Improved patient survival after acute variceal bleeding: a multicenter, cohort study

Current endoscopic therapy of variceal bleeding

Variceal ligation has proved more effective and safer than sclerotherapy and is currently the endoscopic treatment of choice for oesophageal varices. In acute bleeding, vasoactive drugs should be started before endoscopy and maintained for 2-5 days. The efficacy of drugs is improved when associated with emergency endoscopic therapy. Antibiotic prophylaxis should also be used. To prevent rebleeding, both endoscopic ligation and the combination of beta-blockers and nitrates may be used. Adding beta-blockers improves the efficacy of ligation. Haemodynamic responders to beta-blockers+/-nitrates (those with a decrease in portal pressure gradient HVPG to <12 mmHg or by >20% of baseline) have a marked reduction in the risk of haemorrhage and will not need further treatment. Beta-blockers significantly reduce the risk of a first haemorrhage in patients with large varices, and they improve survival. As compared to beta-blockers, endoscopic ligation reduces the risk of first bleeding without affecting mortality, and should be used in patients with contraindications or intolerance to beta-blockers.

Gastrointestinal bleeding in the elderly

Gastrointestinal bleeding affects a substantial number of elderly people and is a frequent indication for hospitalization. Bleeding can originate from either the upper or lower gastrointestinal tract, and patients with gastrointestinal bleeding present with a range of symptoms. In the elderly, the nature, severity, and outcome of bleeding are influenced by the presence of medical comorbidities and the use of antiplatelet medication. This Review discusses trends in the epidemiology and outcome of gastrointestinal bleeding in elderly patients. Specific causes of upper and lower gastrointestinal bleeding are discussed, and recommendations for approaches to endoscopic diagnosis and therapy are given.

Cost of preventing variceal rebleeding with transjugular intrahepatic portal systemic shunt and distal splenorenal shunt

BACKGROUND/AIMS

We examined the cost and cost effectiveness of distal splenorenal shunt (DSRS) and transjugular intrahepatic portosystemic shunt (TIPS) in the prevention of variceal rebleeding.

METHODS

Patients participated in a randomized controlled trial comparing DSRS to TIPS. Quality of life (QOL) was measured using SF-36 preceding randomization and yearly thereafter. Cost utility analysis was performed using TreeAge DATA. Costs for both in- and out-patient events and interventions were obtained for each patient. Costs using coated stents were estimated using different rates of stenosis. Incremental cost effectiveness ratios (ICERs) were determined at 1, 3 and 5 years.

RESULTS

The average yearly costs of managing patients after TIPS and DSRS over 5 years were similar, $16,363 and $13,492, respectively. Cost of TIPS for surviving patients exceeded the cost of DSRS at years 3 and 5 but not significantly. ICERs per life saved favored TIPS at year 5 ($61,000). If coated rather than bare stents were used the cost effectiveness of TIPS increased slightly.

CONCLUSIONS

TIPS is as effective as DSRS in preventing variceal rebleeding and may be more cost effective. TIPS, in all aspects, is equal to DSRS in the prevention of variceal rebleeding in patients who are medical failures.

Hepatic venous pressure gradient and prognosis in patients with acute variceal bleeding treated with pharmacologic and endoscopic therapy

BACKGROUND/AIMS

In acute variceal bleeding (AVB) hepatic venous pressure gradient (HVPG) is associated with prognosis. However, this has not been studied in patients receiving the currently recommended therapy. We evaluate here the performance of early HVPG measurement as a predictor of treatment failure in patients with acute variceal bleeding managed with the current standard treatment and whether clinical variables might be of similar predictive accuracy.

METHODS

We included 117 patients with AVB in whom HVPG was measured within 48 h of admission. The main endpoint was 5-day failure, a composite of uncontrolled bleeding, early rebleeding or death within 5 days.

RESULTS

Eighteen patients (15%) had 5-day failure. Multivariate analysis identified three variables independently associated with 5-day failure: HVPG 20, systolic blood pressure at admission <100 mmHg and non-alcoholic cause of cirrhosis. The discriminative capacity of this model was good (c statistic: 0.79). When only clinical variables were included in the analysis, Child-Pugh class, systolic blood pressure at admission and etiology were the independent predictors. This model had also a good discriminative ability (c statistic: 0.80).

CONCLUSIONS

HVPG independently predicts short-term prognosis in patients with acute variceal bleeding treated with pharmacologic and endoscopic therapy, but similar predictive accuracy can be achieved using only simple clinical variables that have universal applicability.

Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage: a cost-effectiveness analysis

BACKGROUND

Erythromycin is a potent stimulator of gastrointestinal motility. Recent studies have examined the use of intravenous erythromycin to clear the stomach of blood before oesophago-gastroduodenoscopy (EGD) for acute upper gastrointestinal haemorrhage (UGIH). These studies have shown clinical effectiveness.

AIM

To evaluate the cost-effectiveness of this intervention.

METHODS

We sought to determine the cost-effectiveness of erythromycin before EGD from the payer's perspective. We found three relevant studies of erythromycin and used these data for the analysis. We obtained costs for intravenous erythromycin and charges for peptic ulcer hospitalization, EGD, surgery, and angiographic embolization. Complication rates were also incorporated from the literature. We implemented a model of health-related quality of life to measure the impact of the intervention. We created a decision-analysis tree and performed a probabilistic sensitivity analysis.

RESULTS

A strategy of erythromycin prior to EGD resulted in a cost-effective outcome in a majority of trials using willingness-to-pay figures of USD 0, USD 50,000 and USD 100,000 per quality-adjusted life-year (QALY).

CONCLUSION

Because of the implications for cost saving and increase in QALY, we would recommend giving erythromycin prior to EGD for UGIH.

The treatment of acute variceal bleeding

Bleeding from gastroesophageal varices is a frequent and often deadly complication of cirrhosis. Although mortality from an episode of variceal bleeding has decreased in the last 2 decades it is still around 20%. This paper reviews the most recent advancements in the general management and hemostatic treatments of acute variceal bleeding.

Preventing first variceal hemorrhage in cirrhosis

Variceal bleeding is still a life-threatening complication of portal hypertension responsible for an appreciable rate of morbidity and mortality. The most appropriate treatment approach, whether drugs (nonselective beta-blockers) or endoscopic (variceal band ligation) therapy, to prevent the initial bleed, or primary prophylaxis, is an issue of controversy. Meta-analysis of randomized controlled trials indicates that banding seems to be somehow slightly more effective than beta-blockers at preventing a first bleeding episode, but this does not translate to improved survival. The firmness of this conclusion is, in addition, diminished by the small sample size and short follow-up of most studies. Moreover, adverse events due to banding are more severe than those associated with beta-blockers. Thus, beta-blockers remain as first-line therapy in patients with cirrhosis and large esophageal varices. Prophylactic therapy with beta-blockers can be considered in patients with small varices, especially in those with red signs or Child class C liver disease. The available evidence does not support the idea that organic nitrates improve the efficacy of beta-blockers in primary prophylaxis. The method used to establish the dose of beta-blockers and check its effect on hepatic venous pressure gradient (HVPG) has also been disputed. An attractive strategy is to measure the HVPG response to beta-blockers as a guide to primary prophylaxis, with the aim of switching to another therapy, that is, band ligation, in HVPG nonresponders. However, no study has yet demonstrated that banding as rescue therapy in nonresponders lowers the risk of first bleeding and improves survival.

