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Carbonell N. [Gastrointestinal hemorrhage. What indications for endoscopic treatment?]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2004; 28 Spec No 2:B21-7. [PMID: 15150494 DOI: 10.1016/s0399-8320(04)95237-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- Nicolas Carbonell
- Service d'Hépato-Gastroentérologie, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75012 Paris
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102
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Nevens F. [Gastrointestinal hemorrhage. Which indications for endoscopic treatments?]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2004; 28 Spec No 2:B190-3. [PMID: 15150512 DOI: 10.1016/s0399-8320(04)95255-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- Frederik Nevens
- Hépatologie, UZ Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgique
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103
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Pauwels A. Que faire en cas d’échec des traitements pharmacologiques et endoscopiques ? ACTA ACUST UNITED AC 2004; 28 Spec No 2:B194-202. [PMID: 15150513 DOI: 10.1016/s0399-8320(04)95256-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Arnaud Pauwels
- Service d'Hépato-Gastroentérologie, Centre Hospitalier, BP 71, 95503 Gonesse
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104
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Plessier A. Comment traiter une hémorragie digestive aiguë par rupture de varices oesophagiennes. GASTROENTÉROLOGIE CLINIQUE ET BIOLOGIQUE 2004; 28 Spec No 2:B15-20. [PMID: 15150493 DOI: 10.1016/s0399-8320(04)95236-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Aurélie Plessier
- Service d'Hépatologie, Hôpital Beaujon, 100, boulevard du Général Leclerc, 92110 Clichy
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105
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de Franchis R. Somatostatin, somatostatin analogues and other vasoactive drugs in the treatment of bleeding oesophageal varices. Dig Liver Dis 2004; 36 Suppl 1:S93-100. [PMID: 15077917 DOI: 10.1016/j.dld.2003.11.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Somatostatin and its analogues have been compared with a variety of other treatments for the treatment of variceal bleeding in cirrhotic patients. Meta-analyses of studies comparing somatostatin or octreotide with vasopressin or terlipressin have shown that somatostatin is somewhat superior to vasopressin and equivalent to terlipressin in controlling bleeding and has significantly fewer side effects; no difference in mortality was observed. Octreotide was somewhat better than vasopressin and terlipressin in controlling bleeding, with similar mortality. Meta-analysis of trials comparing somatostatin or octreotide with endoscopic sclerotherapy shows that both drugs are equivalent to sclerotherapy for bleeding control, early rebleeding and survival. Complications are much less frequent with drug treatment. Nine trials have compared endoscopic therapy with therapeutic regimens combining endoscopic treatment with somatostatin, octreotide or vapreotide. Meta-analysis show that the combined regimens increase the 5 days bleeding control rate of endoscopic treatments by over 20%, although there is no difference in mortality. Comparisons of somatostatin and octreotide with combined regimens of sclerotherapy + somatostatin and sclerotherapy + octreotide have shown that the combined regimens were better than drug treatments alone in controlling bleeding and preventing early rebleeding, while complications were significantly less frequent with drug therapy.
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Affiliation(s)
- R de Franchis
- Department of Internal Medicine, University of Milan, Gastroenterology and Gastrointestinal Endoscopy Service, IRCCS Policlinico Hospital, Via Pace 9, 20122 Milan, Italy.
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106
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Villanueva C, Aracil C, López-Balaguer JM, Balanzó J. [Combined treatments for esophageal varices]. GASTROENTEROLOGIA Y HEPATOLOGIA 2003; 26:514-23. [PMID: 14534024 DOI: 10.1016/s0210-5705(03)70403-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- C Villanueva
- Unitat de Sagnants. Servei de Patologia Digestiva. Hospital de la Santa Creu i Sant Pau. Barcelona. España.
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107
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Affiliation(s)
- Jaime Bosch
- Hepatic Hemodynamic Laboratory, Liver Unit, IMD, Hospital Clinic, IDIBAPS, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain.
