.

Haemodynamic effects of acute and chronic administration of low-dose carvedilol, a vasodilating beta-blocker, in patients with cirrhosis and portal hypertension

BACKGROUND

Carvedilol is a non-selective vasodilating beta-blocker with weak alpha1 receptor antagonism. Recent studies have demonstrated its potential as a portal hypotensive agent.

AIM

To assess the haemodynamic effects and patient tolerability of the acute and chronic administration of low-dose carvedilol.

METHODS

Haemodynamic measurements were performed in ten cirrhotic patients before and 1 h after the administration of 12.5 mg oral carvedilol. The study was repeated 4 weeks after daily administration of 12.5 mg carvedilol.

RESULTS

After acute administration of carvedilol, there was a 23% reduction in the hepatic venous pressure gradient from 16.37 +/- 2.14 to 12.56 +/- 3.91 mmHg (P < 0.05), with significant falls in the heart rate, mean arterial pressure and cardiac output. Chronic administration resulted in a further fall in the hepatic venous pressure gradient from a baseline of 16.37 +/- 0.71 to 9.27 +/- 1.40 mmHg (P < 0.001) with the mean arterial pressure being unaffected. The drug was well tolerated with only one patient experiencing asymptomatic hypotension.

CONCLUSIONS

The results show that low-dose carvedilol is an extremely potent portal hypotensive pharmacological agent, and is worthy of further investigation in large randomized trials to assess its effect in preventing variceal haemorrhage.

Transjugular intrahepatic portosystemic stent-shunt and its effects on orthotopic liver transplantation

BACKGROUND

It has been reported that preoperative transjugular intrahepatic portosystemic stent-shunt (TIPSS) reduces peri-operative transfusion requirements during orthotopic liver transplant, and may result in fewer episodes of poor, early graft function by reducing portosystemic shunting, thus improving portal blood supply to the graft.

OBJECTIVE

To test the hypotheses that TIPSS improves early graft function and reduces transfusion requirements.

METHODS

A retrospective review of 82 liver transplant recipients between 1993 and 1999 was performed. The subgroups comprised 29 patients who had TIPSS prior to first orthotopic liver transplant and 53 matched controls without TIPSS.

RESULTS

There was no significant difference in the early graft function in the two groups. The prothrombin time before an orthotopic liver transplant was independently predictive of initial poor function. Transfusion requirements and total operating times were similar for both groups, although transfusion requirements were greater in those patients where TIPSS led to technical difficulties during the operation (n = 6). The TIPSS patients required a longer hospital stay than the non-TIPSS patients (41 +/- 8 vs 26 +/- 4 days, P < 0.05). There were significantly more patients needing dialysis in the TIPSS group (41.3% vs 9.4%, P < 0.001). Pulmonary infection was less common in the TIPSS group (P < 0.05), with a trend to reduced wound infections. The 12 month patient and graft survival were similar in both groups. Serum albumin levels assessed before orthotopic liver transplant independently predicted 12 month graft survival.

CONCLUSIONS

TIPSS does not improve early graft function, nor reduce blood transfusion requirements perioperatively. The longer post-operative hospital stay in the TIPSS group is worthy of further study. TIPSS prior to transplantation, despite having the potential for technical operative complications, has no detrimental effects on patient and graft survival, and if required should be undertaken.

Long-term outcomes following percutaneous hepatic vein recanalization for Budd-Chiari syndrome

BACKGROUND & AIMS

A proportion of patients with Budd-Chiari Syndrome (BCS) associated with stenosis or short occlusion of the hepatic vein (HV) or upper inferior vena cava (IVC) can be treated with recanalization by percutaneous venoplasty ± HV stent insertion. We studied the long-term outcomes of this approach.

METHODS

Single-centre retrospective analysis of patients referred for radiological assessment ± intervention over a 27-year period. Of 155 BCS patients, 63 patients who underwent venoplasty were studied and compared to a previously reported series treated by TIPSS (n = 59).