Risk of aspiration pneumonia in suspected variceal hemorrhage: the value of prophylactic endotracheal intubation prior to endoscopy

Variceal hemorrhage (VH) is a lethal complication of portal hypertension. Aspiration occurring during endoscopic intervention for acute VH is a concern; however, few data exist regarding the efficacy of prophylactic intubation to prevent aspiration pneumonia. We reviewed all endoscopic procedures for acute VH from January 1995 to December 2002; only patients with the absence of hepatic encephalopathy greater than stage II and normal chest x-ray at admission were included. The use of prophylactic intubation, post-procedure chest x-ray, and mortality were recorded. Sixty-two patients (69 bleeding episodes) were identified. Elective intubation was performed in 42 patients (47 episodes); pulmonary infiltrates developed in 7 of 42 (17%), with an overall mortality rate of 9 of 42 (21%). Twenty patients (22 episodes) were not intubated. None developed pulmonary infiltrates, and the overall mortality rate was 1 in 20 (5%). We conclude that in patients with suspected variceal bleeding, elective intubation is associated with a substantial risk of aspiration pneumonia.

An economic evaluation of vasoactive agents used in the United Kingdom for acute bleeding oesophageal varices in patients with liver cirrhosis

OBJECTIVE

To conduct an economic evaluation of terlipressin, octreotide and placebo in the treatment of bleeding oesophageal varices (BOV) where endotherapy could be used concomitantly.

METHODS

A discrete event simulation model was created with transition states: bleeding, no bleeding, no bleeding post transjugular intrahepatic portosystemic shunt, post-salvage surgery, and death. Efficacy data on survival, re-bleeding and control of bleeding were obtained from high quality studies reported in Cochrane meta-analyses. Baseline outcomes related to the course of disease and health-state utilities were derived from published sources. Vasoactive treatment costs and all related BOV costs were obtained from published UK sources.

RESULTS

The average aggregated treatment cost per person for all medical interventions at 1 year was lower for terlipressin-treated patients (2623 pounds sterling) compared with those treated using octreotide (2758 pounds sterling) or placebo (2890 pounds sterling). The incremental analysis comparing terlipressin with octreotide and placebo using a cost per quality adjusted life year (QALY) and cost per life year gained (LYG) approach indicated that terlipressin was the dominant BOV treatment option (i.e. it cost less and it was more effective). Based on a maximum willingness to pay of 20,000 pounds sterling/QALY terlipressin was more effective and cost-saving compared to octreotide and placebo for simulations ranging from 42 days to 2 years. In point estimation analyses octreotide was dominant compared to placebo; however, probabilistic sensitivity analysis indicated that octreotide was unlikely to be cost-effective compared to placebo.

CONCLUSIONS

The findings indicated that vasoactive treatment in BOV was cost-saving compared to no vasoactive treatment. Furthermore, terlipressin was the more cost-effective vasoactive treatment for BOV in cirrhotic patients.

Cost-effectiveness analysis of variceal ligation vs. beta-blockers for primary prevention of variceal bleeding

Although both beta-blockade (BB) and endoscopic variceal ligation (EVL) are used for primary prevention of variceal bleeding (VB) in patients with cirrhosis with moderate to large esophageal varices (EVs), the more cost-effective option is uncertain. We created a Markov decision model to compare BB and EVL in such patients, examining both cost-effectiveness (cost per life year [LY]) and cost-utility (cost per quality-adjusted life year [QALY]). Outcomes included cost per LY, cost per QALY, proportions of persons with VB, TIPS, and all-cause mortality. EVL and BB were compared using the incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR). When considering only LYs, initial EVL exceeds the benchmark of 50,000 dollars/LY, with an ICER of 98,407 dollars. However, when quality of life (QoL) is considered, EVL is cost-effective compared to BB (ICUR of 25,548 dollars/QALY). In sensitivity analysis, EVL is cost-effective if the yearly risk of EV bleeding is > or = 0.26 (base case 0.15), the relative risk of bleeding on BB is > or = 0.69 (base case 0.58), or if the relative risk of bleeding with EVL is < 0.27 (base case 0.35). The ICUR favored EVL unless the relative risk of bleeding on BB is < 0.46, the relative risk of bleeding with EVL is > 0.46, or the time horizon is < or = 24 months. Whether EVL is "cost-effective" relative to BB therapy for primary prevention of EV bleeding depends on whether LYs or QALYs are considered. If only LYs are considered, then EVL is not cost-effective compared to BB therapy; however, if QoL is considered, then EVL is cost-effective.

An assessment of endoscopic and concomitant management of acute variceal bleeding at a tertiary care centre

BACKGROUND

Several therapies have been demonstrated to be beneficial in the management of acute variceal bleeding (AVB). The aim of the present study was to characterize the use of these therapies at a Canadian tertiary care centre.

PATIENTS AND METHODS

A comprehensive chart review was performed to assess the management of all adult cirrhotic patients with AVB who were admitted to a university-affiliated, tertiary care centre between April 2001 and March 2004.

RESULTS

A total of 81 AVB patients were identified with a mean age of 53.7+/-13.2 years and a median model for end-stage liver disease score of 14. Endoscopy was performed within 8.2+/-7.6 h of admission. Variceal banding was performed for 87% of patients with esophageal varices, which were the most common source of bleeding (80%). Octreotide was used in 82% of patients for a mean duration of 74.3+/-35.4 h; prophylactic antibiotics were used in 25% of patients and beta-blockers were used in 24% of patients without any contraindications. Follow-up endoscopy was arranged for 46 of 71 (65%) survivors. Prophylactic antibiotic use was associated with the presence of ascites, while beta-blockers were used more often in the last year of the study.

CONCLUSIONS

There is a disconnection between the use of evidence-based recommendations and routine clinical practices in the management of AVB. Deficiencies identified include the lack of use of prophylactic antibiotics and beta-blockers, variable use of octreotide and inadequate follow-up recommendations. There is a need to identify measures to improve the process of care for patients with AVB which would ensure optimal management of these patients.

A simple clinical score predicts high risk for upper gastrointestinal hemorrhages from varices in patients with chronic liver disease

OBJECTIVE

Upper gastrointestinal (GI) bleeding from esophageal or gastric fundus varices is a common complication of portal hypertension in liver cirrhosis and carries a high mortality rate of 20-35%. Stratifying high-risk patients for variceal bleeding is mainly based on endoscopic scoring. The purpose of this study was to develop a simple clinical score to assess the bleeding risk.