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108
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Nidegger D, Ragot S, Berthelémy P, Masliah C, Pilette C, Martin T, Bianchi A, Paupard T, Silvain C, Beauchant M. Cirrhosis and bleeding: the need for very early management. J Hepatol 2003; 39:509-14. [PMID: 12971959 DOI: 10.1016/s0168-8278(03)00322-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND/AIMS Retrospective studies suggest that the prognosis of patients with cirrhosis and variceal hemorrhage has improved in more recent decades. In a prospective cohort study in which the choice of prophylactic therapy was left to each practitioner, we followed cirrhotic patients with medium/large varices to determine factors predictive of bleeding and death. METHODS Three hundred fourteen patients with grades 2 or 3 esophageal varices (Child A and B/C: 218 and 96) were enrolled. One hundred seventy-three patients had no previous history of variceal bleeding. Only 245 patients (100% of patients with prior variceal hemorrhage, 61% of patients without prior hemorrhage) were receiving some form of prophylactic therapy. The median follow-up was 18 months. RESULTS There were 76 bleeding events and 14 related deaths (18%); nine of these deaths occurred within 24 h of bleeding onset (two at home, two during hospital transfer, and five in hospital, a mean of 2.5 h after onset; six involved Child C patients). Twenty-five deaths were not due to bleeding but were closely related to cirrhosis. In a Cox model, the presence of tense ascites (relative risk 3.4, 95% confidence interval, CI 2.5-5.9) and a prior history of hemorrhage (relative risk 4.4, 95% CI 2.6-7.5) were independent predictors of variceal hemorrhage. In patients without a prior history of bleeding, bleeding risk was higher with more prolonged prothrombin time and lower when patients were receiving propranolol. CONCLUSIONS Despite the advent of effective drugs and endoscopic therapy for variceal bleeding, about a quarter of deaths occur very early after bleeding onset, confirming the need for rapid specific management.
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Affiliation(s)
- Delphine Nidegger
- Institut de Santé Publique Faculté de Médecine de Poitiers, Poitiers, France
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109
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Abstract
Portal hypertension as a consequence of liver cirrhosis is responsible for its most common complications: ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, hepatic encephalopathy and the most important one--variceal hemorrhage. Variceal bleeding results in considerable morbidity and mortality. This review covers all areas of importance in the therapy of acute variceal hemorrhage--endoscopic and pharmacological treatment, transjugular intrahepatic portosystemic shunt, surgery and balloon tamponade. Indications and limitations of these therapeutic modalities are widely discussed.
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Affiliation(s)
- Jan Lata
- Department of Internal Medicine and Gastroentrology, Faculty of Medicine, Masaryk University, Brno, Czech Republic.
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110
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Abstract
Variceal haemorrhage is a common medical emergency with a high mortality (30-50%). Adequate resuscitation is vital, and once stabilised the patient should be moved to a high-dependency area. Antibiotics reduce mortality, and the vasoactive drug terlipressin should be administered if early endoscopy is unavailable. Early endoscopy is essential both to make the diagnosis and to allow therapeutic measures to be performed. The evidence suggests that variceal band ligation is the most effective therapy for oesophageal varices. If gastric varices are found at the index endoscopy the evidence at present is inadequate to be certain which is the best treatment, but both endoscopic therapy with cyanoacrylate or thrombin and transjugular intrahepatic portosystemic stent shunt (TIPSS) have been reported to be of benefit. When initial treatments fail, rescue therapy should be initiated. Most authorities agree that TIPSS is the rescue therapy of choice. Many questions remain concerning the treatment of acute variceal bleeding, particularly the ideal therapy for gastric varices and the role of combination vasoactive and endoscopic therapy. Randomised controlled trials are required to answer these important issues.
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Affiliation(s)
- J W Ferguson
- Liver Unit, New Royal Infirmary of Edinburgh, Edinburgh, UK.
