Endoscopic therapy for gastric varices

Bleeding from gastric varices (GVs) is generally more severe than bleeding from esophageal varices (EVs), but is thought to occur less frequently. Although several recent developments in the agents and the techniques have improved the outcome of GV bleeds no consensus has been reached on the optimum treatment. Because the blood flow in the GVs is relatively large and the bleeding is rapid and often profuse endoscopic means of treating bleeding GVs are the treatments of choice. Endoscopic injection of cyanoacrylate glue is the treatment of choice for the control of active bleeding of gastric avarices and to prevent rebleeding. This article reviews the current endoscopic treatment modalities used in gastric variceal bleeding, and the primary and secondary prophylaxis of gastric variceal bleeding.

Refractory acute variceal bleeding: what to do next?

Current recommendations for the treatment of acute variceal bleeding (AVB) are to combine hemodynamic stabilization, antibiotic prophylaxis, pharmacologic agents, and endoscopic treatment. However, despite the application of the current gold-standard pharmacologic and endoscopic treatment, failure to control bleeding or early rebleed within 5 days still occurs in 15% to 20% of patients with AVB. In case of treatment failure of the acute bleeding episode, if bleeding is mild and the patient is hemodynamically stable, a second endoscopic therapy may be attempted. If this fails, or if bleeding is severe, it is usually controlled temporarily with balloon tamponade until a definitive derivative treatment is applied. Transjugular intrahepatic portosystemic shunt is highly effective in this situation; however, despite the control of bleeding, a high proportion of these patients die of liver and multiorgan failure. Strategies intended to improve the prognosis of these patients should focus on identifying those high-risk patients in whom standard therapy is likely to fail, and who are therefore candidates for more aggressive therapies early after the development of AVB.

[Conservative treatment of patients with varicose esophagus veins cirrhosis]

The most significant complication of liver cirrhosis is the syndrome of portal hypertension. Varicose veins of the esophagus and stomach diagnosed in 50-80% of patients with liver cirrhosis and complicated by hemorrhage in 30-50%. The risk of bleeding is determined by the size of varicose veins, severity of liver cirrhosis, severity of inflammatory changes of esophageal mucosa. Conservative treatments don't always yield the desired result, which motivates the search for new pharmacological treatments of portal hypertension complications.

OBJECTIVE

To evaluate the effectiveness of flavonoids diosmin with hesperidin using at liver cirrhosis with varying degrees of portal hypertension severity.

MATERIALS AND METHODS

The study was based on the analysis of complex clinical, laboratory and instrumental examination of 125 patients with cirrhosis of different etiologies. The study didn't include patients with the presence of VEV III degree; hepatocellular insufficiency C class on the Child-Pugh classification; extrahepatic form of portal hypertension and patients with circulatory failure requiring continuous drug therapy. The ratio of male and female studied patients was 71 (56.8%) and 54 (43.2%), respectively, at the age of 33 to 74 years (mean age 52.8 +/- 5.7 years). According to etiology of the disease, all patients were divided into two groups. The first group included 82 (65.6%) patients, the cause of the LC was the abuse of alcohol, second group--43 (34.4%) persons with a viral etiology of LP (HBV or HCV). Endoscopic assessment of the VEV was perfomed by KJ Paquet classification (1983). All patients received therapy with flavonoids (diosmin with hesperidin) for 12 weeks. Efficacy of treatment was evaluated by endoscopic picture of the esophageal mucosa and the state of VEV at 4 and 12 weeks.

RESULTS

Treatment with the flavonoids hesperidin with diasminom showed a positive result in the form of reducing the VEV and reduced the number of varicose veins with a statistically significant in patients with alcoholic liver cirrhosis (p < 0.05).

CONCLUSION

The results indicated the effectiveness of therapy with flavonoids hesperidin with diasmin at portal hypertension in patients with alcoholic cirrhosis, which allows to include them in the complex treatment of medicamental prophylaxis of variceal bleeding.