MATERIAL AND METHODS

A total of 111 patients with chronic liver diseases were included during evaluation for potential liver transplantation and were followed for 6 years. Findings at study entry were analyzed for their value in predicting hemorrhages.

RESULTS

Twenty-four patients (22%) developed upper GI hemorrhages from varices during the follow-up period. Common characteristics at study entry of patients with future bleedings included viral hepatitis or alcoholic etiology, advanced-stage cirrhosis, decreased liver function, impaired hemostasis and endoscopic presence of varices. These parameters were also independent predictors of bleedings. A four-item Bleeding Risk Score, including cholinesterase <2.25 kU/l, international normalized ratio (INR) >1.2, viral or alcoholic etiology and presence of varices, was used to identify patients at high (>2 points) or low (<or=2) risk of bleedings, and found superior in sensitivity and specificity to the Child-Pugh or MELD score.

CONCLUSIONS

A simple clinical score can predict the risk for upper GI bleedings in patients with chronic liver disease. This Bleeding Risk Score may help to supplement current endoscopic and clinical approaches to identify high-risk patients.

Non-invasive diagnosis of cirrhosis and the natural history of its complications

Several methods have been studied in the attempt to reach a diagnosis of cirrhosis by non-invasive means. Although abdominal ultrasound can detect the hepatic and extra-hepatic changes consistent with cirrhosis, its ability to distinguish chronic hepatitis from compensated cirrhosis is limited. Serum markers can rule in or rule out fibrosis in up to 35% of patients but, in individual patients, cannot differentiate the stages of fibrosis reliably. Transient elastography (Fibroscan) might be of value for the non-invasive diagnosis of cirrhosis; however, its reproducibility needs to be further validated. Cirrhosis can be divided into 4 stages: stage 1, no varices, no ascites; stage 2, varices without ascites and without bleeding; stage 3, ascites+/-varices; stage 4, bleeding+/-ascites. Yearly mortality ranges from 1% in stage 1 to 57% in stage 4. The yearly incidence of oesophageal varices is 5-7%; their rate of enlargement is 10-12% per year. The incidence of variceal bleeding is about 25% at 2 years. Bleeding stops spontaneously in about 50% of cases but early rebleeding occurs in 30-40% of patients. Bleeding-related mortality has declined over time and is now around 20% at 6 weeks.

TIPS para o controle das complicações da hipertensão portal: eficácia, fatores prognósticos associados e variações técnicas

OBJETIVO: Avaliar a eficácia do TIPS (transjugular intrahepatic portosystemic shunt) para tratar as complicações clínicas em pacientes com hipertensão portal. MATERIAIS E MÉTODOS: Quarenta e quatro pacientes, sendo 30 do sexo masculino e 14 do feminino e com idade média de 52 anos foram analisados. A indicação para realização de TIPS foi hemorragia gastrintestinal em 28 e ascite refratária em 16. Houve 7 pacientes Child-Pugh A, 24 Child-Pugh B e 11 Child-Pugh C. RESULTADOS: O TIPS foi realizado com sucesso em todos os pacientes (100%), verificando-se queda do gradiente pressórico porto-sistêmico médio de 49,69% (de 18,98 mmHg para 9,55 mmHg). Comprovou-se melhora clínica em 35 pacientes (79,55%). A mortalidade pós-operatóriaia foi de 13,64%, sendo mais incidente nos pacientes Child-Pugh C (45,45%). Os fatores mais relevantes de mau prognóstico foram o aumento da bilirrubina e do nível de creatinina. A sobrevida média de pacientes Child-Pugh A foi de 11,5 meses, nos Child-Pugh B foi de 10,97 meses e nos Child-Pugh C foi de apenas 5,9 meses. Foram observadas complicações em nove casos (20,44%). CONCLUSÃO: O TIPS é eficiente para reduzir a pressão portal. As complicações e a morbi-mortalidade relacionadas com o procedimento podem ser consideradas aceitáveis. A mortalidade foi influenciada por alguns fatores clínicos, tais como classe Child-Pugh C e elevação dos níveis séricos de bilirrubina e creatinina.

Endoscopic therapy for bleeding esophageal varices improves the outcome of Child C cirrhotic patients

BACKGROUND AND AIM

Bleeding from esophageal varices is one of the frequent severe complications arising in patients with liver cirrhosis. The management of esophageal varices is therefore important for patient survival. The purpose of this study was to clarify the predictive factors for mortality in patients with Child C cirrhosis presenting with variceal bleeding.

METHODS

A retrospective analysis of 77 Child C cirrhotic patients with bleeding from esophageal varices was conducted. All patients received endoscopic therapy. Twenty-nine patients received endoscopic variceal ligation, and 48 patients received endoscopic injection sclerotherapy or endoscopic injection sclerotherapy with ligation. Univariate and multivariate analyses of clinical data were performed to identify the prognostic factors for survival for these 77 patients.

RESULTS

Fifty-seven of 77 patients received endoscopic therapy within 24 h after variceal bleeding, and bleeding was controlled in 55 (96.5%). The remaining 20 patients received endoscopic therapy more than 24 h after bleeding. Higher bilirubin level and rebleeding were the predictive parameters for 6-week survival in the 77 patients, according to univariate and multivariate analysis. Higher bilirubin level, refractory ascites, and the presence of hepatocellular carcinoma were the predictive parameters for mortality in 77 patients as determined by multivariate analysis.

CONCLUSIONS

Endoscopic therapy was effective in controlling acute variceal bleeding of Child C cirrhotic patients. The prognosis of Child C stage patients presenting with variceal bleeding depended on the severity of liver damage and the presence of hepatocellular carcinoma.

A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding

BACKGROUND/AIMS

The currently recommended treatment for acute variceal bleeding is the association of vasoactive drugs and endoscopic therapy. However, which emergency endoscopic treatment combines better with drugs has not been clarified. This study compares the efficacy and safety of variceal ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin.

METHODS

Patients admitted with acute gastrointestinal bleeding and with suspected cirrhosis received somatostatin infusion (for 5 days). Endoscopy was performed within 6h and those with esophageal variceal bleeding were randomized to receive either sclerotherapy (N=89) or ligation (N=90).

RESULTS

Therapeutic failure occurred in 21 patients treated with sclerotherapy (24%) and in nine treated with ligation (10%) (RR=2.4, 95% CI=1.1-4.9). Failure to control bleeding occurred in 15% vs 4%, respectively (P=0.02). Treatment group, shock and HVPG >16 mmHg were independent predictors of failure. Side-effects occurred in 28% of patients receiving sclerotherapy vs 14% with ligation (RR=1.9, 95% CI=1.1-3.5), being serious in 13% vs 4% (P=0.04). Six-week survival probability without therapeutic failure was better with ligation (P=0.01).