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111
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Abstract
Variceal hemorrhage accounts for one third of all deaths related to cirrhosis. To date, many modalities of treating variceal bleeding have been devised, including pharmacological therapy. Treatment of variceal hemorrhage includes resuscitation, initial hemostasis, and prevention of complications and recurrent bleeding. Intravenous vasoactive agents such as terlipressin, somatostatin, octreotide, or vapreotide should be administered in patients with suspected variceal bleeding. Endoscopic treatment remains the mainstay of treatment. Endoscopic variceal ligation is safer and more efficacious than sclerotherapy as initial treatment of bleeding esophageal varices, whereas cyanoacrylate injection is the endoscopic treatment of choice for gastric varices. An adjuvant vasoactive agent is useful for the prevention of early rebleeding. Prophylactic antibiotics are increasingly used for prevention of infection, notably spontaneous bacterial peritonitis. Follow-up endoscopic treatment is necessary in order to obliterate residual varices. The combination of a beta blocker and nitrate is an essential component of secondary prophylaxis for recurrent variceal bleeding. Transjugular intrahepatic portosystemic shunt or surgery offers the best salvage therapy in patients with failed hemostasis or breakthrough recurrent bleeding despite medical and endoscopic therapy. Endoscopic ultrasonography is useful in the prediction of recurrence of varices and facilitates visualization and guidance of further treatment of gastric varices. Despite advances in the treatment of variceal bleeding, liver function remains the determining factor of patient survival. Liver transplantation is the only definitive treatment that can alter the course of the disease.
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Affiliation(s)
- Justin C Y Wu
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, People's Republic of China
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112
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D'Amico G, Pietrosi G, Tarantino I, Pagliaro L. Emergency sclerotherapy versus vasoactive drugs for variceal bleeding in cirrhosis: a Cochrane meta-analysis. Gastroenterology 2003; 124:1277-91. [PMID: 12730868 DOI: 10.1016/s0016-5085(03)00269-5] [Citation(s) in RCA: 148] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Emergency sclerotherapy is used as a first-line therapy for variceal bleeding in cirrhosis, although pharmacologic treatment stops bleeding in most patients. We performed a meta-analysis comparing emergency sclerotherapy with pharmacologic treatment. METHODS MEDLINE (1968-2002), EMBASE (1986-2002), and the Cochrane Library (2002;4) were searched to retrieve randomized controlled trials comparing sclerotherapy with vasopressin (+/- nitroglycerin), terlipressin, somatostatin, or octreotide for variceal bleeding in cirrhosis. Outcome measures were failure to control bleeding, rebleeding, blood transfusions, adverse events, and mortality. RESULTS Fifteen trials were identified. Sclerotherapy was not superior to terlipressin, somatostatin, or octreotide for any outcome and to vasopressin for rebleeding, blood transfusions, death, and adverse events; it was superior to vasopressin for the control of bleeding in a single trial flawed by a potential detection bias. Sclerotherapy was associated with significantly more adverse events than somatostatin. In a predefined sensitivity analysis, combining all of the trials irrespective of the control treatment, risk differences (sclerotherapy minus control) and confidence intervals (CIs) were as follows: failure to control bleeding, -0.03 (-0.06 to 0.01); mortality, -0.035 (-0.07 to 0.008); adverse events, 0.08 (0.02 to 0.14). Mortality risk difference was -0.01 (-0.07 to 0.04) in good-quality trials and -0.08 (-0.14 to -0.02) in poor-quality trials. CONCLUSIONS Available evidence does not support emergency sclerotherapy as the first-line treatment of variceal bleeding in cirrhosis when compared with vasoactive drugs, which control bleeding in 83% of patients. Therefore, endoscopic therapy might be added only in pharmacologic treatment failures.
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Affiliation(s)
- Gennaro D'Amico
- Department of Medicine, Ospedale V Cervello, Palermo, Italy.
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113
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Sung JJY. Treatment of Variceal Bleeding. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2003; 6:171-180. [PMID: 12628076 DOI: 10.1007/s11938-003-0018-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Mortality due to variceal bleeding secondary to portal hypertension has decreased significantly in the past 2 decades. Endoscopic therapy has been the mainstay of treatment for acute variceal bleeding. Variceal banding ligation has superceded injection sclerotherapy as the most popular treatment modality for acute bleeding. Multiple banding ligators are widely used with high success in restoring hemostasis. The combination of banding and sclerotherapy may be useful in preventing the early recurrence of varices and rebleeding after initial obliteration of varices. Selective vasoactive agents such as somatostatin analogs also improve the outcome of patients. Radiologic shunting has proven to be an effective salvage procedure when endoscopic treatments fail and may be a good intermediate-stage therapy while the patient is waiting for liver transplantation.
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Affiliation(s)
- Joseph J. Y. Sung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong, China.