Blood loss and transcapillary refill in uncontrolled treated hemorrhage in dogs

OBJECTIVE

This study evaluated retroperitoneal hematomas produced by bilateral injury of iliac arteries (uncontrolled hemorrhage), blood volume loss, transcapillary refill, the effects of volume replacement on retroperitoneal bleeding and the hemodynamic changes with and without treatment.

METHODS

Initial blood volume was determined with Tc(99m)-labelled red cells, and bleeding was evaluated by means of a portable scintillation camera positioned over the abdomen. Previously splenectomized mongrel dogs (16.8 +/- 2.2 kg) were submitted to hemorrhage for 30 minutes and randomized into three groups: I - no treatment (n=7); II - treatment with 32 mL/kg of Lactated Ringer's for three to five minutes (n=7); and III - treatment with 4 mL/kg of 7.5% NaCl plus 6.0% dextran 70 for three to five minutes (n=7). They were studied for an additional 45 minutes.

RESULTS

Volume replacement produced transitory recovery in hemodynamic variables, including mean pulmonary artery pressure, pulmonary capillary wedge pressure and cardiac index, with significant increase in dogs treated with 32 mL/kg of Lactated Ringer's and 7.5% NaCl plus 6.0% dextran 70 (p<0.001, against no treatment), along with a decrease (p<0.001) in the systemic vascular resistance index. Groups II and III had significant initial decreases in hematocrit and hemoglobin. The treated dogs (groups II and III) presented rebleeding, which was greater during treatment with 32 mL/kg of Lactated Ringer's (group II).

CONCLUSIONS

Despite the rebleeding observed in treated groups, the utilization of hypertonic saline solution with dextran proved to be effective in the initial reanimation, producing evident transcapillary refill, while the Lactated Ringer's solution produced capillary extravasation and was ineffective in the initial volume replacement in this model of uncontrolled hemorrhage.

[Risk factors influencing the development of gastroduodenal bleeding]

Bleedings of an ulcerative aetiology are an actual and multiplane problem many years. Obvious communication of the complicated current of a peptic ulcer with various risk factors, such as a tobacco smoking, abusing alcohol, uncontrolled and long reception of ulcerogenic agents (NSAID, anticoagulants etc.), mucosa of stomach H. pylori, is noted by a serious accompanying pathology of other organs and systems. The knowledge of influence of interaction of the facts of risk on development bleedings of an ulcerative aetiology, will allow to develop in due time the complex of medical actions referred on prevention of this terrible complication.

Portal hypertension and variceal hemorrhage

Portal hypertension is a progressively debilitating complication of cirrhosis and a principal cause of mortality in patients who have hepatic decompensation. This article describes the classification system and pathophysiology of portal hypertension. It also discusses a practical approach to prevention of first variceal hemorrhage, general management of the acute bleeding episode, and secondary prophylaxis to prevent rebleeding. Pharmacologic, endoscopic, radiologic, and surgical modalities are all described in detail.

Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation

BACKGROUND

Upper-gastrointestinal haemorrhage is a frequent reason for hospital admission. Although most risk scoring systems for this disorder incorporate endoscopic findings, the Glasgow-Blatchford bleeding score (GBS) is based on simple clinical and laboratory variables; a score of 0 identifies low-risk patients who might be suitable for outpatient management. We aimed to evaluate the GBS then assess the effect of a protocol based on this score for non-admission of low-risk individuals.

METHODS

Our study was undertaken at four hospitals in the UK. We calculated GBS and admission (pre-endoscopy) and full (post-endoscopy) Rockall scores for consecutive patients presenting with upper-gastrointestinal haemorrhage. With receiver-operating characteristic (ROC) curves, we compared the ability of these scores to predict either need for clinical intervention or death. We then prospectively assessed at two hospitals the introduction of GBS scoring to avoid admission of low-risk patients.