CONCLUSIONS

The use of variceal ligation instead of sclerotherapy as emergency endoscopic therapy added to somatostatin for the treatment of acute variceal bleeding significantly improves the efficacy and safety.

Comparative study between nadolol and 5-isosorbide mononitrate vs. endoscopic band ligation plus sclerotherapy in the prevention of variceal rebleeding in cirrhotic patients: a randomized controlled trial

BACKGROUND

After variceal bleeding, cirrhotic patients should receive secondary prophylaxis.

AIM

To compare nadolol plus 5-isosorbide mononitrate (5-ISMN) with endoscopic band ligation. The end points were rebleeding, treatment failure and death.

METHODS

One hundred and nine cirrhotic patients with a recent variceal bleeding were randomized: nadolol plus 5-ISMN in 57 patients and endoscopic band ligation in 52 patients.

RESULTS

The mean follow-up was 17 and 19 months in nadolol plus 5-ISMN and endoscopic band ligation groups, respectively. No differences were observed between groups in upper rebleeding (47% vs. 46%), variceal rebleeding (40% vs. 36%), failure (32% vs. 22%), major complications (7% vs. 13.5%) and death (19% vs. 20%), respectively. The actuarial probability of remaining free of rebleeding, failure and deaths were similar in both groups. Time to rebleeding shows that endoscopic band ligation patients had an early rebleed, with a median of 0.5 month (95% CI: 0.0-4.2) compared with patients from nadolol plus 5-ISMN, 7.6 months (95% CI: 2.9-12.3, P < 0.013). Multivariate analysis indicated that outcome-specific predictive factor(s) for rebleeding was Child A vs. B + C (P < 0.01); for failure was Child A vs. B + C (P < 0.02); and for death ascites (P < 0.01) and rebleeding (P < 0.02).

CONCLUSION

This trial suggests no superiority of endoscopic band ligation over nadolol plus 5-ISMN mononitrate for the prevention of rebleeding in cirrhotic patients.

Pharmacologic therapy for gastrointestinal bleeding due to portal hypertension and esophageal varices

Cirrhosis results in portal hypertension in many patients. The major complications of portal hypertension include development of ascites and esophageal or gastric varices. Varices lead to hemorrhage and death in a significant proportion of patients. This review focuses on the pharmacologic approach to management of portal hypertension in patients at risk of variceal hemorrhage, or those who have already had variceal bleeding. Pharmacologic therapy is used for 1) primary prevention of bleeding, 2) management of acute bleeding, and 3) prevention of recurrent bleeding (secondary prophylaxis). For acute esophageal variceal hemorrhage, a variety of pharmacologic agents are used, including somatostatin, octreotide, vapreotide, lanreotide, terlipressin, and vasopressin (with nitrates). For primary and secondary prevention of esophageal variceal hemorrhage, beta-blockers remain the mainstay therapy.

Transjugular intrahepatic portosystemic shunt in treatment of 56 patients with cirrhosis and portal hypertension

AIM: To observe the clinical effect and complications of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of liver cirrhosis with portal hypertension.

METHODS: Fifty-six patients of liver cirrhosis with portal hypertension were treated with TIPS. Portal pressure, flow rate of portal blood, flow rate in the shunt, internal diameter of portal and splenic veins, blood routine before and after TIPS were measured, respectively.

RESULTS: TIPS was successfully performed in all the 56 patients (100%). The portal pressure (cmH₂O) post-TIPS was 22.5 ± 3.5 (P < 0.01 vs pre-TIPS 43.5 ± 4.5). The flow rate of portal blood (cm/s) post-TIPS was 12.5 ± 4.0 (P < 0.01 vs pre-TIPS 46.0 ± 16.5). The flow rate in the shunt was 158.0 ± 60.0 cm/s. The internal diameter of portal and splenic vein (cm) post-TIPS were 1.13 ± 0.086 and 0.90 ± 0.056, respectively (P < 0.01 vs pre-TIPS 1.52 ± 0.082 and 1.26 ± 0.034, respectively). Hypersplenism was found in 30 patients, and the numbers of leukocytes (×10⁹/L), platelets (×10⁹/L) and the levels of hemoglobin (×g/L) post-TIPS were 3.92 ± 0.76, 80.74 ± 16.82 and 118.20 ± 10.24 (P < 0.01 vs pre-TIPS 2.65 ± 0.58, 42.56 ± 12.34 and 86.52 ± 12.68). The clinical symptoms of 56 patients with avrix and ascites were alleviated obviously. Common complications were hepatic encephalopathy, shunt stenosis and occlusion.

CONCLUSION: TIPS is a useful treatment in controlling varceal bleeding, decreasing portal pressure and partially alleviating hypersplenism.

Hemorheology in patients with liver cirrhosis: special emphasis on its relation to severity of esophageal variceal bleeding

BACKGROUND

Patients with decreased blood viscosity are supposed to have a higher risk of bleeding and increased severity of bleeding (severity of bleeding proportional to transmural pressure x area of variceal tear/blood viscosity). However, the hemorheological factors have never been assessed in patients with esophageal variceal bleeding. Therefore, the purpose of the present study was to examine the hemorheological factors in liver cirrhotic patients with special emphasis on the outcome of variceal bleeding.

METHODS

Forty-two liver cirrhosis patients with variceal bleeding and another 44 matched patients without bleeding were enrolled. The hemorheological and hemostatic factors of their peripheral blood were examined. The clinical course was under careful surveillance.

RESULTS

Patients with poor hepatic reserve (Child B + C vs A) had lower whole blood viscosity (4.34 +/- 0.56 mPa.s vs 5.06 +/- 1.35 mPa.s, P < 0.05), lower hematocrit levels (32.86 +/- 5.97% vs 36.62 +/- 5.44%, P < 0.05), lower platelet counts (79.7 +/- 47.6 x 10(3)/mL vs 108.0 +/- 71.2 x 10(3)/mL, P < 0.05) and prolonged prothrombin time (2.88 +/- 2.33 s vs 1.27 +/- 1.37 s, P < 0.05). Patients with bleeding (vs non-bleeding group) had lower hematocrit levels (31.44 +/- 5.75% vs 36.57 +/- 5.19%, P < 0.01) and lower fibrinogen levels (226.7 +/- 92.7 mg/dL vs 286.4 +/- 111.8 mg/dL, P < 0.05). Patients with bleeding with shock had worse liver cirrhosis (Child A/B/C = 0/5/4 vs 11/18/4, P < 0.05), lower whole blood viscosity (4.01 +/- 0.17 mPa.s vs 4.57 +/- 0.76 mPa.s, P < 0.05), reduced erythrocyte aggregability (2.94 +/- 0.41 vs 3.54 +/- 0.61, P < 0.001), and lower platelet counts (56.22 +/- 17.05 x 10(3)/mL vs 88.87 +/- 38.12 x 10(3)/mL, P < 0.001). The Child-Pugh grade and erythrocyte aggregability were two independent factors associated with bleeding shock.