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114
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Scientific surgery. Br J Surg 2002. [DOI: 10.1002/bjs.225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
The BJS is committed to the practice of surgery based on scientific evidence. Each month we will publish a list of randomized trials and meta-analyses collated from English-language publications. A collection of all these papers will be available in the Scientific Surgery Archive which will be held on the BJS website together with links to free Medline sites where the full papers can be accessed (see below for details). If you have published a recent randomized trial which has not been featured in Scientific Surgery, the Editors would be pleased to receive a reprint and consider its inclusion.
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115
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Affiliation(s)
- Juan G Abraldes
- Hepatic Hemodynamic Laboratory. Liver Unit, IMD, Hospital Clínic, IDIBAPS, University of Barcelona, Spain
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116
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Morpurgo M, Monfardini C, Hofland LJ, Sergi M, Orsolini P, Dumont JM, Veronese FM. Selective alkylation and acylation of alpha and epsilon amino groups with PEG in a somatostatin analogue: tailored chemistry for optimized bioconjugates. Bioconjug Chem 2002; 13:1238-43. [PMID: 12440858 DOI: 10.1021/bc0100511] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The effects of the type and location of polymer grafting on the biological activity of different mono-PEG derivatives of the somatostatin analogue RC160 were evaluated. A chemical strategy to obtain mono-PEG alkylation or acylation of the peptide's alpha-terminal or lysil-epsilon primary amines was devised. Selective BOC protection of the two available primary amines, followed by reaction with two different PEG reagents and removal of the protecting group, was carried out. Chemical characterization, structural studies, and the evaluation of the biological activity of the bioconjugates synthesized allowed the identification of the one having characteristics more suitable for therapeutic application. This corresponds to the mono-epsilon-lysil-pegylated form, obtained by reductive alkylation, where the amine's positive charge is preserved. The results obtained suggest the importance of preliminary studies in the development of new polymer-peptide conjugates with improved pharmacological properties.
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Affiliation(s)
- Margherita Morpurgo
- Universitá degli Studi di Padova, Dipartimento Scienze Farmaceutiche, via Marzolo, 5, 35131 Padova, Italy
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117
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D'amico G, Criscuoli V, Fili D, Mocciaro F, Pagliaro L. Meta-analysis of trials for variceal bleeding. Hepatology 2002; 36:1023-4; author reply 1024-5. [PMID: 12297857 DOI: 10.1053/jhep.2002.34737] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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118
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Are Somatostatin Analogues (Octreotide and Lanreotide) Effective in Promoting Healing of Enterocutaneous Fistulas? J Wound Ostomy Continence Nurs 2002. [DOI: 10.1097/00152192-200209000-00005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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119
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Affiliation(s)
- David Patch
- Liver Transplantation Unit and Hepato-biliary Medicine, Hampstead, NW3 London, UK.
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120
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Affiliation(s)
- Juan G Abraldes
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Barcelona, Spain
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121
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Abstract
Portal hypertension is the main complication of cirrhosis and is responsible for its most common complications: variceal hemorrhage, ascites, and portosystemic encephalopathy. Portal hypertension is the result of increased intrahepatic resistance and increased portal venous inflow. Vasodilatation (splanchnic and systemic) and the hyperdynamic circulation are hemodynamic abnormalities typical of cirrhosis and portal hypertension. Gastroesophageal varices result almost solely from portal hypertension, although the hyperdynamic circulation contributes to variceal growth and hemorrhage. Ascites results from sinusoidal hypertension and sodium retention, which is in turn secondary to vasodilatation and activation of neurohumoral systems. Hepatic hydrothorax results from the passage of ascites across the diaphragm and into the pleural space. The hepatorenal syndrome represents the result of extreme vasodilatation with an extreme decrease in effective blood volume that leads to maximal activation of vasoconstrictive systems, renal vasoconstriction, and renal failure. Spontaneous bacterial peritonitis is a potentially lethal infection of ascites that occurs in the absence of a local source of infection. Portosystemic encephalopathy is a consequence of both portal hypertension (shunting of blood through portosystemic collaterals) and hepatic insufficiency resulting in the accumulation of neurotoxins in the brain.
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Affiliation(s)
- Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut 06520, USA.
