The treatment of portal hypertension: a meta-analytic review

A Noninferiority Trial Comparing 2 Days vs 5 Days of Terlipressin and Ceftriaxone in Terms of 5-Day Rebleeding for Patients With Acute Gastroesophageal Variceal Hemorrhage

INTRODUCTION

This trial was to shorten the duration of both vasoconstrictors and prophylactic antibiotics to only 2 days in the therapy of acute gastroesophageal variceal hemorrhage.

METHODS

After successful endoscopic hemostasis of gastroesophageal variceal hemorrhage, eligible patients were randomized to receive terlipressin infusion 1 mg per 6 hours and ceftriaxone 1 g daily for 5 days (group A) or a similar regimen for 2 days (group B). Primary end points were very early rebleeding at 5 days, and secondary end points included 48-hour hemostasis, 42-day rebleeding, and hospitalization days.

RESULTS

Group A comprised 48 patients, and group B comprised 52 patients. Both groups were comparable in the severity of liver disease. Forty-eight-hour initial hemostasis was 95.8% in group A and 100% in group B ( P = 0.13). Very early rebleeding between 3 and 5 days occurred in 1 patient (2.1%) in group A and 2 patients (3.8%) in group B ( P = 0.60). The difference was 1.8% and the 95% confidence interval was -1.31% to 2.08%, which demonstrated noninferiority. Forty-two-day rebleeding occurred in 5 patients (10.4%) in group A and 4 patients (7.7%) in group B ( P = 0.63). The median hospitalization days were 8.5 ± 3.8 days in group A vs 5.6 ± 2.6 days in group B ( P < 0.001).

DISCUSSION

After successful endoscopic hemostasis of acute variceal bleeding, combination of 2-day terlipressin infusion and ceftriaxone therapy was not inferior to the 5-day regimen in terms of very early rebleeding, with the advantage of shortening hospitalization stay.

Correlation of non-invasive parameters with upper gastrointestinal endoscopy findings for presence and grading of gastroesophageal varices in liver cirrhosis patients

Background

Development of esophageal varices is one of the major complications of liver cirrhosis, and endoscopy is used to see the presence, grading, and long-term monitoring of esophageal varices which is an invasive and unpleasant procedure. There is no adequate data available showing noninvasive methods can be used for the same.

Methods

Seventy patients with liver cirrhosis participated in the study. Factors like portal vein diameter, spleen size, platelet count, serum bilirubin, Child-Pugh score, prothrombin time (PT), and PT INR were observed and correlated endoscopically with the presence and grading of esophageal varices in all patients.

Results

The platelet count, portal vein diameter, serum bilirubin, spleen bipolar diameter, and PT had statistically significant correlations with the presence of varices. Among them, platelet count, portal vein diameter, and serum bilirubin also had statistically significant correlations with the grading of varices. Monitoring of these noninvasive parameters can help in monitoring variceal growth.

Conclusions

Noninvasive parameters can be used effectively to predict the presence and grading of esophageal varices and at the same time keep the rate of undiagnosed varices acceptably low. By using noninvasive parameters, patients can be benefited by decreasing the requirement of repeated endoscopic evaluation which is an unpleasant procedure and availability is also limited.

Gastro‑oesophageal reflux disease in liver cirrhosis: Possible pathogenesis and clinical intervention (Review)

Oesophageal variceal bleeding is a common complication of decompensated liver cirrhosis (LC). Some studies have reported that reflux oesophagitis (RE) is a risk factor for upper gastrointestinal bleeding, and greatly impacts the quality of life. However, the frequency and mechanism of gastro-oesophageal reflux disease (GERD) in LC remain unclear. The present review explored the possible pathogenesis, and analysed the advantages and disadvantages of the interventional measures and the need for implementation of these measures. By combining the comprehensive terms associated with LC, GERD and RE, EMBASE, Medline/PubMed and the Cochrane Library were systematically searched. The underlying pathological mechanism of GERD in LC was summarized: Transient relaxation of the lower oesophageal sphincter, delayed gastric emptying, increased intra-abdominal pressure, increased intragastric pressure and excessive nitric oxide production destroyed the 'anti-reflux barrier', causing gastric content reflux. Proton pump inhibitors (PPIs) have been widely used empirically to lower the risk of oesophageal venous rupture and bleeding. However, long-term use of acid inhibitors in patients with LC may induce complications, such as spontaneous bacterial peritonitis. The metabolic half-life of PPIs is prolonged in patients with severe liver function impairment. Therefore, the indications for using acid inhibitors lack clarity. However, after endoscopic oesophageal variceal eradication, additional benefits may be gained from the long-term use of PPIs in small doses.

Management of Acute Upper Gastrointestinal Bleeding in Critical Care Transport

Upper gastrointestinal bleeding is a relatively common and life-threatening condition encountered by critical care transport crews. It is of paramount importance that transport crews understand the underlying pathophysiology of variceal and nonvariceal gastrointestinal bleeding as well as the nuanced management of this patient population. This article reviews the current clinical evidence on initial resuscitation, medical management, and advanced invasive therapies (such as balloon tamponade devices) that transport crews should be familiar with to manage these patients. In addition, we present a novel method of continuous balloon pressure monitoring of balloon tamponade devices that is applicable to the transport environment.

Liver Cirrhosis and Portal Hypertension

The understanding of pathogenesis of portal hypertension in patients with liver cirrhosis continues to evolve. In addition to progressive fibrosis, cirrhosis is characterized by parenchymal extinction and vascular remodelling, causing architectural distortion. Existence of prothrombotic state and more recently, intestinal bacterial dysbiosis are recently described in the pathogenesis of portal hypertension. Clinically significant portal hypertension (CSPH) is an important prognostic milestone in patients with liver cirrhosis. This is a pre-symptomatic phase that predicts the development of varices, ascites and importantly increased risk of Hepatocellular carcinoma (HCC). CSPH is associated with significantly reduced survival. Endoscopic surveillance is necessary in these patients. Non-selective Beta-blocker is the preferred therapy for primary prophylaxis in the management of portal hypertension. Patients with acute variceal bleed should be resuscitated appropriately, followed by vasoactive drugs and endoscopic therapy. Early TIPS should be considered in those with refractory bleed or in endoscopic treatment failure. Application of artificial intelligence and machine learning may be useful in future for identifying patients at risk of variceal hemorrhage.

Risk of variceal hemorrhage and pretransplant mortality in children with biliary atresia

BACKGROUND AND AIMS

The natural history of gastroesophageal variceal hemorrhage (VH) in biliary atresia (BA) is not well characterized. We analyzed risk factors, incidence, and outcomes of VH in a longitudinal multicenter study.

APPROACH AND RESULTS

Participants enrolled in either an incident (Prospective Database of Infants with Cholestasis [PROBE]) or prevalent (Biliary Atresia Study of Infants and Children [BASIC]) cohort of BA were included. Variceal hemorrhage (VH) was defined based on gastrointestinal bleeding in the presence of varices accompanied by endoscopic or nontransplant surgical intervention. Cumulative incidence of VH and transplant-free survival was compared based on features of portal hypertension (e.g., splenomegaly, thrombocytopenia) and clinical parameters at baseline in each cohort (PROBE: 1.5 to 4.5 months after hepatoportoenterostomy [HPE]; BASIC: at enrollment > 3 years of age). Analyses were conducted on 869 children with BA enrolled between June 2004 and December 2020 (521 in PROBE [262 (51%) with a functioning HPE] and 348 in BASIC). The overall incidence of first observed VH at 5 years was 9.4% (95% CI: 7.0-12.4) in PROBE and 8.0% (5.2-11.5) in BASIC. Features of portal hypertension, platelet count, total bilirubin, aspartate aminotransferase (AST), albumin, and AST-to-platelet ratio index at baseline were associated with an increased risk of subsequent VH in both cohorts. Transplant-free survival at 5 years was 45.1% (40.5-49.6) in PROBE and 79.2% (74.1-83.4) in BASIC. Two (2.5%) of 80 participants who had VH died, whereas 10 (12.5%) underwent transplant within 6 weeks of VH.

CONCLUSIONS

The low risk of VH and associated mortality in children with BA needs to be considered in decisions related to screening for varices and primary prophylaxis of VH.

Single Puncture TIPS—A 3D Fusion Image-Guided Transjugular Intrahepatic Portosystemic Shunt (TIPS): An Experimental Study

Background: The use of a transjugular intrahepatic portosystemic shunt (TIPS) has been established as an effective treatment for portal hypertension. Despite the rapid development of this use, serious peri-procedural complications have been reported in over 10% of cases. This has largely been attributed to the access to the portal vein, also referred to as a “blind puncture”, which often requires multiple attempts. The aim of this study was to demonstrate the safety, reproducibility and accuracy of the use of real-time 3D fusion image-guided (3DFIG) single puncture TIPS to minimize the complications that are related to the “blind puncture” of TIPS procedures. Methods: A 3DFIG TIPS approach was utilized on 22 pigs by combining pre-procedural cross-sectional imaging (CT, MR or CBCT) with intra-procedural cone beam CT or angiogram imaging, which allowed for the improved 3D visual spatial orientation of the portal vein and real-time tracking of the needle in 3D. Results: Thirty-five portosystemic shunts were successfully deployed in all 22 subjects without any peri-procedural complications. Overall, 91% (32/35) of the procedures were carried out using a single puncture. In addition, the mean fluoroscopy time in our study was more than 12 times lower than the proposed reference level that has previously been proposed for TIPS procedures. Conclusion: Multi-modality real-time 3DFIG TIPS can be performed safely using a single puncture, without complications, and can potentially be used in both emergency and non-emergency clinical situations.