RESULTS

Patients treated with HV interventions (32 venoplasty alone, 31 endovascular stents): mean age, 34.9 ± 10.9; M:F ratio 27:36; median follow-up, 113.0 months; 62% of patients had ≥1 haematological risk factor. Technical success was 100%, with symptom resolution in 73%. Cumulative secondary patency at 1, 5, 10 years was 92%, 79%, 79% and 69%, 69%, 64% in the stenting and venoplasty groups respectively. Where long-term patency was not achieved, 10 patients required TIPSS, and 8 underwent surgery. Actuarial survival at 1, 5, 10 years was 97%, 89% and 85%. When compared to TIPSS, HV interventions resulted in similar patency and survival rates but significantly lower procedural complications (9.5% vs 27.1%) and hepatic encephalopathy (0% vs 18%). Patient age predicted survival following multivariate analysis.

CONCLUSIONS

Our data support the stepwise approach to management of BCS, with very good outcomes from venoplasty combined with stenting when required. TIPSS should only be offered where HV interventions are not feasible or unsuccessful.

Beta-blockers in portal hypertension: new developments and controversies

There are many studies investigating the role of non-selective beta-blockers in portal hypertension. Satisfactory reduction in portal pressure is possible in a third to half of patients with propranolol and nadolol, although combining these drugs with nitrates may be more effective. Carvedilol is a more potent agent than propranolol in reducing portal pressure, particularly in non-responders, and is better tolerated. All these drugs have been studied in primary and secondary prophylaxis, sometimes in combination with band ligation and/or nitrates. There is some evidence to support combining these agents with band ligation, despite a lack of survival benefit and increased adverse events. Hemodynamic monitoring can help select non-responders who may benefit from additional therapies such as band ligation, as lack of response is associated with worse outcomes. Propranolol should be used with caution in patients with refractory ascites, although the current evidence is not of sufficient quality to justify not using these drugs in such situations. Beta-blockers have been shown to reduce bacterial translocation and spontaneous bacterial peritonitis in cirrhosis.

Review article: recent advances in the management of bleeding gastric varices

Gastric variceal bleeding can be challenging to the clinician. Tissue adhesives can control acute bleeding in over 80%, with rebleeding rates of 20-30%, and should be first-line therapy where available. Endoscopic ultrasound can assist in better eradication of varices. The potential risks of damage to equipment and embolic phenomena can be minimized with careful attention to technique. Variceal band ligation is an alternative to tissue adhesives for the management of acute bleeding, but not for secondary prevention due to a higher rate of rebleeding. Endoscopic therapy with human thrombin appears promising, with initial haemostasis rates typically over 90%. The lack of controlled studies for thrombin prevents universal recommendation outside of clinical trials. Balloon occluded retrograde transvenous obliteration is a recent technique for patients with gastrorenal shunts, although its use is limited to clinical trials. Transjugular intrahepatic portosystemic stent shunt is an option for refractory bleeding and secondary prophylaxis, with uncontrolled studies demonstrating initial haemostasis obtained in over 90%, and rebleeding rates of 15-30%. Non-cardioselective beta-blockers are an alternative to transjugular intrahepatic portosystemic stent shunt for secondary prophylaxis, although the evidence is limited. Shunt surgery should be considered in well-compensated patients. Splenectomy or embolization is an option in patients with segmental portal hypertension.

Autoimmune hepatitis and liver transplantation: indications, results, and management of recurrent disease

For those with autoimmune hepatitis (AIH), indications for liver transplantation include end-stage liver failure (as suggested by a MELD score >16), the onset of liver cancer, intractable symptoms that make the patient's life intolerable, and fulminant liver failure; outcomes are excellent, with 10-year survival in excess of 70%. For those with a fulminant presentation, the impact of corticosteroids is controversial and liver transplantation may be required. Autoimmune hepatitis recurs in approximately one third and may be detected up to 10 years or more post-transplant. There are no agreed-on criteria for the diagnosis, and differentiation from rejection and other causes of graft damage can be difficult. There is no strong correlation between the prevalence of recurrent AIH (rAIH) and graft loss from rAIH. Treatment of recurrent disease with the addition or increase in corticosteroids is often successful, although long-term data are lacking and some may progress to graft failure despite increased treatment. There remains controversy over the role for protocol liver biopsies to detect recurrent disease and the best immunosuppressive strategies to prevent and treat recurrence.

Endothelin-1 contributes to maintenance of systemic but not portal haemodynamics in patients with early cirrhosis: a randomised controlled trial

BACKGROUND AND AIMS

Increased endothelin (ET)-1 activity may contribute to the complications of cirrhosis and portal hypertension. The aim of this study was to assess the systemic and portal haemodynamic effects of selective ET-A and ET-B receptor antagonism in patients with cirrhosis.