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122
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Abstract
Important advances have been made in the management of variceal bleeding. Despite these advances, bleeding in the patient with cirrhosis remains one of the most demanding clinical challenges that a gastroenterologist or gastrointestinal surgeon may face. The aim is to identify the source of bleeding, control active bleeding and prevent rebleeding. This requires a multidisciplinary team, and the optimal management algorithm depends on the clinical circumstance of the patient and the local availability of endoscopic, radiological and surgical expertise. Injection sclerotherapy is effective in stopping acute variceal bleeding, but has the drawback of a high incidence of complications. Endoscopic variceal ligation is just as effective, and is associated with fewer complications. An overtube allows repeated introductions of the endoscope to be more tolerable for the patient and protects the airway against aspiration of blood; its use should be encouraged in patients with massive bleeding. Newer ligators can deliver multiple bands without removal of the scope but the high cost of these disposable devices limits their widespread use. Bleeding from gastric varices is even more challenging; the treatment of choice is injection with cyanoacrylate glue. To prevent rebleeding, beta-blockers are recommended for all patients with large varices (including those which have never bled). Injection sclerotherapy or band ligation, conducted at weekly intervals after the initial control of bleeding, is equally effective at obliterating varices and decreasing the risk of further hemorrhage; band ligation results in fewer complications. Other newer treatment modalities for variceal bleeding, such as somatostatin analogs, transjugular intrahepatic portasystemic shunt and liver transplantation, offer more optimal approaches to control bleeding and prevent rebleeding, but may be prohibitively expensive. Even for the most affluent communities, affordability, cost-effectiveness, and resource rationing are important considerations in management of patients with cirrhosis complicated by gastrointestinal bleeding.
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Affiliation(s)
- Sydney Chung
- Endoscopy Centre, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.
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123
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Abstract
Variceal hemorrhage complicates cirrhosis in as many as 50% of patients and results in considerable morbidity and mortality. This review covers all areas of importance in the prevention and treatment of this area, highlighting recent developments. Primary prophylaxis prevents first bleed, and pharmacotherapy with beta-blockade is the most widely accepted option. In an acute variceal hemorrhage, initial resuscitation and multiple organ support are paramount and are recommended along with antibiotic prophylaxis and specific medical therapies that may be given empirically before emergency endoscopy to reduce bleeding. Endoscopic techniques usually arrest bleeding, but when they fail, salvage therapy in the form of balloon tamponade, then transjugular intrahepatic portosystemic shunts or surgery, may be appropriate. Secondary prophylaxis to prevent rebleeding is often instituted in the ICU and is vital to prevent recurrence of this life-threatening complication.
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Affiliation(s)
- Rachael Harry
- Institute of Liver Studies, Kings College Hospital, London, England, UK
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124
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Bañares R, Albillos A, Rincón D, Alonso S, González M, Ruiz-del-Arbol L, Salcedo M, Molinero LM. Endoscopic treatment versus endoscopic plus pharmacologic treatment for acute variceal bleeding: a meta-analysis. Hepatology 2002; 35:609-15. [PMID: 11870374 DOI: 10.1053/jhep.2002.31354] [Citation(s) in RCA: 256] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Endoscopic therapy, involving either injection sclerosis or band ligation, is considered the intervention of first choice for acute variceal bleeding (AVB). Pharmacologic agents have also been shown to be highly effective in the control of the bleeding episode. The purpose of this meta-analysis was to assess whether vasoactive drugs may improve the efficacy of endoscopic therapy (injection sclerosis or band ligation) in the control of AVB and thus increase survival rates. Computer databases and scientific meeting abstracts from 1994 to 2001 were used to search for randomized trials that compared the combined use of endoscopic and drug therapy with endoscopic therapy alone in the control of AVB. Eight trials involving 939 patients fulfilled the selection criteria and the following evaluated by standard meta-analysis methods: initial hemostasis, 5-day hemostasis, 5-day mortality, and adverse events. Combined treatment improved initial control of bleeding (relative risk [RR], 1.12; 95% confidence interval (CI), 1.02-1.23), and 5-day hemostasis (RR, 1.28; 95% CI, 1.18-1.39), with numbers of patients needed to treat (NNT) of 8 and 5, respectively. The difference in favor of combined treatment remained significant when trials that used drugs other than octreotide or that included a low proportion of alcoholic patients (<40%) or high-risk cirrhotic patients (<35%) were excluded. Mortality was not significantly decreased by combined therapy (RR, 0.73; 95% CI, 0.45-1.18). Severe adverse events were similar in both groups. In conclusion, in patients with AVB, pharmacologic agents improve the efficacy of endoscopic therapy to achieve initial control of bleeding and 5-day hemostasis, yet fail to affect mortality.