CONCLUSIONS

Whole blood viscosity, hematocrit levels and platelet counts were lower in patients with advanced liver cirrhosis. Advanced liver cirrhosis and reduced erythrocyte aggregability were independent factors for hypovolemic shock in cirrhotic patients with esophageal variceal bleeding. However, the causal relationship between hemorheology and bleeding needs to be clarified in further studies.

Portal hypertensive enteropathy

The available data on the use of VCE in patients who have cirrhosis and portal hypertension are inadequate to reach a firm conclusion about the usefulness of this diagnostic tool in this patient population. In fact, only retrospective case series exist, in which the characteristics of the patients are heterogeneous in terms of severity of liver disease and of portal hypertension, etiology of cirrhosis, and indication for VCE. In addition, the controls included in the studies are heterogeneous or poorly described. In spite of this, it appears that in patients with portal hypertension, the small bowel frequently shows mucosal abnormalities. Such abnormalities appear to be particularly frequent in patients who have severe portal hypertension and in those with low hemoglobin levels. The clinical significance of these findings remains undefined, however, especially in view of the fact that small bowel lesions also have been found in about 10% of patients with arthritis not taking nonsteroidal anti-inflammatory drugs and in 13.8% of healthy subjects [41,42]. Therefore,large prospective studies are needed to evaluate the prevalence and clinical significance of small bowel mucosal changes in patients who have cirrhosis. Such studies should compare patients who have cirrhosis with healthy subjects. A comparison between cirrhotic patients with a history of intestinal bleeding and bleeding patients without cirrhosis also would be interesting.

Similarities and differences in outcomes of cirrhosis due to nonalcoholic steatohepatitis and hepatitis C

The objective of this study was to prospectively define outcomes of cirrhosis due to nonalcoholic steatohepatitis (NASH) and compare them with those associated with hepatitis C virus (HCV) infection. We compared 152 patients with cirrhosis due to NASH with 150 matched patients with cirrhosis due to HCV. Over 10 years, 29/152 patients with cirrhosis due to NASH died compared with 44/150 patients with HCV (P < .04). This was mainly due to the lower mortality rate in patients with Child class A cirrhosis due to NASH versus HCV (3/74 vs. 15/75; P < .004). There were no significant across-group differences in mortality in patients with Child class B or C cirrhosis. Sepsis was the most common cause of death in both groups; patients with NASH had a higher cardiac mortality (8/152 vs. 1/150; P < .03). Patients with Child class A cirrhosis due to NASH also had a significantly lower risk of decompensation, defined by a 2-point increase in Child-Turcotte-Pugh score (P < .007). Cirrhosis due to NASH was associated with a lower rate of development of ascites (14/101 vs. 40/97 patients at risk; P < .006). NASH also had a significantly lower risk of development of hepatocellular carcinoma (10/149 vs. 25/147 patients at risk; P < .01). In conclusion, compensated cirrhosis due to NASH is associated with a lower mortality rate compared with that due to HCV. It is also associated with a lower rate of development of ascites, hyperbilirubinemia, and hepatocellular carcinoma. However, cardiovascular mortality is greater in patients with NASH.

Evolution of endoscopic therapy for esophageal varices

Endoscopic treatment for bleeding esophageal varices was first described 65 years ago, but the technique was not widely adopted until the 1970s. Rapid progress since then has resulted in new, more effective forms of endoscopic treatment. Currently, endoscopic therapy is the primary treatment for patients with bleeding esophageal varices at most centers. This review traces the evolution of endoscopic treatment, summarizes current outcomes data, and speculates on future development.

Improved prognosis for patients hospitalized with esophageal varices in Sweden 1969-2002

Liver cirrhosis may be complicated by the development of esophageal varices. The treatment of esophageal varices has changed radically during the last 30 years. Our aim was to study whether the prognosis for patients with esophageal varices had improved in Sweden between 1969 and 2002. We linked register data from the Hospital Discharge Register and from the Causes of Death Register at The National Board of Health in Sweden between 1969 and 2002 to identify and follow-up all patients with esophageal varices according to International Classification of Diseases-8, -9, and -10. There were 12,281 patients hospitalized with esophageal varices, and for all patients there was an increase in the 5-year survival in the years between 1969 and 1979 as opposed to the years between 1990 and 2002. Better survival occurred for women compared with men, for younger patients compared with older, and for patients hospitalized in the latest decade compared with the earlier decades. We found a significant decrease in the mortality caused by esophageal varices during the years studied but no decrease attributable to other causes. In conclusion, mortality for patients hospitalized with esophageal varices in Sweden decreased between 1969 and 2002. The decrease is seen for both 1- and 5-year mortality, and this suggests that the use of new treatment strategies both for acute variceal hemorrhage and secondary prophylaxis has had an impact on prognosis.

Endoscopic Approaches to Upper Gastrointestinal Bleeding

Treatment for most patients with upper gastrointestinal bleeding has shifted from the operating room to the endoscopy suite. Endoscopic treatment has resulted in substantial benefit for patients with bleeding from peptic ulcer. Ulcers associated with high-risk stigmata of recent hemorrhage (SRH) not treated endoscopically have 40 per cent to 100 per cent risk of continued or recurrent bleeding and up to a 35 per cent chance of requiring surgical control of bleeding. Endoscopic therapy has reduced the risk of recurrent bleeding to 10 per cent to 20 per cent and the need for surgery to 5 per cent to 10 per cent. These improvements translate to shorter hospital stays, fewer transfusions, lower costs, and less morbidity. Similar progress has been made for patients bleeding from esophageal varices. Mortality for a first variceal bleed is now approximately 20 per cent as compared with 40 per cent to 60 per cent in past decades. Rebleeding after initially successful endoscopic hemostasis is often best treated by a second attempt at endoscopic control. The decision regarding management of recurrent bleeding should be made at the time initial endoscopic control is achieved. Local factors such as experience of the endoscopic team, availability of interventional radiologists, and individual patient characteristics should guide these decisions. Failures of endoscopic control and patients with massive hemorrhage still require operative intervention.

Bleeding caused by portal hypertension

Variceal bleeding is one of the dreaded complications of portal hypertension. Patients who have suspected or proven cirrhosis should undergo diagnostic upper endoscopy to detect medium and large gastro-esophageal varices. Patients with medium and large gastro-esophageal varices should be treated with non-selective beta-blockers (propranolol or nadolol), and these agents should be titrated to a heart rate of 55 beats per minute or adverse effects. If there are contraindications to or if patients are intolerant to beta-blockers, it is appropriate to consider prophylactic banding therapy for individuals with medium-to-large esophageal varices. When patients who have cirrhosis present with GI bleeding, they should be resuscitated and receive octreotide or other vasoactive agents. Endoscopy should be performed promptly to diagnose the source of bleeding and to provide endoscopic therapy (preferably banding). The currently available treatment for acute variceal bleeding provides hemostasis in most patients. These patients, however, are at significant risk for rebleeding unless secondary prophylaxis is provided. Although various pharmacological, endoscopic, radiological, and surgical options are available, combined pharmacological and endoscopic therapy is the most common form of secondary prophylaxis. TIPS is a radiologically placed portasystemic shunt, and if placed in suitable patients, it can provide effective treatment for patients with variceal bleeding that is refractory to medical and endoscopic therapy.