METHODS

Sixteen patients with cirrhosis and portal hypertension (aged 52 (1) years, Pugh score 6.2 (0.3)) underwent 24 studies with infusions of: (A) selective ET-A antagonist, BQ-123 (n = 8), at 1000 and 3000 nmol/min; (B) selective ET-B antagonist, BQ-788 (n = 8), at 100 and 300 nmol/min; or (C) matched saline placebo (n = 8) in a double blind randomised manner. Haemodynamic measurements were performed through pulmonary artery, hepatic venous, and femoral artery catheters.

RESULTS

Baseline patient characteristics were well matched. Compared with placebo, BQ-123 decreased mean arterial pressure (MAP -15 (11) mm Hg (-18%); p<0.02) and pulmonary vascular resistance index (PVRI -81 (54) dyn x s x m2/cm5 (-64%); p<0.05), with no effect on hepatic venous pressure gradient (HVPG), cardiac index (CI), or systemic vascular resistance index (SVRI). Compared with placebo, BQ-788 increased MAP (+11 (3) mm Hg (+12%); p<0.03) and SVRI (+1101 (709) dyn x s x m2/cm5 (+50%); p<0.05), reduced CI (-1.0 (0.4) l/min/m2 (-29%); p = 0.05) with no effect on HVPG or PVRI.

CONCLUSIONS

ET-1 contributes to maintenance of systemic and pulmonary haemodynamics without acutely affecting HVPG in patients with early cirrhosis. In this group of patients, the use of selective ET-A and ET-B antagonists for the management of variceal haemorrhage is likely to be limited.

The role of carvedilol in the management of portal hypertension

Carvedilol is a potent noncardioselective beta-blocker, with weak vasodilating properties because of alpha 1 blockade. A reduction in both intrahepatic and portocollateral resistance contribute to enhanced effects on portal pressure. There are 10 published hemodynamic studies involving 168 patients investigating the role of carvedilol in portal hypertension. A reduction in the hepatic venous pressure gradient of up to 43% (range 10-43%) has been reported, particularly after chronic administration. However, tolerability at doses greater than 12.5 mg/day was comprised because of a fall in mean arterial pressure (MAP), particularly in ascitic patients. Carvedilol was more effective than propranolol in reducing hepatic venous pressure gradient in two of three studies, albeit with a greater decrease in MAP. One study showed deterioration of pre-existing ascites with carvedilol. The addition of nitrates to propranolol was less effective than carvedilol monotherapy in another study. A large multicentre, randomized controlled trial comparing carvedilol with variceal band ligation for the prevention of variceal bleeding has been published. Carvedilol resulted in fewer episodes of bleeding, although there was no difference in survival. Carvedilol was well tolerated. Carvedilol is a promising agent, and seems to be more effective than propranolol in hemodynamic studies. The efficacy in primary prevention of variceal bleeding suggests that carvedilol has a role in the management of clinically significant portal hypertension.

Variceal band ligation versus beta-blockers for primary prevention of variceal bleeding: a meta-analysis

BACKGROUND/AIMS

Variceal band ligation (VBL) can reduce the rate of the first variceal by 45-52% compared with beta-blockers (BBs). We performed an updated meta-analysis of nine randomized controlled trials published as full papers, comparing VBL with BB for primary prevention.

METHODS

Relative risk (RR) was computed using a random effects model. Sensitivity analysis was performed using a fixed effects model. Publication bias was also assessed using funnel plots and the rank correlation test.

RESULTS

In total, 734 patients were studied (356, VBL; 378, BB). The pooled RR favoured VBL for first variceal bleed [0.63; 95% confidence interval (CI), 0.43-0.92] with number needed to treat being 13 (95% CI, 7-33), and for adverse events resulting in treatment withdrawal (0.24; 95% CI, 0.12-0.47) with the corresponding number needed to treat being 10 (95% CI, 6-25). Banding-related bleeding occurred in six patients (fatal in two). No difference was seen in bleeding-related deaths (RR, 0.71; 95% CI, 0.38-1.32), or overall mortality (RR, 1.09; 95% CI, 0.86-1.38). No significant heterogeneity or publication bias was present, and outcomes remained robust after sensitivity analyses.