Variceal Bleeding: Beyond Banding

Despite advances in the management of complications of portal hypertension, variceal bleeding continues to be associated with significant morbidity and mortality. While endoscopic variceal band ligation remains first line therapy for treating bleeding and high-risk non-bleeding esophageal varices, alternate therapies have been explored, particularly in cases of refractory bleeding. The therapies being explored include stent placement, hemostatic powder use, over-the-scope clips and others. For gastric variceal bleeding, endoscopic ultrasound-guided therapies have recently emerged as promising interventions for hemostasis. The aim of this article is to highlight these alternative therapies and their potential role in the management of gastric and esophageal variceal bleeding.

Multi-Spectroscopic, thermodynamic and molecular docking studies to investigate the interaction of eplerenone with human serum albumin

The binding of small molecular drugs with human serum albumin (HSA) has a crucial influence on their pharmacokinetics. The binding interaction between the antihypertensive Eplerenone (EPL)and HSA was investigated using multi-spectroscopic techniques for the first time. These techniques include UV-Vis spectroscopy, Fourier Transform Infrared (FT-IR), native fluorescence spectroscopy, synchronous fluorescence spectroscopy and molecular docking approach. The fluorescence spectroscopic study showed that EPL quenched HSA inherent fluorescence. The mechanism for quenching of HSA by EPL has been determined to be static in nature and confirmed by UV absorption and fluorescence spectroscopy. The modified Stern-Volmer equation was used to estimate the binding constant (K_b ) as well as the number of bindings (n). The results indicated that the binding occurs at a single site (Kb;2.238 x 10³ L mol^-1 at 298 K). The enthalpy and entropy changes (∆H and ∆S) were 58.061 and 0.258 K J mol^-1 , respectively, illustrating that the principal intermolecular interactions stabilizing the EPL-HSA system are hydrophobic forces. Synchronous fluorescence spectroscopy revealed that EPL binding to HSA occurred around the tyrosine residue (Tyr) and this agreed with the molecular docking study. The FRET analysis confirmed the static quenching mechanism. The esterase enzyme activity of HSA was also evaluated showing its decrease in the presence of EPL. Furthermore, docking analysis and site-specific markers experiment revealed that EPL binds with HSA at subdomain IB (site III).

Balloon Tamponade for the Management of Gastrointestinal Bleeding

BACKGROUND

Acute gastrointestinal bleeding is a potentially life-threatening condition that requires rapid intervention. In critically ill patients who are refractory to other therapies, balloon tamponade devices can be lifesaving.

OBJECTIVE

We provide a review of balloon tamponade devices for gastric and esophageal variceal bleeding for emergency clinicians.

DISCUSSION

Balloon tamponade is intended for hemodynamically unstable patients with massive gastrointestinal bleeding and inability to perform endoscopy, failed endoscopy, delay in endoscopy, or the need to stabilize before transfer. There are 3 main tamponade devices: the Linton-Nachlas tube, the Sengstaken-Blakemore tube, and the Minnesota tube. Each tamponade device has some unique features including the number of balloons and ports. We describe the technique with pearls and pitfalls for placement.

CONCLUSIONS

It is essential for emergency physicians to be familiar with balloon tamponade for acute gastrointestinal bleeding. We review the common balloon tamponade devices, and this article is intended to serve as a resource for those interested in expanding their knowledge of balloon tamponade. © 2022 Elsevier Inc.

Long-term outcomes of hemostatic therapy for variceal bleeding and the challenge pending in the post-direct-acting antivirals era

Background and study aims

This study evaluated the longterm outcomes of mainly endoscopic hemostatic therapy for gastrointestinal variceal bleeding and of the transition of hemostatic therapy.

Patients and methods

Among 1,163 patients treated for gastrointestinal varices between April 2006 and June 2020, a total of 125 patients who underwent emergency hemostatic therapy were enrolled. Survival rates and secondary evaluation points were analyzed. Additionally, patients were classified into two groups: the previous and latter term. Patients' background, therapeutic method, and treatment results were compared between the groups.

Results

94.4% had cirrhosis. The average Child-Pugh score was 8.90. Successful primary hemostasis rate was 98.4%, and 5.6% died within 2 weeks, all with a Child-Pugh score ≥9. The respective 1- and 5-year survival rates for Child-Pugh grade A/B were 81.3% and 55.4%, while those for Child-Pugh grade C were 58.1% and 17.8%. Child-Pugh grade C or hepatocellular carcinoma was significantly associated with poor prognosis. In total, 21.6% experienced variceal re-bleeding; 62.9% of these cases were triggered by continued alcohol consumption. There was no significant difference in survival between patients with and without variceal re-bleeding and in post-treatment survival between the previous and latter terms. In the latter term, the number of cases caused by continued alcohol consumption significantly increased.

Conclusions

Multidisciplinary treatment and continuation of proper management after hemostatic therapy for variceal bleeding are crucial. Continued alcohol consumption leads to variceal bleeding and re-bleeding; its proper management, including alcohol abstinence, is one of the major challenges left in the post-directacting antivirals era.

Management of Refractory Variceal Bleed in Cirrhosis

Acute variceal bleeding is the major cause of mortality in patients with cirrhosis. The standard medical and endoscopic treatment has reduced the mortality of variceal bleeding from 50% to 10-20%. The refractory variceal bleed is either because of failure to control the bleed or failure of secondary prophylaxis. The patients refractory to standard medical therapy need further interventions. The rescue therapies include balloon tamponade, self-expanding metal stents (SEMS) placement, shunt procedures, including transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), and endoscopic ultrasound (EUS) guided coiling. In cases where endoscopic variceal ligation (EVL) has failed and the variceal bleeding continues, temporary measures like balloon tamponade can be used to achieve hemostasis and as a bridge to definitive measures. SEMS being in use for refractory bleed is preferred over balloon tamponade due to the reduced complication rate. The shunting procedures are highly effective in reducing portal pressure and represent the gold standard for uncontrolled variceal bleeding. The surgical shunts, as well as nonshunt surgeries such as devascularization have become less popular with the increasing use of minimally invasive techniques like TIPS. TIPS have high success rates in controlling refractory variceal bleeding. The mortality rate is greater in high-risk patients undergoing salvage TIPS, and hence, pre-emptive TIPS should be considered in these patients. BRTO is an interventional radiologic procedure used in the management of bleeding gastric and ectopic varices. The availability of gastrorenal or splenorenal shunts is required for the BRTO procedure, which helps to reach and obliterate the cardiofundal varices through the femoral or jugular vein approach. The EUS guided coiling and glue injection have shown promising results, and further randomized controlled trials are required to establish their efficacy for refractory variceal bleeding.

Primary prophylaxis of variceal bleeding in patients with cirrhosis: A comparison of different strategies

Patients with cirrhosis and esophageal varices bleed at a yearly rate of 5%-15%, and, when variceal hemorrhage develops, mortality reaches 20%. Patients are deemed at high risk of bleeding when they present with medium or large-sized varices, when they have red signs on varices of any size and when they are classified as Child-Pugh C and have varices of any size. In order to avoid variceal bleeding and death, individuals with cirrhosis at high risk of bleeding must undergo primary prophylaxis, for which currently recommended strategies are the use of traditional non-selective beta-blockers (NSBBs) (i.e., propranolol or nadolol), carvedilol (a NSBB with additional alpha-adrenergic blocking effect) or endoscopic variceal ligation (EVL). The superiority of one of these alternatives over the others is controversial. While EVL might be superior to pharmacological therapy regarding the prevention of the first bleeding episode, either traditional NSBBs or carvedilol seem to play a more prominent role in mortality reduction, probably due to their capacity of preventing other complications of cirrhosis through the decrease in portal hypertension. A sequential strategy, in which patients unresponsive to pharmacological therapy would be submitted to endoscopic treatment, or the combination of pharmacological and endoscopic strategies might be beneficial and deserve further investigation.