FINDINGS

Of 676 people presenting with upper-gastrointestinal haemorrhage, we identified 105 (16%) who scored 0 on the GBS. For prediction of need for intervention or death, GBS (area under ROC curve 0.90 [95% CI 0.88-0.93]) was superior to full Rockall score (0.81 [0.77-0.84]), which in turn was better than the admission Rockall score (0.70 [0.65-0.75]). When introduced into clinical practice, 123 patients (22%) with upper-gastrointestinal haemorrhage were classified as low risk, of whom 84 (68%) were managed as outpatients without adverse events. The proportion of individuals with this condition admitted to hospital also fell (96% to 71%, p<0.00001).

INTERPRETATION

The GBS identifies many patients presenting to general hospitals with upper-gastrointestinal haemorrhage who can be managed safely as outpatients. This score reduces admissions for this condition, allowing more appropriate use of in-patient resources.

[Effect of combined therapy with Kangyanling and Omeprazole on digestive dysfunction in burned patients]

OBJECTIVE

To observe the curative effects of combined therapy with Kangyanling (KYL, a Chinese herbal preparation) and Omeprazole on post-burn digestive dysfunction.

METHODS

Patients with post-burn digestive dysfunction were assigned to two groups, the 32 in the treated group, including 18 with acute stress gastrointestinal mucosal hemorrhagic lesion and 14 with toxic enteroparalysis, were treated by KYL plus Omeprazole, and the 20 patients in the control group, 11 with acute stress gastrointestinal mucosal hemorrhagic lesion and 9 with toxic enteroparalysis were treated with Omeprazole alone. The pH value in gastric mucosa was determined before and 12 h after treatment, the hemostasis effects in 48 h, and the anti-paralysis effects in 72 h were observed as well.

RESULTS

The pH value in gastric mucosa of both groups before therapy were all lower than the normal range, it raised after treatment in the treated group (P < 0.05), approaching to the normal range, but with no significant change in the control group. The total hemostatic rate and the anti-paralysis rate was 77.8% and 85.7% respectively in the treated group, and 45.5% and 0% in the control group, all shown statistical significance between groups (P < 0.05).

CONCLUSION

Combined therapy with Kangyanling and Omeprazole has obvious curative effects on post-burn gastric dysfunction.

Long-term outcomes of acute gastric variceal bleeding in 48 patients following treatment with cyanoacrylate

OBJECTIVES

(1) Study the effectiveness of intravariceal injection of n-butyl-2-cyanoacrylate to treat acute gastric variceal (GV) bleeding and (2) study the impact of the type of GV and hepatic function on endoscopic hemostasis and mortality outcomes.

METHODS

Fourty-eight patients with acute GV bleeding underwent intravariceal injection of n-butyl-2-cyanoacrylate and were followed until death or study conclusion (12-52 months).

RESULTS

Primary hemostasis (no re-bleeding within 48 h) was accomplished in 42 patients (87.5%). Appearance of the bleeding site at the time of initial endoscopy, grade of cirrhosis and location of GV were not significant predictors of immediate hemostasis. Early re-bleeding (48 h to 6 weeks) occurred in 20.5% of patients and late re-bleeding (beyond 6 weeks) in 20.5% of patients. While the Child-Pugh score was predictive of re-bleeding and mortality, the type of GV and stigmata at initial endoscopy were not significant predictors of re-bleeding and mortality. Over a mean follow-up of 18 months, mortality rates were 43.9% and bleeding was the commonest cause of death.

CONCLUSION

Endoscopic injection of n-butyl-2-cyanoacrylate is effective and safe for treating bleeding GV. Patients with poor hepatic function are at higher risk of re-bleeding and death after acute gastric variceal bleed.