Characteristics, prognosis and outcome of patients with oesophageal varices in a university hospital in Sweden 1994-1999

OBJECTIVE

Patients with liver cirrhosis, portal hypertension and oesophageal varices are known to have high morbidity and mortality. The knowledge of incidence, aetiology and outcome in Sweden in recent years is limited.

MATERIAL AND METHODS

All patients with oesophageal varices diagnosed for the first time at Sahlgrenska University Hospital during the 6-year period 1994-1999 were retrospectively studied. Information about the aetiology of liver cirrhosis and oesophageal varices, as well as about the proportion of bleeding and non-bleeding varices, endoscopic and pharmacological treatment and outcome, was analyszed.

RESULTS

312 patients were retrieved, 297 with liver cirrhosis (197 diagnosed before first bleeding (P), 92 after bleeding (B) and 8 at autopsy) and 15 with portal vein thrombosis without cirrhosis. Fifty-four percent had alcoholic liver disease. Fifty-five percent in group B and 13% in group P had at least one bleeding episode during follow-up (p<0.001). There was no significant difference in survival between groups B and P. Twenty-six percent of the cirrhotics died of liver failure and 19% from variceal bleeding. In a multivariate analysis, variables predicting mortality were: Child-Pugh class, group B, age and bilirubin levels.

CONCLUSIONS

Variceal bleeding is still a strong risk factor for recurrent bleeding, but few die from their first bleeding. This concurs with studies indicating declining mortality from variceal bleeding. However, this patient group still has a high mortality from other causes.

Determining the extent of quality health care for hospitalized patients with cirrhosis

BACKGROUND/AIMS

Since few data are available concerning the clinical course of decompensated hepatitis C virus (HCV)-related cirrhosis, the aim of the present study was to define the natural long-term course after the first hepatic decompensation.

METHODS

Cohort of 200 consecutive patients with HCV-related cirrhosis, and without known hepatocellular carcinoma (HCC), hospitalized for the first hepatic decompensation.

RESULTS

Ascites was the most frequent first decompensation (48%), followed by portal hypertensive gastrointestinal bleeding (PHGB) (32.5%), severe bacterial infection (BI) (14.5%) and hepatic encephalopathy (HE) (5%). During follow-up (34+/-2 months) there were 519 readmissions, HCC developed in 33 (16.5%) patients, and death occurred in 85 patients (42.5%). The probability of survival after diagnosis of decompensated cirrhosis was 81.8 and 50.8% at 1 and 5 years, respectively. HE and/or ascites as the first hepatic decompensation, baseline Child-Pugh score, age, and presence of more than one decompensation during follow-up were independently correlated with survival.

CONCLUSIONS

Once decompensated HCV-related cirrhosis was established, patients showed not only a very high frequency of readmissions, but also developed decompensations different from the initial one. These results contribute to defining the natural course and prognosis of decompensated HCV-related cirrhosis.

MELD score and hepatocellular carcinoma identify patients at different risk of short-term mortality among cirrhotics bleeding from esophageal varices

BACKGROUND/AIMS

The role of model for end stage liver disease (MELD) and the presence of hepatocellular carcinoma (HCC) as risk factors of short-term mortality in patients bleeding from oesophageal varices were evaluated.

METHODS

From February 2002 to August 2003, 172 cirrhotic patients admitted for the first episode of bleeding from oesophageal varices received vasoactive and endoscopic therapy. Patients' survival was evaluated at 6 weeks and 3 months. The role of MELD and HCC as independent risk factors of mortality was evaluated.

RESULTS

In the 172 patients, the overall mortality was 21.5% at 6 weeks and 30.2% at 3 months. MELD score resulted a good predictor of mortality either at 6 weeks or 3 months. Fifty-four patients (31.3%) had HCC. The presence of advanced HCC was an independent risk factor of mortality at 3 months. Patients with MELD score>15 and advanced HCC had a significantly worse survival than patients with MELD<or=15 and without HCC or with early HCC either at 6 weeks or 3 months

CONCLUSIONS

MELD score and the presence of HCC allow to identify patients at different risk of short-term mortality among cirrhotic patients at first episode of bleeding from oesophageal varices.

Beta blocker prophylaxis for patients with variceal hemorrhage

GOALS

To characterize beta blocker therapy for the primary and secondary prevention of variceal hemorrhage.

BACKGROUND

Variceal hemorrhage is one of the more frequent and severe complications of portal hypertension due to liver disease. Beta blocker therapy has been demonstrated to decrease risk of first bleed in patients with evidence of varices and recurrent bleeding and mortality in patients with history of prior variceal hemorrhage.

STUDY

A total of 106 patients with liver disease hospitalized with suspected variceal hemorrhage were retrospectively reviewed.

RESULTS

Half of patients had known varices, 44 (41.5%) of whom had experienced prior variceal hemorrhage. Only 21 (20%) were receiving beta blocker therapy at admission and 41 (48%) at discharge. The majority were not receiving therapy for primary prophylaxis (94%). Specific characteristics associated with beta blocker use could not be identified, although more patients with history of greater than two variceal hemorrhages were receiving beta blocker at admission (73% vs. 41%, P = 0.04)

CONCLUSIONS

This study suggests that liver disease patients with varices are often not receiving beta blocker therapy to reduce risk of first or subsequent variceal hemorrhage. Opportunity exists to optimize use of this proven prophylactic treatment and bridge an apparent gap in standard of care.

Acute upper gastrointestinal bleeding in patients with liver cirrhosis and in noncirrhotic patients: epidemiology and predictive factors of mortality in a prospective multicenter population-based study

GOALS

To assess epidemiologic features and predictive factors of mortality of acute upper gastrointestinal bleeding (UGIB).

STUDY

During a 6-month period, a prospective population-based study including all the UGIB occurring in a geographic area of 3 million people was conducted. Data from cirrhotic patients were compared with those of noncirrhotic patients.

RESULTS

A total of 2,133 UGIB were recorded, 21.9% in cirrhotic patients (n = 468). Endoscopic hemostasis was performed in 46.5% and 8.3% in cirrhotic and noncirrhotic patients, respectively (P < 0.001). Mortality during hospitalization was 23.5% in cirrhotic patients and 11.2% in noncirrhotic patients (P < 0.001). Six independent predictive factors of mortality were observed in both patient groups: a prothrombin level less than 40%, an UGIB occurring in inpatients, a concomitant digestive carcinoma, a hematemesis revealing the UGIB, a recent use of steroid drugs, and age over 60 years. Four other predictive factors of mortality were also identified in noncirrhotic patients.