Role of early transjugular intrahepatic portosystemic stent-shunt in acute variceal bleeding: An update of the evidence and future directions

Variceal bleeding is a serious complication of cirrhosis and portal hypertension. Despite the improvement in management of acute variceal bleed (AVB), it still carries significant mortality. Portal pressure is the main driver of variceal bleeding and also a main predictor of decompensation. Reduction in portal pressure has been the mainstay of management of variceal bleeding. Transjugular intrahepatic porto-systemic stent shunt (TIPSS) is a very effective modality in reducing the portal hypertension and thereby, controlling portal hypertensive bleeding. However, its use in refractory bleeding (rescue/salvage TIPSS) is still associated with high mortality. “Early” use of TIPSS as a “pre-emptive strategy” in patients with AVB at high risk of failure of treatment has shown to be superior to standard treatment in several studies. While patients with Child C cirrhosis (up to 13 points) clearly benefit from early-TIPSS strategy, it’s role in less severe liver disease (Child B) and more severe disease (Child C > 13 points) remains less clear. Moreover, standard of care has improved in the last decade leading to improved 1-year survival in high-risk patients with AVB as compared to earlier “early” TIPSS studies. Lastly in the real world, only a minority of patients with AVB fulfil the stringent criteria for early TIPSS. Therefore, there is unmet need to explore role of early TIPSS in management of AVB in well-designed prospective studies. In this review, we have appraised the role of early TIPSS, patient selection and discussed future directions in the management of patients with AVB.

Usefulness of Endoscopic Ultrasound with the Jelly-Filling Method for Esophageal Varices

Although the importance of endoscopic ultrasound (EUS) for esophageal varices (EVs) has been demonstrated, it is difficult to obtain sufficient EUS images with the water-filling method because of poor water stagnation in the esophagus. In this study on EVs, we aimed to evaluate the usefulness of the jelly-filling method for EUS. Consecutive patients who underwent EUS for EVs were included. The quality of EUS images, the diagnostic ability of the presence of blood vessels inside and outside the esophageal wall, and the procedure time were compared between the jelly-filling and water-filling methods. Thirty cases were analyzed (jelly-filling method in 13 and water-filling method in 17). The EUS image quality score was significantly higher in the jelly-filling method (jelly vs. water; three points vs. two points, p < 0.001). Additionally, EUS image quality scores in both nonexperts and experts were significantly higher in the jelly-filling method. The diagnostic ability of the presence of perforation veins was significantly higher in the jelly-filling method (jelly vs. water; 100% vs. 52.9%, p = 0.004). However, the procedure time was significantly longer in the jelly-filling method (p = 0.024). In conclusion, EUS using the jelly-filling method for EVs provided sufficient image quality.

Clinical algorithms for the prevention of variceal bleeding and rebleeding in patients with liver cirrhosis

Portal hypertension (PH), a common complication of liver cirrhosis, results in development of esophageal varices. When esophageal varices rupture, they cause significant upper gastrointestinal bleeding with mortality rates up to 20% despite state-of-the-art treatment. Thus, prophylactic measures are of utmost importance to improve outcomes of patients with PH. Several high-quality studies have demonstrated that non-selective beta blockers (NSBBs) or endoscopic band ligation (EBL) are effective for primary prophylaxis of variceal bleeding. In secondary prophylaxis, a combination of NSBB + EBL should be routinely used. Once esophageal varices develop and variceal bleeding occurs, standardized treatment algorithms should be followed to minimize bleeding-associated mortality. Special attention should be paid to avoidance of overtransfusion, early initiation of vasoconstrictive therapy, prophylactic antibiotics and early endoscopic therapy. Pre-emptive transjugular intrahepatic portosystemic shunt should be used in all Child C10-C13 patients experiencing variceal bleeding, and potentially in Child B patients with active bleeding at endoscopy. The use of carvedilol, safety of NSBBs in advanced cirrhosis (i.e. with refractory ascites) and assessment of hepatic venous pressure gradient response to NSBB is discussed. In the present review, we give an overview on the rationale behind the latest guidelines and summarize key papers that have led to significant advances in the field.

Pathophysiology and Management of Variceal Bleeding

Cirrhosis is the fifth leading cause of death in adults. Advanced cirrhosis can cause significant portal hypertension (PH), which is responsible for many of the complications observed in patients with cirrhosis, such as varices. If portal pressure exceeds a certain threshold, the patient is at risk of developing life-threatening bleeding from varices. Variceal bleeding has a high incidence among patients with liver cirrhosis and carries a high risk of mortality and morbidity. The management of variceal bleeding is complex, often requiring a multidisciplinary approach involving pharmacological, endoscopic, and radiologic interventions. In terms of management, three stages can be considered: primary prophylaxis, active bleeding, and secondary prophylaxis. The main goal of primary and secondary prophylaxis is to prevent variceal bleeding. However, active variceal bleeding is a medical emergency that requires swift intervention to stop the bleeding and achieve durable hemostasis. We describe the pathophysiology of cirrhosis and PH to contextualize the formation of gastric and esophageal varices. We also discuss the currently available treatments and compare how they fare in each stage of clinical management, with a special focus on drugs that can prevent bleeding or assist in achieving hemostasis.

The Association Between Hepatic Venous Pressure Gradient Baseline and the Response Rate of Carvedilol on Portal Hypertension

Objective: To assess the association between hepatic venous pressure gradient (HVPG) baseline and the response rate of cirrhotic in patients who received carvedilol treatment. Methods: In total 48 cirrhotic patients with a basic HVPG value greater than 12 mmHg were included (from July 2011 to October 2014). All patients received carvedilol treatment and underwent the second HVPG measurement 7 days later. In the following, all participants received an endoscopic variceal ligation (EVL) treatment. Results: HVPG was significantly reduced from 16.04 ± 3.10 to 12.76 ± 5.26 mmHg following carvedilol treatment. The response rate was about 58.33% (28/48). The response rate of the HVPG < 16 mmHg group (71.4%) was significantly higher than that of the HVPG ≥ 16 mmHg group (40%) (P < 0.05). Patients were followed up for a median of 26 months, ranged from 6 to 33 months. During the follow-up period (two years), the rebleeding rate was 9.97% and 49.56% in HVPG < 16 and HVPG ≥ 16 mmHg groups, respectively, with a statistically significant difference (P = 0.004). Also, the mortality rate (at 2 years) was 5.26% and 21.05%, respectively, which was significant (P = 0.035). Conclusions: This study demonstrated that the response rate of carvedilol on portal hypertension may be affected by the HVPG baseline, and the carvedilol was effective in reducing HVPG, especially for those with a HVPG < 16 mmHg.

Update on New Aspects of the Renin-Angiotensin System in Hepatic Fibrosis and Portal Hypertension: Implications for Novel Therapeutic Options

There is considerable experimental evidence that the renin angiotensin system (RAS) plays a central role in both hepatic fibrogenesis and portal hypertension. Angiotensin converting enzyme (ACE), a key enzyme of the classical RAS, converts angiotensin I (Ang I) to angiotensin II (Ang II), which acts via the Ang II type 1 receptor (AT1R) to stimulate hepatic fibrosis and increase intrahepatic vascular tone and portal pressure. Inhibitors of the classical RAS, drugs which are widely used in clinical practice in patients with hypertension, have been shown to inhibit liver fibrosis in animal models but their efficacy in human liver disease is yet to be tested in adequately powered clinical trials. Small trials in cirrhotic patients have demonstrated that these drugs may lower portal pressure but produce off-target complications such as systemic hypotension and renal failure. More recently, the alternate RAS, comprising its key enzyme, ACE2, the effector peptide angiotensin-(1–7) (Ang-(1–7)) which mediates its effects via the putative receptor Mas (MasR), has also been implicated in the pathogenesis of liver fibrosis and portal hypertension. This system is activated in both preclinical animal models and human chronic liver disease and it is now well established that the alternate RAS counter-regulates many of the deleterious effects of the ACE-dependent classical RAS. Work from our laboratory has demonstrated that liver-specific ACE2 overexpression reduces hepatic fibrosis and liver perfusion pressure without producing off-target effects. In addition, recent studies suggest that the blockers of the receptors of alternate RAS, such as the MasR and Mas related G protein-coupled receptor type-D (MrgD), increase splanchnic vascular resistance in cirrhotic animals, and thus drugs targeting the alternate RAS may be useful in the treatment of portal hypertension. This review outlines the role of the RAS in liver fibrosis and portal hypertension with a special emphasis on the possible new therapeutic approaches targeting the ACE2-driven alternate RAS.

Transcatheter embolization for stomal varices: A report of three patients

Stomal varices are rare and ectopic varices defined as dilated portosystemic collateral veins located in sites other than the gastro-esophageal region. These sometimes cause recurrent bleedings and can be life-threatening. Optimal treatments have yet to be established. We report 3 cases of repetitive bleeding stomal varices in which resolution of bleeding was obtained over the medium term with minimally invasive approaches including balloon-occluded retrograde transvenous obliteration and variceal embolization by ultrasound-guided direct puncture. Rebleeding did not occur in any patients within 2-15 months of follow-up. Serious complications over Clavien-Dindo grade I were not found.

Anticoagulant Treatment for Splanchnic Vein Thrombosis in Liver Cirrhosis: A Systematic Review and Meta-Analysis

BACKGROUND

 Splanchnic vein thrombosis (SVT) is a common complication in patients with liver cirrhosis. The aim of this study was to evaluate the efficacy and safety of anticoagulant therapy for SVT in cirrhotic patients.