Diagnostic evaluation of patients presenting with bleeding per rectum by colonoscopy

BACKGROUND

Rectal bleeding is a manifestation of lower gastrointestinal bleed, which means bleeding from a site distal to ligament of Treitz. Annual incidence of this problem has been estimated to be 20% and mortality as 11%. Patients complaining of haematochezia are suspected of having lower GI bleeding and proctosigmoidoscopy followed by colonoscopy is the examination of choice for diagnosis and treatment. Previous evidence suggested that in our country, frequencies of different aetiologies of lower GI bleed are different from the West. This study validated the previous findings. The Objective of this study was to determine the causes of rectal bleeding in adult patients at Military Hospital, Rawalpindi.

METHODS

One hundred and five adult patients with visible rectal bleed, irrespective of their gender were selected by non-probability convenient sampling from general medical OPD and general medical wards. Patients with suspected upper GI source of bleeding; haemorrhoidal bleed and acute infectious diarrhoea were excluded from the study. All patients were subjected to fibre-optic colonoscopy after necessary preparation and findings were recorded. Biopsies taken from suspected lesions were clinically indicated. Diagnosis was based on colonoscopic and histopathologic findings.

RESULTS

A total of 105 patients (77 male and 28 female) with mean age 41.04 yrs were part of the study. Colonoscopy showed abnormal findings in 85 (84%) patients. The commonest diagnosis was ulcerative colitis, which was found in 48 (46%) patients. It was followed by colorectal carcinoma, 11 (10%) patients, and non-specific colitis, 9 (8%) patients. Other less frequent findings were colonic diverticuli, 7 (6%) patients, solitary rectal ulcer, 5 (4%) patients, colonic polyps in 3 (2.5%) patients and one case each of telangiectasia and Crohn's disease.

CONCLUSION

Colonoscopy has very high diagnostic yield and would be recommended in the workup of patients presenting with bleeding per rectum. Ulcerative colitis was the leading cause of bleeding per rectum in this study; while infrequent findings of Crohn's disease, polyps and diverticuli indicate that these are uncommon in this region.

Prognostic role of the initial portal pressure gradient reduction after TIPS in patients with cirrhosis

BACKGROUND

The aim of this study was to determine the prognostic relevance of the portal pressure gradient (PPG) before and after transjugular intrahepatic portosystemic stent shunt (TIPS) insertion in patients with liver cirrhosis and recurrent oesophageal variceal bleeding.

METHODS

118 cirrhotic patients (Child A/B/C, 41/56/21; Child score, 7.7+/-2.0; baseline PPG, 21.8+/-4.7 mmHg) underwent TIPS for the prevention of variceal rebleeding. A multivariate logistic regression analysis was applied to identify the independent determinants of rebleeding and survival. The estimated rebleeding rate and the estimated survival were compared by log-rank testing.

RESULTS

TIPS insertion reduced the PPG by 53.2+/-17.7%. During follow-up 21 patients suffered significant rebleeding (17.8%); bleeding-related mortality was 3.4% (four patients). The median survival [95% confidence intervals (CI)] was 48.2 (39.8; 60.8) months. The multivariate Cox model identified creatinine as the only independent predictor of survival, and the initial decrease of the PPG after TIPS as the only independent predictor of rebleeding. PPG before TIPS (21.8+/-4.7 mmHg) and the gradient at the time of rebleeding (22.0+/-2.9 mmHg) did not differ significantly. Patients with an initial decrease of the PPG after TIPS <30% were at the highest risk for rebleeding. Patients with an initial decrease of the PPG >60% rarely suffered from rebleeding.

CONCLUSIONS

The initial decrease in the PPG after TIPS is a predictor for the risk of rebleeding but not for survival after TIPS. For that reason, in patients undergoing TIPS placement for the prevention of recurrent bleeding from oesophageal varices, an initial reduction of the PPG of 30-50% should be attempted.

Primary and secondary nonvariceal upper gastrointestinal bleeding

BACKGROUND

Upper gastrointestinal (UGI) bleeding is associated with a mortality rate of up to 14% in emergency hospital admissions (primary bleeding), and up to 28% in hospitalized patients (secondary bleeding).