CONCLUSIONS

Although epidemiologic features, clinical course, management, and prognosis of UGIB were quite different in cirrhotic and noncirrhotic patients, the majority of predictive factors of mortality were the same in both patient groups. These data underline the major role of debilitated status and hepatic failure in the prognosis of UGIB in cirrhotic patients.

Primary prophylaxis against variceal bleeding: beta-blockers, endoscopic ligation, or both?

Variceal bleeding is one of the complications of cirrhosis that leads to significant morbidity and mortality. It is recommended that all patients with cirrhosis be screened for gastroesophageal varices and those with large varices should be offered primary prophylaxis. Nonselective beta-blockers (nadolol or propranolol) are the treatment of choice for primary prophylaxis but there are a number of limitations to their use. A number of studies have evaluated the efficacy of variceal band ligation (VBL) in providing primary prophylaxis, either in comparison to no treatment or to beta-blockers. VBL is very effective in preventing the initial bleed when compared to no treatment, but it is not superior to beta-blockers. In this issue of the journal the effect of beta-blockers on bleeding in patients undergoing VBL is examined and no benefit compared to VBL alone is shown. Thus, patients with large varices should be treated with beta-blockers and VBL should be offered to those cirrhotics who are unable to take beta-blockers. Further study is required to determine if VBL in combination with beta-blockers is more effective than the beta-blockers alone.

Anesthesia for liver transplant surgery

Liver transplantation offers patients with liver disease an optimal chance for long-term survival. Current indications, preoperative assessment, patient selection, intraoperative anesthetic management and outcomes are described. The management of special situations, including retransplantation, pediatric transplantation, and fulminant hepatic failure are also reviewed. The success of liver transplantation has led to increased demand. This demand, coupled with a nonexpanding supply of deceased donor organs, has resulted in a shortage of grafts and prolonged waiting times. Novel solutions using segmental liver grafts from living donors, and the challenges associated with this approach, are discussed.

Diagnosis and treatment of portal hypertension

Prevention of the first variceal haemorrhage should start when the patients have developed medium-sized to large varices. Non-selective beta-blockers and band ligation are equally effective in preventing the first bleeding episode. Rubber band ligation is the first choice for patients with contraindications or intolerance to beta-blockers. Treatment of acute bleeding should aim at controlling bleeding and preventing early rebleeding and complications, especially infections. Combined endoscopic (band ligation or sclerotherapy) and pharmacological treatment with vasoactive drugs can control bleeding in up to 90% of patients. Antibiotic prophylaxis is an integral part of the treatment of acute variceal haemorrhage, and must be started as soon as possible. Emergency transjugular intrahepatic portosystemic stent shunt (TIPS) is the standard rescue therapy for patients failing combined endoscopic and pharmacological treatment. All patients who survive a variceal bleed should be treated with beta-blockers or band ligation to prevent rebleeding. All patients in whom bleeding cannot be controlled or who continue to rebleed can be treated with salvage TIPS or, in selected cases, with surgical shunts. Liver transplantation should be considered for patients with severe liver insufficiency in which first-line treatments fail.

The characteristics and the prognosis for patients presenting with actively bleeding esophageal varices at endoscopy

BACKGROUND

It remains unresolved whether the prognosis is worse for patients who present with actively bleeding varices at endoscopy compared with those in whom variceal bleeding has stopped.

METHODS

Patients with acute esophageal variceal bleeding were enrolled in this study and were divided into two groups: an active bleeding group and an inactive bleeding group. All patients had band ligation shortly after endoscopic examination and underwent elective ligation procedures until the varices were obliterated. Patients were followed for 1 year or until death. Short- and long-term prognoses were compared.

RESULTS

The active bleeding group included 54 patients and the inactive bleeding included 251 patients. Initial hemostasis was achieved in 93% in the active group and 99% in the inactive group ( p = not significant). The rate of recurrent variceal bleeding within 30 days was 24% in the active bleeding group vs. 12% in the inactive bleeding group ( p = 0.01); the mortality rates were 18% and 8%, respectively ( p = 0.03 in a single statistical test; however, Bonferroni correction for the multiple testing of data removed this significance). The rate of recurrent variceal bleeding within 1 year was 37% in the active bleeding group and 27% in the inactive bleeding group ( p = 0.06); the mortality rates were 22% and 21%, respectively ( p = not significant).

CONCLUSIONS

Whether variceal bleeding is active or inactive at endoscopy, variceal ligation is equally effective for control of bleeding. The rates of recurrent bleeding and mortality at 1 month were significantly higher among patients with active bleeding. However, the mortality rate was similar for both groups at 1 year.

Recombinant factor VIIa for upper gastrointestinal bleeding in patients with cirrhosis: a randomized, double-blind trial

BACKGROUND & AIMS

Upper gastrointestinal bleeding (UGIB) is a severe and frequent complication of cirrhosis. Recombinant coagulation factor VIIa (rFVIIa) has been shown to correct the prolonged prothrombin time in patients with cirrhosis and UGIB. This trial aimed to determine efficacy and safety of rFVIIa in cirrhotic patients with variceal and nonvariceal UGIB.

METHODS

A total of 245 cirrhotic patients (Child-Pugh < 13; Child-Pugh A = 20%, B = 52%, C = 28%) with UGIB (variceal = 66%, nonvariceal = 29%, bleeding source unknown = 5%) were randomized equally to receive 8 doses of 100 microg/kg rFVIIa or placebo in addition to pharmacologic and endoscopic treatment. The primary end point was a composite including: (1) failure to control UGIB within 24 hours after first dose, or (2) failure to prevent rebleeding between 24 hours and day 5, or (3) death within 5 days.

RESULTS

Baseline characteristics were similar between rFVIIa and placebo groups. rFVIIa showed no advantage over standard treatment in the whole trial population. Exploratory analyses, however, showed that rFVIIa significantly decreased the number of failures on the composite end point (P = 0.03) and the 24-hour bleeding control end point (P = 0.01) in the subgroup of Child-Pugh B and C variceal bleeders. There were no significant differences between rFVIIa and placebo groups in mortality (5- or 42-day) or incidence of adverse events including thromboembolic events.

CONCLUSIONS

Although no overall effect of rFVIIa was observed, exploratory analyses in Child-Pugh B and C cirrhotic patients indicated that administration of rFVIIa significantly decreased the proportion of patients who failed to control variceal bleeding. Dosing with rFVIIa appeared safe. Further studies are needed to verify these findings.

Review article: definition and diagnosis in portal hypertension--continued problems with the Baveno consensus?