METHODS

 In this systematic review and meta-analysis, studies reporting on SVT recanalization and progression, recurrent venous thromboembolism (VTE), major bleeding, and overall mortality were searched in MEDLINE, EMBASE, and ClinicalTrial.gov up to December 2019. Pooled proportions and risk ratios (RRs) with corresponding 95% confidence intervals (CIs) were calculated.

RESULTS

 A total of 1,475 patients were included in 26 studies (23 observational and 3 randomized controlled trials). In patients receiving anticoagulant therapy, SVT recanalization occurred in 68% (95% CI, 62-74; 571/842 patients; 22 studies), SVT progression in 6% (95% CI, 4-9; 25/748 patients; 22 studies), recurrent VTE in 10% (95% CI, 4-22; 48/399 patients; 7 studies), major bleeding in 6% (95% CI, 4-10; 58/785 patients; 18 studies), and overall mortality in 9% (95% CI, 6-14; 68/787 patients; 17 studies). Anticoagulant treatment was associated with higher SVT recanalization (RR 3.19; 95% CI, 1.42-7.17), lower thrombosis progression (RR 0.28; 95% CI, 0.15-0.52), major bleeding (RR 0.52; 95% CI, 0.28-0.97), and overall mortality (RR 0.42; 95% CI, 0.24-0.73) compared with no treatment.

CONCLUSION

 Anticoagulant therapy seems to improve vein recanalization and to reduce SVT progression, major bleeding, and overall mortality in cirrhotic patients with SVT. The incidence of recurrent VTE during anticoagulation remains substantial.

Adherence to Non-Selective Beta Blockers for Prevention of Variceal Bleeding in Cirrhotic Patients

BACKGROUND AND AIM

Long-term use of non-selective beta blockers (NSBBs) is essential for the prevention of esophageal variceal bleeding in liver cirrhosis but may impair the patient's adherence. The present study aimed to investigate the adherence to NSBBs to prevent variceal bleeding in cirrhotic patients.

METHODS

All patients who had an indication of NSBBs for the prophylaxis of variceal bleeding between February 2018 and June 2019 were screened. Clinical pharmacists gave pre-medication education and recorded the adherence to NSBBs during the patients' hospitalizations. Factors associated with poor adherence were evaluated by univariate logistic regression analysis. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. The relationship between poor adherence during follow-up and variceal bleeding after discharge was also evaluated.

RESULTS

Overall, 108 patients were screened, of whom 12 were intolerant to NSBBs. Among the 96 remaining patients who could take NSBBs, the average change of heart rate after NSBBs was -10.49 b.p.m. Twenty-two (22.9%) patients had poor adherence to NSBBs due to their refusal to take NSBBs (n = 2), complete forgetfulness to take NSBBs (n = 10), and refusal or forgetfulness to monitor heart rate (n = 10). Univariate logistic regression analysis demonstrated that only older age was significantly associated with poor adherence (OR: 1.065, 95% CI: 1.019-1.114, P = 0.005). Patients with poor adherence during follow-up were more likely to develop variceal bleeding after discharge.

CONCLUSION

A significant proportion of cirrhotic patients had poor adherence to NSBBs during their hospitalizations. Further studies should explore how to improve the patient's adherence to NSBBs.

Influence of gastroesophageal flap valve on esophageal variceal bleeding in patients with liver cirrhosis

OBJECTIVES

Esophageal variceal bleeding can be fatal in patients with liver cirrhosis. The aim of this study was to investigate the relationship between gastroesophageal flap valve (GEFV) and esophageal variceal bleeding.

METHODS

Subjects were cirrhotic patients with endoscopically diagnosed esophageal varices treated at our hospital between 2005 and 2019, excluding those with F3 form and red color (RC) signs at first endoscopy. Sixty-five patients with normal GEFV (Hill grade I or II) and 42 with abnormal GEFV (Hill grade III or IV) were enrolled. Propensity score matching eliminated the baseline differences, resulting in a sample size of 30 patients per cohort. The primary endpoint was esophageal variceal bleeding, and the secondary endpoint was variceal bleeding or appearance of RC sign. We analyzed the cumulative incidences and predictors of each endpoint.

RESULTS

The 3-, 5-, and 10-year cumulative incidences of the primary endpoints were all 3.4% in the normal GEFV group, and 19.0%, 24.6% and 34.0% in the abnormal GEFV group, respectively (log-rank P = 0.011). Cumulative incidence of the secondary endpoint was 13.8%, 33.1% and 39.2% in the normal GEFV group, and 42.2%, 54.6% and 84.9% in the abnormal GEFV group, respectively (log-rank P = 0.001). In multivariate Cox regression analyses, hazard ratios of abnormal GEFV of the primary and secondary endpoints were 12.79 (95% confidence interval 1.331-122.8) and 3.600 (1.653-7.840), respectively.

CONCLUSIONS

Abnormal GEFV was an independent risk factor for esophageal variceal bleeding and appearance of RC sign.

Selective Esophagogastric Devascularization in the Modified Sugiura Procedure for Patients with Cirrhotic Hemorrhagic Portal Hypertension: A Randomized Controlled Trial

AIM

Portal hypertension is a series of syndrome commonly seen with advanced cirrhosis, which seriously affects patient's quality of life and survival. This study was designed to access the efficacy and safety of selective esophagogastric devascularization in the modified Sugiura procedure for patients with cirrhotic hemorrhagic portal hypertension.

METHODS

Sixty patients with hepatitis B cirrhotic hemorrhagic portal hypertension and meeting the inclusion criteria were selected and randomly divided by using computer into the selective modified Sugiura group (sMSP group, n = 30) and the modified Sugiura group (MSP group, n = 30). The primary endpoint measurement is the postoperative rebleeding rate. Secondary endpoint measurements included free portal venous pressure, liver Child-Pugh score, liver volume, portal vein width and blood flow velocity, survival rate, quality of life, and dysphagia as well as other complications one year postoperatively. This trial is registered with ChiCTR, number ChiCTR2000033468.

RESULTS

There was no statistically significant difference in rebleeding rates within one year after surgery between patients in the sMSP and MSP groups (χ = 0.11, p=0.73). In comparison with the MSP group, the Child-Pugh score of liver function in the sMSP group significantly increased (χ = 6.4, p=0.04) and the incidence of dysphagia was significantly reduced (χ = 6.23, p=0.01) one year after surgery. There was a statistically significant difference in the quality of life between the two groups. However, there were no statistically significant differences in free portal venous pressure (MD = -3.44, 95% CI: -7.87 to 0.98, p=0.12), postoperative liver volume (3 months: MD = -258.81, 95% CI: -723.21 to 205.57, p=0.24; 1 year: MD = -320.12, 95% CI: -438.43 to 102.78, p=0.16), postoperative portal vein width (3 months: MD = -0.06, p=0.50; 1 year: MD = 0.17, p=0.21), portal vein flow velocity (3 months: MD = 1.64, p=0.21; 1 year: MD = -1.19, p=0.57), 1-year survival rate (χ = 1.01, p=0.31), and other complications between the two groups.

CONCLUSIONS

Selective esophagogastric devascularization in the modified Sugiura procedure may not lower the incidence of rebleeding in the short term based on our findings. However, it may significantly improve quality of life of patients with cirrhotic hemorrhagic portal hypertension, improve liver function, and reduce postoperative dysphagia.

Cirrhotic portal hypertension: From pathophysiology to novel therapeutics

Portal hypertension and bleeding from gastroesophageal varices is the major cause of morbidity and mortality in patients with cirrhosis. Portal hypertension is initiated by increased intrahepatic vascular resistance and a hyperdynamic circulatory state. The latter is characterized by a high cardiac output, increased total blood volume and splanchnic vasodilatation, resulting in increased mesenteric blood flow. Pharmacological manipulation of cirrhotic portal hypertension targets both the splanchnic and hepatic vascular beds. Drugs such as angiotensin converting enzyme inhibitors and angiotensin II type receptor 1 blockers, which target the components of the classical renin angiotensin system (RAS), are expected to reduce intrahepatic vascular tone by reducing extracellular matrix deposition and vasoactivity of contractile cells and thereby improve portal hypertension. However, these drugs have been shown to produce significant off-target effects such as systemic hypotension and renal failure. Therefore, the current pharmacological mainstay in clinical practice to prevent variceal bleeding and improving patient survival by reducing portal pressure is non-selective -blockers (NSBBs). These NSBBs work by reducing cardiac output and splanchnic vasodilatation but most patients do not achieve an optimal therapeutic response and a significant proportion of patients are unable to tolerate these drugs. Although statins, used alone or in combination with NSBBs, have been shown to improve portal pressure and overall mortality in cirrhotic patients, further randomized clinical trials are warranted involving larger patient populations with clear clinical end points. On the other hand, recent findings from studies that have investigated the potential use of the blockers of the components of the alternate RAS provided compelling evidence that could lead to the development of drugs targeting the splanchnic vascular bed to inhibit splanchnic vasodilatation in portal hypertension. This review outlines the mechanisms related to the pathogenesis of portal hypertension and attempts to provide an update on currently available therapeutic approaches in the management of portal hypertension with special emphasis on how the alternate RAS could be manipulated in our search for development of safe, specific and effective novel therapies to treat portal hypertension in cirrhosis.