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Affiliation(s)
- Rafael Bañares
- Gastroenterology Unit, Hospital General Gregorio Marañón, Department of Medicine, Universidad Complutense, Madrid, Spain
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125
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D'Amico G, Pietrosi G, Tarantino I, Pagliaro L. Emergency sclerotherapy versus medical interventions for bleeding oesophageal varices in cirrhotic patients. Cochrane Database Syst Rev 2002:CD002233. [PMID: 11869632 DOI: 10.1002/14651858.cd002233] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Emergency sclerotherapy is widely used as a first line therapy for variceal bleeding in cirrhosis, although pharmacological treatment may stop bleeding in the majority of patients. OBJECTIVES To assess whether emergency sclerotherapy is superior to pharmacological treatment for variceal bleeding in cirrhosis. SEARCH STRATEGY Electronic and manual searches were combined until April 2001. SELECTION CRITERIA Randomised clinical trials comparing sclerotherapy with vasoactive treatments (vasopressin (plus minus nitroglycerin), terlipressin, somatostatin, or octreotide) for acute variceal bleeding in cirrhotic patients. DATA COLLECTION AND ANALYSIS Two independent reviewers identified eligible trials and extracted data. Outcome measures were failure to control bleeding, five-day treatment failure, rebleeding before other elective treatments, 42-day rebleeding, mortality before other elective treatments, 42-day mortality, number of blood transfusions, and adverse events. Data were analysed by a random effects model according to the vasoactive treatment. Sensitivity analyses included combined analysis of all the trials irrespective of the vasoactive drug, fixed effects model analyses, type of publication, methodological quality, and adequacy of generation of the randomisation list and of allocation concealment. MAIN RESULTS Twelve trials including 1146 patients (pts) were identified. One trial compared sclerotherapy with vasopressin, one with terlipressin, four with somatostatin, and six with octreotide. No significant differences were found comparing sclerotherapy with each vasoactive drug for any outcomes. Combining all the trials irrespective of the vasoactive drug, risk differences (95% confidence intervals) were: failure to control bleeding (11 RCTs, 977 pts) -0.03 (-0.07 to 0.01); five-day failure rate (7 RCTs, 759 pts) -0.05 (-0.12 to 0.01); rebleeding (11 RCTs, 1082 pts) -0.01(-0.06 to 0.04); rebleeding before other elective treatments (9 RCTs, 975 pts) -0.02 (-0.06 to 0.03); mortality (12 RCTs, 1146 pts) -0.04 (-0.08 to 0.00); mortality before other elective treatments (5 RCTs, 474 pts) -0.02 (-0.07 to 0.04); transfused blood units (7 RCTs, 793 pts) (weighted mean difference) -0.17 (-0.52 to 0.19). Adverse events (11 RCTs, 1082 pts) and serious adverse events (5 RCTs, 602 pts) were significantly more frequent with sclerotherapy: risk differences 0.08 (0.02 to 0.14) and 0.05 (0.02 to 0.08), respectively. Results were consistent across all the other sensitivity analyses. REVIEWER'S CONCLUSIONS We found no convincing evidence to support the use of emergency sclerotherapy for variceal bleeding in cirrhosis as the first, single treatment when compared with vasoactive drugs.
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Affiliation(s)
- G D'Amico
- Medicine, Ospedale V Cervello, Via Trabucco 180, Palermo, Italy, 90146.
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126
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Affiliation(s)
- A I Sharara
- Department of Medicine, American University of Beirut Medical Center, Lebanon
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127
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Affiliation(s)
- C R Weinberg
- Biostatistics Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC 27709, USA
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128
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Affiliation(s)
- A K Burroughs
- Hepatobiliary and Liver Transplantation Unit, Royal Free Hospital, NW3 2QG, London, UK.
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