CONCLUSIONS

VBL was superior to BB in preventing the first variceal bleed, with fewer adverse events resulting in treatment discontinuation. Careful attention to technique and patient selection are important to minimize iatrogenic complications with VBL. VBL has a role in patients with poor drug compliance, or tolerance, and in those who bleed on BB therapy.

Chronic administration of losartan, an angiotensin II receptor antagonist, is not effective in reducing portal pressure in patients with preascitic cirrhosis

OBJECTIVES

Plasma angiotensin II (ANG II) concentrations are elevated in cirrhosis and have been implicated as a cause of portal hypertension. We aimed to study both the systemic and portal hemodynamics, and tolerability after chronic administration of losartan, an ANG II receptor antagonist.

METHODS

Twelve patients with preascitic cirrhosis were studied: mean age of 53.8 +/- 3.3 yr; average Child-Pugh score of 5.8 +/- 0.3; alcohol etiology (5), hepatitis B/C (1/3), primary biliary cirrhosis (3). No patients were on diuretics or vasoactive medication. Hemodynamic measurements were performed at baseline and 4 weeks after daily administration of 25 mg losartan.

RESULTS

There was no significant change in the hepatic venous pressure gradient (15.4 +/- 1.5 to 13.6 +/- 1.6 mmHg, -11.7%, p = NS), despite a significant reduction in the wedge hepatic venous pressure (20.3 +/- 1.8 to 17.3 +/- 1.8 mmHg, -14.8%, p < 0.05). Cardiac output, hepatic blood flow, systemic vascular resistance, creatinine clearance, and natriuresis were unaffected. The plasma renin activity increased significantly from 2.7 +/- 0.4 to 5.2 +/- 1.1 ng/ml/h (p < 0.05). There was a significant reduction in the mean arterial pressure from 96.9 +/- 3.3 to 89.3 +/- 3.5 mmHg, -7.8 +/- 3.0% (p = 0.02), with 1 patient experiencing symptomatic hypotension.

CONCLUSIONS

Chronic administration of low-dose losartan does not lead to a significant reduction in the portal pressure gradient. Losartan is unlikely to be useful in the management of patients with early cirrhosis, who are at risk of variceal bleeding.

Review article: a drug therapy for the prevention of variceal haemorrhage

The development of varices is a major complication of cirrhosis, and variceal haemorrhage has a high mortality. There have been major advances in the primary and secondary prevention of variceal haemorrhage over the last 20 years involving endoscopic, radiological and pharmacological approaches. This review concentrates principally on drug therapy, particularly on the numerous haemodynamic studies. Many of these drugs have not been studied in clinical trials, but provide data about the underlying pathogenesis of portal hypertension. Also covered in this review are the randomized controlled trials and meta-analyses that involve a large number of patients. These trials involve relatively few drugs such as non-selective beta-blockers and nitrates. Correlations between haemodynamic and clinical parameters are discussed. Despite the recent increase in the use of alternative endoscopic therapies, an effective and well tolerated drug remains a clinically important research goal.

Transjugular intrahepatic portosystemic stent-shunt in the management of gastric and ectopic varices

Uncertainty exists about the ideal therapy for gastric and ectopic varices owing to relatively few controlled studies. Endoscopic therapy with tissue adhesives and thrombin appear promising. Transjugular intrahepatic portosystemic stent-shunt has a role in patients with refractory gastric variceal bleeding in the presence of a patent portal vein. The addition of coil embolization may be particularly useful for ectopic varices, as these can continue to bleed despite successful portal pressure reduction. The high efficacy of transjugular intrahepatic portosystemic stent-shunt has to be balanced against the potential for increased encephalopathy. Balloon occluded retrograde transvenous obliteration is a recent technique for patients with gastro-renal shunts and large gastric varices. Early results are promising, and balloon occluded retrograde transvenous obliteration may be valuable in patients who bleed at lower portal pressures, in the encephalopathic patient, or where the portal vein is not patent. Its use may be limited by availability or lack of technical expertise, and caution is required in patients with large oesophageal varices.