Portosystemic shunts versus endoscopic intervention with or without medical treatment for prevention of rebleeding in people with cirrhosis

BACKGROUND

People with liver cirrhosis who have had one episode of variceal bleeding are at risk for repeated episodes of bleeding. Endoscopic intervention and portosystemic shunts are used to prevent further bleeding, but there is no consensus as to which approach is preferable.

OBJECTIVES

To compare the benefits and harms of shunts (surgical shunts (total shunt (TS), distal splenorenal shunt (DSRS), or transjugular intrahepatic portosystemic shunt (TIPS)) versus endoscopic intervention (endoscopic sclerotherapy or banding, or both) with or without medical treatment (non-selective beta blockers or nitrates, or both) for prevention of variceal rebleeding in people with liver cirrhosis.

SEARCH METHODS

We searched the CHBG Controlled Trials Register; CENTRAL, in the Cochrane Library; MEDLINE Ovid; Embase Ovid; LILACS (Bireme); Science Citation Index - Expanded (Web of Science); and Conference Proceedings Citation Index - Science (Web of Science); as well as conference proceedings and the references of trials identified until 22 June 2020. We contacted study investigators and industry researchers.

SELECTION CRITERIA

Randomised clinical trials comparing shunts versus endoscopic interventions with or without medical treatment in people with cirrhosis who had recovered from a variceal haemorrhage.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. When possible, we collected data to allow intention-to-treat analysis. For each outcome, we estimated a meta-analysed estimate of treatment effect across trials (risk ratio for binary outcomes). We used random-effects model meta-analysis as our main analysis and as a means of presenting results. We reported differences in means for continuous outcomes without a meta-analytic estimate due to high variability in their assessment among all trials. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

We identified 27 randomised trials with 1828 participants. Three trials assessed TSs, five assessed DSRSs, and 19 trials assessed TIPSs. The endoscopic intervention was sclerotherapy in 16 trials, band ligation in eight trials, and a combination of band ligation and either sclerotherapy or glue injection in three trials. In eight trials, endoscopy was combined with beta blockers (in one trial plus isosorbide mononitrate). We judged all trials to be at high risk of bias. We assessed the certainty of evidence for all the outcome review results as very low (i.e. the true effects of the results are likely to be substantially different from the results of estimated effects). The very low evidence grading is due to the overall high risk of bias for all trials, and to imprecision and publication bias for some outcomes. Therefore, we are very uncertain whether portosystemic shunts versus endoscopy interventions with or without medical treatment have effects on all-cause mortality (RR 0.99, 95% CI 0.86 to 1.13; 1828 participants; 27 trials), on rebleeding (RR 0.40, 95% CI 0.33 to 0.50; 1769 participants; 26 trials), on mortality due to rebleeding (RR 0.51, 95% CI 0.34 to 0.76; 1779 participants; 26 trials), and on occurrence of hepatic encephalopathy, both acute (RR 1.60, 95% CI 1.33 to 1.92; 1649 participants; 24 trials) and chronic (RR 2.51, 95% CI 1.38 to 4.55; 956 participants; 13 trials). No data were available regarding health-related quality of life. Analysing each modality of portosystemic shunts individually (i.e. TS, DSRS, and TIPS) versus endoscopic interventions with or without medical treatment, we are very uncertain if each type of shunt has effect on all-cause mortality: TS, RR 0.46, 95% CI 0.19 to 1.13; 164 participants; 3 trials; DSRS, RR 0.93, 95% CI 0.65 to 1.33; 352 participants; 4 trials; and TIPS, RR 1.10, 95% CI 0.92 to 1.31; 1312 participants; 19 trial; on rebleeding: TS, RR 0.28, 95% CI 0.14 to 0.56; 127 participants; 2 trials; DSRS, RR 0.26, 95% CI 0.11 to 0.65; 330 participants; 5 trials; and TIPS, RR 0.44, 95% CI 0.36 to 0.55; 1312 participants; 19 trials; on mortality due to rebleeding: TS, RR 0.25, 95% CI 0.06 to 0.96; 164 participants; 3 trials; DSRS, RR 0.31, 95% CI 0.13 to 0.74; 352 participants; 5 trials; and TIPS, RR 0.65, 95% CI 0.40 to 1.04; 1263 participants; 18 trials; on acute hepatic encephalopathy: TS, RR 1.66, 95% CI 0.70 to 3.92; 115 participants; 2 trials; DSRS, RR 1.70, 95% CI 0.94 to 3.08; 287 participants; 4 trials, TIPS, RR 1.61, 95% CI 1.29 to 1.99; 1247 participants; 18 trials; and chronic hepatic encephalopathy: TS, Fisher's exact test P = 0.11; 69 participants; 1 trial; DSRS, RR 4.87, 95% CI 1.46 to 16.23; 170 participants; 2 trials; and TIPS, RR 1.88, 95% CI 0.93 to 3.80; 717 participants; 10 trials. The proportion of participants with shunt occlusion or dysfunction was overall 37% (95% CI 33% to 40%). It was 3% (95% CI 0.8% to 10%) following TS, 7% (95% CI 3% to 13%) following DSRS, and 47.1% (95% CI 43% to 51%) following TIPS. Shunt dysfunction in trials utilising polytetrafluoroethylene-covered stents was 17% (95% CI 11% to 24%). Length of inpatient hospital stay and cost were not comparable across trials. Funding was unclear in 16 trials; 11 trials were funded by government, local hospitals, or universities.

AUTHORS' CONCLUSIONS

Evidence on whether portosystemic shunts versus endoscopy interventions with or without medical treatment in people with cirrhosis and previous hypertensive portal bleeding have little or no effect on all-cause mortality is very uncertain. Evidence on whether portosystemic shunts may reduce bleeding and mortality due to bleeding while increasing hepatic encephalopathy is also very uncertain. We need properly conducted trials to assess effects of these interventions not only on assessed outcomes, but also on quality of life, costs, and length of hospital stay.

Defining the advantages and exposing the limitations of endoscopic variceal ligation in controlling acute bleeding and achieving complete variceal eradication

BACKGROUND

Bleeding esophageal varices (BEV) is a potentially life-threatening complication in patients with portal hypertension with mortality rates as high as 25% within six weeks of the index variceal bleed. After control of the initial bleeding episode patients should enter a long-term surveillance program with endoscopic intervention combined with non-selective β-blockers to prevent further bleeding and eradicate EV.

AIM

To assess the efficacy of endoscopic variceal ligation (EVL) in controlling acute variceal bleeding, preventing variceal recurrence and rebleeding and achieving complete eradication of esophageal varices (EV) in patients who present with BEV.

METHODS

A prospectively documented single-center database was used to retrospectively identify all patients with BEV who were treated with EVL between 2000 and 2018. Control of acute bleeding, variceal recurrence, rebleeding, eradication and survival were analyzed using Baveno assessment criteria.

RESULTS

One hundred and forty patients (100 men, 40 women; mean age 50 years; range, 21–84 years; Child-Pugh grade A = 32; B = 48; C = 60) underwent 160 emergency and 298 elective EVL interventions during a total of 928 endoscopy sessions. One hundred and fourteen (81%) of the 140 patients had variceal bleeding that was effectively controlled during the index banding procedure and never bled again from EV, while 26 (19%) patients had complicated and refractory variceal bleeding. EVL controlled the acute sentinel variceal bleed during the first endoscopic intervention in 134 of 140 patients (95.7%). Six patients required balloon tamponade for control and 4 other patients rebled in hospital. Overall 5-d endoscopic failure to control variceal bleeding was 7.1% (n = 10) and four patients required a salvage transjugular intrahepatic portosystemic shunt. Index admission mortality was 14.2% (n = 20). EV were completely eradicated in 50 of 111 patients (45%) who survived > 3 mo of whom 31 recurred and 3 rebled. Sixteen (13.3%) of 120 surviving patients subsequently had 21 EV rebleeding episodes and 10 patients bled from other sources after discharge from hospital. Overall rebleeding from all sources after 2 years was 21.7% (n = 26). Sixty-nine (49.3%) of the 140 patients died, mainly due to liver failure (n = 46) during follow-up. Cumulative survival for the 140 patients was 71.4% at 1 year, 65% at 3 years, 60% at 5 years and 52.1% at 10 years.

CONCLUSION

EVL was highly effective in controlling the sentinel variceal bleed with an overall 5-day failure to control bleeding of 7.1%. Although repeated EVL achieved complete variceal eradication in less than half of patients with BEV, of whom 62% recurred, there was a significant reduction in subsequent rebleeding.

Successful hybrid surgery for ileal conduit stomal varices following oxaliplatin-based chemotherapy in a patient with advanced colorectal cancer

BACKGROUND

Ectopic variceal bleeding is a rare but life-threatening complication of portal hypertension (PH). Oxaliplatin-based chemotherapy for colorectal cancer (CRC) is associated with sinusoidal obstruction syndrome of the liver, which can lead to PH.