AIM

To characterize and compare the clinical pictures and outcome of primary and secondary nonvariceal UGI bleeding.

STUDY

A retrospective, case-control design was used. The files of all consecutive patients admitted to our tertiary academic center between January 1, 2001 and December 31, 2002 for UGI bleeding were reviewed for demographic and clinical data, treatment details, number of blood transfusions, endoscopic procedures, surgical procedures, and mortality.

RESULTS

Compared to primary UGI bleeding, secondary bleeding was associated with female sex, older age, more chronic diseases, intake of more drugs, hospitalization in internal medicine departments, longer hospital stay, fewer endoscopic procedures, and less Helicobacter pylori-related peptic ulcer disease. Total mortality rate in the secondary bleeders was 30.3% versus 4.6% in the primary bleeders (P<0.0001). There was no significant difference between primary and secondary bleeders in treatment with nonsteroidal anti-inflammatory agents or aspirin, severity of bleeding, or death related to gastrointestinal bleeding.

CONCLUSIONS

Despite the significant differences in the clinical picture of primary and secondary bleeders, the severity of bleeding appear to be similar in both groups. Although there was a trend towards a higher gastrointestinal-related mortality in secondary bleeders, it was not statistically significant.

Bleeding index after the first course of endoscopic treatment for esophageal varices in liver cirrhotic patients with and without hepatocellular carcinoma

BACKGROUND/AIMS

We retrospectively evaluated variable clinical data on admission to reliably predict bleeding from esophageal varices after the first course of endoscopic treatment in liver cirrhosis patients with and without hepatocellular carcinoma.

METHODOLOGY

We analyzed 27 clinical factors from the medical records of 118 patients who received their first course of endoscopic treatment for esophageal varices. Factors significantly related to bleeding were extracted using Cox's regression model, and the bleeding index was prepared by combining these factors.

RESULTS

The cumulative nonbleeding rates after treatment for esophageal varices were 82.1% at 1 year, 64.6% at 3 years and 53.7% at 5 years. By the multivariate analysis, age, the presence of hepatocellular carcinoma, hemoglobin, lactate dehydrogenase and alpha-fetoprotein were selected as significant factors that contributed independently to the post-therapeutic bleeding from esophageal varices (P<0.05). The bleeding index was calculated using the following formula: bleeding index = - 0.045 x Age + 0.934 x hepatocellular carcinoma - 0.151 x hemoglobin + 0.108 x lactate dehydrogenase + 0.842 x alpha-fetoprotein.

CONCLUSIONS

The bleeding index, based on 5 factors, will in future be an appropriate index to predict the post-therapeutic bleeding from esophageal varices.

Blatchford scoring system is a useful scoring system for detecting patients with upper gastrointestinal bleeding who do not need endoscopic intervention

BACKGROUND AND AIM

Several scoring systems have been devised to identify patients with upper gastrointestinal (UGI) bleeding who are at a high risk of adverse outcomes. We retrospectively evaluated the accuracy of the Blatchford scoring system for assessing the need for clinical intervention in cases of UGI bleeding admitted to the emergency department (ED).

METHODS

This was a retrospective study conducted on patients who underwent emergency GI endoscopy at the ED of our hospital. Those who needed blood transfusion, operative or endoscopic interventions to control the hemorrhage were classified into the 'high risk' group.

RESULTS

Of the 93 enrolled patients, 70 (75.3%) were classified into the high risk group. The Blatchford score was significantly higher in the high risk group than in the low risk group. When a cut-off value of 2 was used, the sensitivity and specificity of the Blatchford scoring system were determined to be 100% and 13%, respectively. Thus, the Blatchford scoring system was deemed to be useful for distinguishing between the high risk group and the low risk group of patients with GI hemorrhage admitted to the ED.

CONCLUSION

The Blatchford scoring system is accurate for identifying definitively low-risk patients of GI hemorrhage, even prior to the performance of emergency UGI endoscopy at the ED.