Transjugular intrahepatic portosystemic stent-shunt: technical factors and new developments

The introduction of expandable metal stents in the mid 1980s led to the development of transjugular intrahepatic portosystemic stent-shunt (TIPSS) as we know it today. Short-lived detrimental effects on the hyperdynamic circulation in cirrhosis accompany the acute reduction in portal pressure following TIPSS creation. Caution is needed in patients with cardiac dysfunction or pulmonary hypertension. With increasing expertise and careful patient selection, fatal procedural complications are rare and TIPSS can even be safely used as a bridge to liver transplantation. Shunt insufficiency and hepatic encephalopathy are more common following TIPSS. Currently, however, novel approaches to tackling both these limitations exist. These include the combination of uncovered TIPSS with variceal band ligation, and the introduction of polytetrafluoroethylene covered stents. Despite the lack of controlled studies, covered stents are now widely used and have the potential to drastically reduce shunt insufficiency, the need for long-term shunt surveillance and even hepatic encephalopathy.

Study protocol for a randomised controlled trial of carvedilol versus variceal band ligation in primary prevention of variceal bleeding in liver cirrhosis (CALIBRE trial)

INTRODUCTION

Liver cirrhosis is the fifth largest cause of adult deaths, and a major complication, variceal bleeding is associated with a 1-year mortality of 40%. There is uncertainty on the first-line therapy for prevention of variceal bleeding owing to a lack of adequately powered trials comparing non-selective beta blockers, in particular carvedilol, with variceal band ligation.

METHODS AND ANALYSIS

CALIBRE is a multicentre, pragmatic, randomised controlled, open-label trial with an internal pilot. The two interventions are carvedilol 12.5 mg od or variceal band ligation (VBL). Patients with liver cirrhosis and medium to large oesophageal varices that have never bled are eligible for inclusion. The primary outcome is any variceal bleeding within 1 year of randomisation. Secondary endpoints include time to variceal bleed, mortality, transplant-free survival, adverse events, complications of cirrhosis, health-related quality of life, use of healthcare resources, patient preference and use of alternative or crossover therapies. The sample size is 2630 patients over a 4-year recruitment period, across 66 hospitals in the UK.

ETHICS AND DISSEMINATION

The study has been approved by a National Health Service (NHS) Research Ethics Committee (REC) (reference number 18/NE/0296). The results of this trial will be submitted for publication in a peer reviewed journal. Participants will be informed via a link to a preview of the publication. A lay summary will also be provided via email or posted to participants prior to publication (ISRCTN reference number: 73887615).

Randomised controlled trial of long term portographic follow up versus variceal band ligation following transjugular intrahepatic portosystemic stent shunt for preventing oesophageal variceal rebleeding

BACKGROUND/AIMS

Transjugular intrahepatic portosystemic stent shunt (TIPSS) is effective in the prevention of variceal rebleeding but requires invasive portographic follow up. This randomised controlled trial aims to test the hypothesis that combining variceal band ligation (VBL) with TIPSS can obviate the need for long term TIPSS surveillance without compromising clinical efficacy, and can reduce the incidence of hepatic encephalopathy.

PATIENTS/METHODS

Patients who required TIPSS for the prevention of oesophageal variceal rebleeding were randomised to either TIPSS alone (n = 39, group 1) or TIPSS plus VBL (n = 40, group 2). In group 1, patients underwent long term TIPSS angiographic surveillance. In group 2, patients entered a banding programme with TIPSS surveillance only continued for up to one year.

RESULTS

There was a tendency to higher variceal rebleeding in group 2 although this did not reach statistical significance (8% v 15%; relative hazard 0.58; 95% confidence interval (CI) 0.15-2.33; p = 0.440). Mortality (47% v 40%; relative hazard 1.31; 95% CI 0.66-2.61; p = 0.434) was similar in the two groups. Hepatic encephalopathy was significantly less in group 2 (20% v 39%; relative hazard 2.63; 95% CI 1.11-6.25; p = 0.023). Hepatic encephalopathy was not statistically different after correcting for sex and portal pressure gradient (p = 0.136).

CONCLUSIONS

TIPSS plus VBL without long term surveillance is effective in preventing oesophageal variceal rebleeding, and has the potential for low rates of encephalopathy. Therefore, VBL with short term TIPSS surveillance is a suitable alternative to long term TIPSS surveillance in the prevention of oesophageal variceal rebleeding.