CASE PRESENTATION

Here, we report a successful hybrid surgery that included intraoperative obliteration of ileal conduit stomal varices (ICSVs) for a 66-year-old woman with CRC and liver metastasis that had been treated multimodally during the previous 4 years, including 17 courses of oxaliplatin-based chemotherapy. She was admitted to our hospital for massive hemorrhage from an ileal conduct stoma. Image findings showed ICSVs as a part of portosystemic shunt, which were afferently supplied from the superior mesenteric vein (SMV) and drained by the numerous cutaneous veins connected to the left femoral vein. Obliteration of the stomal varices by interventional radiologic techniques alone was inappropriate because of difficulties of cannulating the efferent cutaneous veins. We, therefore, performed hybrid surgery for the ICSV, which included cannulation into the SMV branch and antegrade obliteration of the varices with a 5% solution of ethanolamine oleate with iopamidol under blocking the SMV flow, using a vascular clip and ligation. Hemorrhage in her ileal conduit stoma disappeared completely.

CONCLUSION

Customized treatment of ectopic varices should be based on their precise vascular anatomy; hybrid surgery with intraoperative angiography is an alternative treatment for ectopic varices such as ICSV.

Update on Shunt Surgery

Background

Bleeding from esophagogastric varices is a life-threatening complication from portal hypertension. It occurs in 15% of patients and has a mortality rate of 20-35%.

Summary

The primary therapy for variceal bleeding is medical. In cases of recurrent bleeding, a definitive therapy is required. In cases of parenchymal decompensation, liver transplantation is the causal therapy, but if liver function is preserved, portal decompression is the therapy of choice. The use of the transjugular intrahepatic portosystemic shunt (TIPS) has achieved widespread acceptance, although evidence for surgical shunts is comparable or better in patients with good hepatic reserve. The type of surgical shunt depends on the patent veins of the portomesenteric system. If total occlusion is present, a devascularization procedure might be indicated.

Key Messages

Therapy, taking into account liver function, morphology of the portovenous system, and imminent liver transplantation, should be performed by an interdisciplinary team of gastroenterologists, interventional radiologists, and gastrointestinal surgeons.

Interventions for preventing and managing advanced liver disease in cystic fibrosis

BACKGROUND

Cystic fibrosis is an autosomal recessive inherited defect in the cystic fibrosis transmembrane conductance regulator (CFTR) gene resulting in abnormal regulation of salt and water movement across the membranes. In the liver this leads to focal biliary fibrosis resulting in progressive portal hypertension and end-stage liver disease in some individuals. This can be asymptomatic, but may lead to splenomegaly and hypersplenism, development of varices and variceal bleeding, and ascites; it has negative impact on overall nutritional status and respiratory function in this population. Prognosis is poor once significant portal hypertension is established. The role and outcome of various interventions for managing advanced liver disease (non-malignant end stage disease) in people with cystic fibrosis is currently unidentified. This is an updated version of a previously published review.

OBJECTIVES

To review and assess the efficacy of currently available treatment options for preventing and managing advanced liver disease in children and adults with cystic fibrosis.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. Date of last search: 19 November 2019. We also searched the reference lists of relevant articles and reviews and online trials registries. Date of last search: 01 January 2020.

SELECTION CRITERIA

Any published and unpublished randomised controlled trials and quasi-randomised controlled trials of advanced liver disease in cystic fibrosis with cirrhosis or liver failure, portal hypertension or variceal bleeding (or both).

DATA COLLECTION AND ANALYSIS

Authors independently examined titles and abstracts to identify potentially relevant trials, but none were eligible for inclusion in this review.

MAIN RESULTS

A comprehensive search of the literature did not identify any published eligible randomised controlled trials.

AUTHORS' CONCLUSIONS

In order to develop the best source of evidence, there is a need to undertake randomised controlled trials of interventions for preventing and managing advanced liver disease in adults and children with cystic fibrosis.

Combined Laparoscopic Splenectomy and Esophagogastric Devascularization versus Open Splenectomy and Esophagogastric Devascularization for Portal Hypertension due to Liver Cirrhosis

This study was conducted to compare the feasibility, safety and effectiveness of the combined-laparoscopic splenectomy and esophagogastric devascularization (C-LSED) with open splenectomy and esophagogastric devascularization surgery (OSED) in patients with portal hypertension due to liver cirrhosis. From February 2014 to June 2018, 68 patients with portal hypertension were diagnosed as having serious gastroesophageal varices and/or hypersplenism in our center. Thirty patients underwent C-LSED and 38 patients received OSED. Results and outcomes were compared retrospectively. No patients of C-LSED group required an intraoperative conversion to open surgery. Significantly shorter operating time, less blood loss, lower transfusion rates, shorter postoperative hospital stay, lower rates of complications were found in C-LSED group than in C-LSED group (P<0.05). No death and rebleeding were documented in both groups during the follow-up periods of one year. Postoperative endoscopy revealed that varices in the patients of both groups were alleviated significantly from severe to mild, and in a part of cases, the varices disappeared. The final results suggest that the C-LSED technique is superior to open procedure, due to slightly invasive, simplified operative procedure, significantly shorter operating time, less intraoperative bleeding and lower post-operative complication rates. And C-LSED offers comparable long-term effects to open surgery.

Emergent Transjugular Intrahepatic Portosystemic Shunt Creation in Acute Variceal Bleeding

Emergent transjugular intrahepatic portosystemic shunt (TIPS) creation is most commonly employed in the setting of acute variceal hemorrhage. Given a propensity for decompensation, these patients often require a multidisciplinary, multimodal approach involving prompt diagnosis, pharmacologic therapy, and endoscopic intervention. While successful in the majority of cases, failure to medically control initial bleeding can prompt interventional radiology consultation for emergent portal decompression via TIPS creation. This article discusses TIPS creation in emergent, acute variceal hemorrhage, reviewing the natural history of gastroesophageal varices, presentation and diagnosis of acute variceal hemorrhage, pharmacologic therapy, endoscopic approaches, patient selection and risk stratification for TIPS, technical considerations for TIPS creation, adjunctive embolotherapy, and the role of salvage TIPS versus early TIPS in acute variceal hemorrhage.

Remaining challenges for the noninvasive diagnosis of esophageal varices in liver cirrhosis

Although endoscopy is the recommended method for detecting esophageal varices, noninvasive methods for diagnosing esophageal varices are needed to avoid unnecessary invasive endoscopic examinations. In recent years, many studies have been performed to predict the presence of high-risk varices in noninvasive ways. The most widely used tools for noninvasive screening for esophageal varices are the Baveno VI and expanded Baveno VI criteria. Even these accepted criteria are not 100% accurate and have some limitations. Here, we summarize the current literature on the noninvasive diagnosis of esophageal varices in liver cirrhosis patients and highlight the remaining issues.

Short-term vasoactive agent treatment driven by physicians' preference in acute esophageal variceal bleeding in a tertiary center

Background

Vasoactive drugs are frequently used in combination with endoscopic variceal ligation (EVL) in treatment of acute esophageal variceal bleeding (EVB). The aim of study was to assess physicians’ preference of vasoactive agents in acute EVB, their reasons of preference and efficacy and safety of these short course regimens.

Methods

Cirrhotic patients with suspected EVB were screened (n = 352). Eligible patients were assigned based on the physician’s preference to either somatostatin (group S) or terlipressin (group T) followed by EVL. In group S, intravenous bolus (250 µg) of somatostatin followed by 250 µg/hour was continued for three days. In group T, 2 mg bolus injection of terlipressin was followed by 1 mg infusion every 6 h for three days.

Results

A total of 150 patients were enrolled; 41 in group S and 109 in group T. Reasons for physician preference was convenience in administration (77.1%) for group T and good safety profile (73.2%) for group S. Very early rebleeding within 49–120 h occurred in one patient in groups S and T (p = 0.469). Four patients in group S and 14 patients in group T have variceal rebleeding episodes within 6–42 d (p = 0.781). Overall treatment-related adverse effects were compatible in groups S and T (p = 0.878), but the total cost of terlipressin and somatostatin differed i.e., USD 621.32 and USD 496.43 respectively.

Conclusions

Terlipressin is the preferred vasoactive agent by physicians in our institution for acute EVB. Convenience in administration and safety profile are main considerations of physicians. Safety and hemostatic effects did not differ significantly between short-course somatostatin or terlipressin, although terlipressin is more expensive.

Biomaterials in Gastroenterology: A Critical Overview

In spite of the large diversity of diagnostic and interventional devices associated with gastrointestinal endoscopic procedures, there is little information on the impact of the biomaterials (metals, polymers) contained in these devices upon body tissues and, indirectly, upon the treatment outcomes. Other biomaterials for gastroenterology, such as adhesives and certain hemostatic agents, have been investigated to a greater extent, but the information is fragmentary. Much of this situation is due to the paucity of details disclosed by the manufacturers of the devices. Moreover, for most of the applications in the gastrointestinal (GI) tract, there are no studies available on the biocompatibility of the device materials when in intimate contact with mucosae and other components of the GI tract. We have summarized the current situation with a focus on aspects of biomaterials and biocompatibility related to the device materials and other agents, with an emphasis on the GI endoscopic procedures. Procedures and devices used for the control of bleeding, for polypectomy, in bariatrics, and for stenting are discussed, particularly dwelling upon the biomaterial-related features of each application. There are indications that research is progressing steadily in this field, and the establishment of the subdiscipline of "gastroenterologic biomaterials" is not merely a remote projection. Upon the completion of this article, the gastroenterologist should be able to understand the nature of biomaterials and to achieve a suitable and beneficial perception of their significance in gastroenterology. Likewise, the biomaterialist should become aware of the specific tasks that the biomaterials must fulfil when placed within the GI tract, and regard such applications as both a challenge and an incentive for progressing the research in this field.