The goals of the Baveno workshops were to develop consensus definitions of key events related to portal hypertension and variceal bleeding, and to produce guidelines to facilitate the conduct and reporting of clinical trials. The consensus definitions concern the diagnosis of active bleeding, failure to control bleeding, the criteria to distinguish continuing bleeding from rebleeding, and the means of assessing failure to prevent rebleeding. The guidelines concern the timing of diagnostic endoscopy, the policy for blood volume restitution, the measures to prevent infection and encephalopathy, and the treatment options for acute bleeding, as well as primary and secondary prophylaxis. The intention of the experts who developed the guidelines was that, as feedback from their practical application develops, they should be adapted to better fit the practical needs. The applicability of the Baveno definitions has been evaluated in a study where the definitions of clinically significant bleeding, failure to control bleeding, the time frame for the acute bleeding episode and the definition of rebleeding were tested. The main criticism raised in this study was that tachycardia, one of the criteria that define failure to control bleeding, was misleading in 15% of patients who had the symptom but were not bleeding.

Improved survival after variceal bleeding in patients with cirrhosis over the past two decades

Over the past two decades, new treatment modalities have been introduced for the management of variceal bleeding. The aim of this retrospective study in a single center was to assess whether these treatments have improved the prognosis for cirrhotic patients with variceal bleeding. We reviewed the clinical records of all patients with cirrhosis admitted to our Liver Intensive Care Unit due to variceal bleeding during the years 1980, 1985, 1990, 1995, and 2000. Whereas balloon tamponade was still the first-line treatment in 1980, patients treated in 2000 received a vasoactive agent, an endoscopic treatment, and an antibiotic prophylaxis in, respectively, 90%, 100%, and 94% of cases. The in-hospital mortality rate steadily decreased over the study period: 42.6%, 29.9%, 25%, 16.2%, and 14.5% in 1980, 1985, 1990, 1995, and 2000, respectively (P < .05). Mortality decreased from 9% in 1980 to 0% in 2000 in Child-Turcotte-Pugh class A patients, from 46% to 0% in class B patients, and from 70% to 32% in class C patients. This improved survival was associated with a decrease of rebleeding (from 47% in 1980 to 13% in 2000) and bacterial infection rates (from 38% to 14%). On multivariable analysis, endoscopic therapy and antibiotic prophylaxis were independent predictors of survival. In conclusion, in-hospital mortality of patients with cirrhosis and variceal bleeding decreased threefold over the past two decades, in concurrence with an early and combined use of pharmacological and endoscopic therapies and short-term antibiotic prophylaxis.

A cost-utility analysis of secondary prophylaxis for variceal hemorrhage

BACKGROUND

Secondary prophylaxis for esophageal variceal hemorrhage (VH) is recommended, but there has never been a cost-utility analysis of its implementation.

OBJECTIVE

The objective was to compare the cost utility of various strategies for the secondary prophylaxis of VH including (a) observation alone, (b) medical therapy (MED), (c) endoscopic band ligation (EBL), (d) endoscopic band ligation plus medical therapy (EBL + M), and (e) transjugular intrahepatic portosystemic shunt (TIPS), and to examine the effect of adherence on these strategies.

METHODS

A Markov model was developed for all five strategies, and included surveillance, risk of hepatic encephalopathy, complications, and nonadherence.

DATA SOURCES

Published literature and the Health Care Financing Administration.

TARGET POPULATION

People with cirrhosis and a history of controlled VH.

TIME HORIZON

Three years.

PERSPECTIVE

Third-party payer.

OUTCOME MEASURES

Incremental cost-effectiveness ratios for quality-adjusted life-years (QALYs) gained.

RESULTS OF BASE-CASE ANALYSIS

Combination EBL + M was the optimal strategy, dominating all other strategies including observation, meaning that it was more effective and less expensive than the others. In addition, EBL alone dominated observation and TIPS in terms of QALYs, and MED alone dominated the strategy of observation in terms of QALYs.

RESULTS OF SENSITIVITY ANALYSIS

Important variables affecting the optimal strategy were the odds ratio (OR) of VH with EBL compared to MED, the OR of VH with EBL + M compared to EBL, and patients' preferences regarding taking the medication as reflected in the associated toll exacted on the health state utility. Variations in these parameters within the range of clinical plausibility allowed EBL or MED to become the optimal strategy. TIPS was the optimal strategy only if adherence rates for all strategies were less than 12%. RESULTS OF MONTE CARLO ANALYSIS: Neither observation nor TIPS was ever the optimal strategy, and EBL + M was optimal in 62% of cases. If the variables identified in the sensitivity analysis were controlled, then EBL + M was optimal in 95% of cases.

CONCLUSIONS

TIPS should be reserved only for patients with very poor adherence. Otherwise, patients are best served by medications, EBL, or a combination of both, depending on the comparative rates of rebleeding with each and patients' preferences regarding medical therapy. The redundancy of combination band ligation plus medical therapy can improve outcomes, particularly in the setting of poor patient adherence.

Esophageal bleeding disorders

PURPOSE OF REVIEW

Esophageal varices and Mallory Weiss syndrome are the two major esophageal bleeding disorders. Although there have been major breakthroughs in the treatment of peptic ulcer bleeding, the management of esophageal bleeding disorders remains a challenging problem. This review focuses on studies published in the previous 12 months that provide further understanding of the appropriate treatment of various esophageal bleeding disorders. Other uncommon causes of esophageal bleeding are also discussed.

RECENT FINDINGS

With the advances in endoscopic and pharmacologic treatments, mortality resulting from variceal hemorrhage has been substantially reduced. Band ligation is the first-line endoscopic treatment of esophageal variceal hemorrhage. Vasoactive agents such as somatostatin analog and terlipressin are both safe and effective pharmacologic treatments of esophageal variceal hemorrhage. Use of a nonselective beta-blocker is still the most widely accepted treatment for both primary and secondary prophylaxis. However, the effectiveness of beta-blockers is limited by intolerance and nonresponders in a significant proportion of patients. Thus, endoscopic band ligation is used increasingly as an alternative strategy for primary prophylaxis. A transjugular intrahepatic portosystemic shunt should be reserved as rescue therapy for failure of medical and endoscopic treatments. In recent years, noninvasive surrogate markers have been reported to identify high-risk patients with large esophageal varices. Platelet count, spleen diameter, and their ratio are accurate predictors of esophageal varices in patients with cirrhosis. The endosonographic measurement of the cross-sectional surface area predicts the risk of variceal hemorrhage. For Mallory Weiss syndrome, endoscopic clipping is an emerging treatment modality, especially for deep laceration with risk of perforation.

SUMMARY

A combination of various clinical, laboratory, and endosonographic parameters accurately predicts the risk of variceal hemorrhage. A streamlined screening strategy allows more cost-effective use of endoscopy and prompt prophylactic treatment for high-risk esophageal varices.