Selective versus non‐selective shunts for the prevention of variceal rebleeding

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess the benefits and harms of any type of selective shunt versus any type of non‐selective shunt for the prevention of oesophagogastric variceal rebleeding in people with portal hypertension.

Functional magnetic resonance imaging-based assessment of terlipressin vs. octreotide on renal function in cirrhotic patients with acute variceal bleeding (CHESS1903): study protocol of a multicenter randomized controlled trial

BACKGROUND

Acute variceal bleeding is one of the critical complications in patients with liver cirrhosis. Severe renal vasoconstriction in consequence of low peripheral vascular resistance triggers the reduction of glomerular filtration rate (GFR), and thus induces acute kidney injury (AKI)/hepato-renal syndrome (HRS). Terlipressin and octreotide have been used in the management of cirrhotic patients with variceal bleeding. Also, terlipressin has been recommended as the international first-line pharmacological therapy for the treatment of HRS. In addition, the use of renal functional magnetic resonance imaging (fMRI) has become increasingly prevalent in research and clinical applications. However, the renal function-protective effect of terlipressin and octreotide and the value of fMRI in monitoring renal function remains unclear in patients with cirrhosis undergoing acute variceal bleeding.

METHODS

This is a multicenter, randomized controlled trial (RCT). Participants will be 1:1 assigned randomly into either terlipressin or octreotide groups. Sixty participants with clinically and/or pathologically diagnosed cirrhosis and active gastroesophageal variceal bleeding (GVB) will be recruited in several sites in China. Participants will receive either the treatment of terlipressin or octreotide after assigned into each group. The primary end point for the trial is the renal function. The secondary end points are (I) renal perfusion; (II) renal blood oxygenation; (III) failure to control bleeding; (IV) intra-hospital rebleeding; (V) intra-hospital mortality; (VI) adverse events (AE); (VII) overall survival. Statistical analysis including multivariate Cox regression, Kaplan-Meier analysis with log-rank test, etc. will be conducted.

DISCUSSION

The study will provide new insight into the protection of renal function in the process of the treatment of variceal bleeding in patients with cirrhosis.

TRIAL REGISTRATION NUMBER

NCT04028323.

Band ligation versus beta-blockers for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis

BACKGROUND

Portal hypertension commonly accompanies advanced liver disease and often gives rise to life-threatening complications, including haemorrhage from oesophageal and gastrointestinal varices. Variceal haemorrhage commonly occurs in children with chronic liver disease or portal vein obstruction. Prevention is therefore important. Following numerous randomised clinical trials demonstrating efficacy of non-selective beta-blockers and endoscopic variceal ligation in decreasing the incidence of variceal haemorrhage, primary prophylaxis of variceal haemorrhage in adults has become the established standard of care. Hence, band ligation and beta-blockers have been proposed to be used as primary prophylaxis of oesophageal variceal bleeding in children.

OBJECTIVES

To determine the benefits and harms of band ligation compared with any type of beta-blocker for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis.

SEARCH METHODS

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register (February 2019), CENTRAL (December 2018), PubMed (December 2018), Embase Ovid (December 2018), LILACS (Bireme; January 2019), and Science Citation Index Expanded (Web of Science; December 2018). We scrutinised the reference lists of the retrieved publications and performed a manual search from the main paediatric gastroenterology and hepatology conferences (NASPGHAN and ESPGHAN) abstract books from 2009 to 2018. We searched ClinicalTrials.gov for ongoing clinical trials. There were no language or document type restrictions.

SELECTION CRITERIA

We planned to include randomised clinical trials irrespective of blinding, language, or publication status for assessment of benefits and harms. We planned to also include quasi-randomised and other observational studies retrieved with the searches for randomised clinical trials for report of harm.

DATA COLLECTION AND ANALYSIS

We planned to summarise data from randomised clinical trials using standard Cochrane methodologies.

MAIN RESULTS

We found no randomised clinical trials assessing band ligation versus beta-blockers for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis.

AUTHORS' CONCLUSIONS

Randomised clinical trials assessing the benefits or harms of band ligation versus beta-blockers for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis are lacking. There is a need for well-designed, adequately powered randomised clinical trials to assess the benefits and harms of band ligation versus beta-blockers for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. Those randomised clinical trials should include patient-relevant clinical outcomes such as mortality, failure to control bleeding, and adverse events.

Comparision between portosystemic shunts and endoscopic therapy for prevention of variceal re-bleeding: a systematic review and meta-analysis

Background:

Portosystemic shunts, including surgical portosystemic shunts and transjugular intra-hepatic portosystemic shunt (TIPS), may have benefit over endoscopic therapy (ET) for treatment of variceal bleeding in patients with cirrhotic portal hypertension; however, whether there being a survival benefit among them remains unclear. This study was to compare the effect of three above-mentioned therapies on the short-term and long-term survival in patient with cirrhosis.

Methods:

Using the terms “variceal hemorrhage or variceal bleeding or variceal re-bleeding” OR “esophageal and gastric varices” OR “portal hypertension” and “liver cirrhosis,” the Cochrane Central Register of Controlled Trials, PubMed, Embase, and the references of identified trials were searched for human randomized controlled trials (RCTs) published in any language with full texts or abstracts (last search June 2017). Risk ratio (RR) estimates with 95% confidence interval (CI) were calculated using random effects model by Review Manager. The quality of the included studies was evaluated using the Cochrane Collaboration's tool for the assessment of the risk of bias.

Results:

Twenty-six publications comprising 28 RCTs were included in this analysis. These studies included a total of 2845 patients: 496 (4 RCTs) underwent either surgical portosystemic shunts or TIPS, 1244 (9 RCTs) underwent either surgical portosystemic shunts or ET, and 1105 (15 RCTs) underwent either TIPS or ET. There was no significant difference in overall mortality and 30-day or 6-week survival among three interventions. Compared with TIPS and ET, separately, surgical portosystemic shunts were both associated with a lower bleeding-related mortality (RR = 0.07, 95% CI = 0.01–0.32; P < 0.001; RR = 0.17, 95% CI = 0.06–0.51, P < 0.005) and rate of variceal re-bleeding (RR = 0.23, 95% CI = 0.10–0.51, P < 0.001; RR = 0.10, 95% CI = 0.04–0.24, P < 0.001), without a significant difference in the rate of postoperative hepatic encephalopathy (RR = 0.52, 95% CI = 0.25–1.00, P = 0.14; RR = 1.09, 95% CI = 0.59–2.01, P = 0.78). TIPS showed a trend toward lower variceal re-bleeding (RR = 0.46, 95% CI = 0.36–0.58, P < 0.001), but a higher incidence of hepatic encephalopathy than ET (RR = 1.78, 95% CI = 1.34–2.36, P < 0.001).

Conclusions:

The overall analysis revealed that there seem to be no short-term and long-term survival advantage, but surgical portosystemic shunts are with the lowest bleeding-related mortality among the three therapies. Surgical portosystemic shunts may be the most effective without an increased risk of hepatic encephalopathy and TIPS is superior to ET but at the cost of a higher incidence of hepatic encephalopathy. However, some of findings should be interpreted with caution due to the lower level of evidence and the existence of significant heterogeneity.

Band ligation versus no intervention for primary prevention of upper gastrointestinal bleeding in adults with cirrhosis and oesophageal varices

BACKGROUND

The presence of oesophageal varices is associated with the risk of upper gastrointestinal bleeding. Endoscopic variceal ligation is used to prevent this occurrence but the ligation procedure may be associated with complications.

OBJECTIVES

To assess the beneficial and harmful effects of band ligation versus no intervention for primary prevention of upper gastrointestinal bleeding in adults with cirrhosis and oesophageal varices.

SEARCH METHODS

We combined searches in the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, and Science Citation Index with manual searches. The last search update was 9 February 2019.

SELECTION CRITERIA

We included randomised clinical trials comparing band ligation verus no intervention regardless of publication status, blinding, or language in the analyses of benefits and harms, and observational studies in the assessment of harms. Included participants had cirrhosis and oesophageal varices with no previous history of variceal bleeding.

DATA COLLECTION AND ANALYSIS

Three review authors extracted data independently. The primary outcome measures were all-cause mortality, upper gastrointestinal bleeding, and serious adverse events. We undertook meta-analyses and presented results using risk ratios (RRs) with 95% confidence intervals (CIs) and I² values as a marker of heterogeneity. In addition, we calculated the number needed to treat to benefit (NNTTB) for the primary outcomes . We assessed bias control using the Cochrane Hepato-Biliary domains; determined the certainty of the evidence using GRADE; and conducted sensitivity analyses including Trial Sequential Analysis.

MAIN RESULTS

Six randomised clinical trials involving 637 participants fulfilled our inclusion criteria. One of the trials included an additional small number of participants (< 10% of the total) with non-cirrhotic portal hypertension/portal vein block. We classified one trial as at low risk of bias for the outcome, mortality and high risk of bias for the remaining outcomes; the five remaining trials were at high risk of bias for all outcomes. We downgraded the evidence to moderate certainty due to the bias risk. We gathered data on all primary outcomes from all trials. Seventy-one of 320 participants allocated to band ligation compared to 129 of 317 participants allocated to no intervention died (RR 0.55, 95% CI 0.43 to 0.70; I² = 0%; NNTTB = 6 persons). In addition, band ligation was associated with reduced risks of upper gastrointestinal bleeding (RR 0.44, 95% CI 0.28 to 0.72; 6 trials, 637 participants; I² = 61%; NNTTB = 5 persons), serious adverse events (RR 0.55, 95% CI 0.43 to 0.70; 6 trials, 637 participants; I² = 44%; NNTTB = 4 persons), and variceal bleeding (RR 0.43, 95% CI 0.27 to 0.69; 6 trials, 637 participants; I² = 56%; NNTTB = 5 persons). The non-serious adverse events reported in association with band ligation included oesophageal ulceration, dysphagia, odynophagia, retrosternal and throat pain, heartburn, and fever, and in the one trial involving participants with either small or large varices, the incidence of non-serious side effects in the banding group was much higher in those with small varices, namely ulcers: small versus large varices 30.5% versus 8.7%; heartburn 39.2% versus 17.4%. No trials reported on health-related quality of life.Two trials did not receive support from pharmaceutical companies; the remaining four trials did not provide information on this issue.

AUTHORS' CONCLUSIONS

This review found moderate-certainty evidence that, in patients with cirrhosis, band ligation of oesophageal varices reduces mortality, upper gastrointestinal bleeding, variceal bleeding, and serious adverse events compared to no intervention. It is unlikely that further trials of band ligation versus no intervention would be considered ethical.

Case Control Study of Post-endoscopic Variceal Ligation Bleeding Ulcers in Severe Liver Disease: Outcomes and Management

Background and Aims: The management of post-endoscopic variceal ligation (EVL) bleeding ulcers (PEBUs) is currently based on local expertise and patients liver disease status. The present retrospective study investigated associations between the endoscopic morphology of PEBUs and patient outcomes. Methods: Patients underwent EVL (primary or secondary), from January 2015 to January 2018, in two tertiary care hospitals in India (ILBS New Delhi and Dharamshila Narayana New Delhi). Mortality rates were determined at post-EVL day five and week six. PEBUs were typified based on Jamwal & Sarin classification system as follows: A, ulcer with active spurting; B, ulcer with ooze; C, ulcer base with visible vessel or clot; and D, clean or pigmented base. Results: Of 3854 EVL procedures, 141 (3.6%) patients developed PEBU, and 46/141 (32.6%) suffered mortality. Among the former, the PEBU types A, B, C, and D accounted for 17.7, 26.2, 36.3, and 19.8%, respectively. Of those who died, 39.1, 30.4, 21.7, and 8.8% had PEBU types A, B, C, and D. Treatments included transjugular intrahepatic portosystemic shunts (TIPS), esophageal self-expandable metal stent (SEMS), glue and sclerosant injection, Sengstaken-Blakemore tube placement and liver transplant. On univariate analysis, no correlation with hepatic venous pressure gradient, TIPS placement, size of varices, or number of bands was found. The Model for End-Stage Liver Disease (MELD)-sodium score correlated positively with outcome. After adjusting for MELD-sodium score, mortality was best predicted by type-A ulcer (p = 0.024; OR 8.95, CI 1.34-59.72). Conclusions: PEBU occurred in 3.6% of a large EVL cohort. Stratifying patients based on PEBU type can help predict outcomes, independent of the MELD-sodium score. Classifying PEBUs by endoscopic morphology may inform treatment strategies, and warrants further validation.

Prior Esophagogastric Devascularization Followed by Splenectomy for Liver Cirrhosis with Portal Hypertension: A Modified Laparoscopic Technique

Purpose

This study was conducted to introduce a novel modified surgical technique for laparoscopic splenectomy and esophagogastric devascularization (LSED) and its safety and efficiency.

Methods

From June 2016 to November 2017, 86 patients were diagnosed with portal hypertension and serious gastroesophageal varices in our center. Of them, 32 patients underwent LSED and 54 received the modified LSED. Results and outcomes were compared retrospectively.

Results

There were no significant differences in preoperative patient characteristics of the two groups. No intraoperative deaths took place in both groups. The intraoperative blood loss was apparently less in the M-LSED group (P < 0.05). There was no conversion in the M-LSED group; four patients receiving LSED were converted to hand-assisted LSED due to profuse bleeding during operation (P < 0.05). Operation time was significantly shorter in the M-LSED group (P < 0.05). Otherwise, postoperative hospital stay was shorter in the M-LSED group (P < 0.05). There were no significant differences in postoperative complications between the two groups (P > 0.05).

Conclusions

Our study showed that the modified LSED was a safe and effective approach with low conversion rate, less intraoperative bleeding, less blood transfusion, and shorter operation time and postoperative hospital stay compared with classical LSED. Moreover, this technique is relatively easy and technically feasible.

Carvedilol for prevention of variceal bleeding: a systematic review and meta-analysis

Background

Beta-blockers are used for prophylaxis of variceal bleeding. Our aim was to assess the efficacy and safety of carvedilol for primary or secondary prevention of variceal bleeding in patients with cirrhosis.

Methods

We searched Medline, Embase, CENTRAL and gray literature sources for randomized controlled trials (RCTs) comparing carvedilol with placebo or any active intervention. We synthesized data using random effects models. We summarized the strength of evidence using GRADE criteria.

Results

We included 13 trials with 1598 patients. Carvedilol was as efficacious as endoscopic variceal ligation (EVL) (4 RCTs, risk ratio [RR] 0.74, 95% confidence interval [CI] 0.37-1.49) or propranolol (3 RCTs, RR 0.76, 95%CI 0.27-2.14) for primary prevention of variceal bleeding. Likewise, carvedilol was as efficacious as EVL (3 RCTs, RR 1.10, 95%CI 0.75-1.61), non-selective beta-blockers (NSBBs) plus isosorbide-5-mononitrate (2 RCTs, RR 1.02, 95%CI 0.70-1.51) or propranolol (2 RCTs, RR 0.39, 95%CI 0.15-1.03) for secondary prevention of variceal bleeding. Carvedilol was associated with lower all-cause mortality compared to EVL (3 RCTs, RR 0.51, 95%CI 0.33-0.79). There was no difference in any other efficacy outcome. Finally, there were no significant differences in the safety profiles compared with EVL and NSBBs. Our confidence in the effect estimates for all outcomes was very low.

Conclusion

Carvedilol is as efficacious and safe as standard-of-care interventions for the primary and secondary prevention of variceal bleeding.

Changes in transient elastography in early cirrhotic patients after receiving nonselective B-blocker for primary variceal bleeding prophylaxis: Three-month follow up

Background and Aim

A nonselective B‐blocker (NSBB) is recommended for primary prophylaxis of variceal bleeding. The impact of treatment with NSBB on modulating transient elastography (TE) has not been reported. The aim of the study is to investigate the effect of NSBB treatment on TE in early cirrhotic patients.

Methods

In this prospective study, we enrolled all early cirrhotic patients who underwent esophagogastroduodenoscopy (EGD) and showed small esophageal varices (EV) at our institute for a period of 1 year. The TE and heart rate (HR) of all participants were measured before and 3 months after receiving NSBB.

Results

Thirty‐nine patients receiving propanolol for 3 months were analyzed. There were 16 patients in the HR responder group (41%) and 23 patients in the HR nonresponder group (59%). The reduction of TE was preferably found in the HR responder group compared with the HR nonresponder group, in which mean changes in TE were −5.6 and −0.7 kPa, respectively (P = 0.23). In addition, we categorized the patients using their TE responses. Twenty‐five patients (64.1%) showed reduced TE during the follow‐up period, in which the mean TE value change was −2.94 kPa. Using correlation analysis, TE and HR responses were insignificantly correlated (r = 0.23, P = 0.15).

Conclusion

The NSBB administered for 3 months mainly improved TE value in early cirrhotic patients even though the changes of HR and TE did not correlate. Further study is needed to confirm whether the monitoring of TE change may be a better predictor for pharmacological response than the HR response.

Cirrhosis and Portal Hypertension in the Pediatric Population

Cirrhosis is a complex process in which the architecture of the liver is replaced by structurally abnormal nodules due to cirrhosis. Cirrhosis frequently leads to the development of portal hypertension. In children, portal hypertension may be caused by a wide range of etiologies, including extrahepatic portal vein obstruction, biliary atresia, alpha 1 antitrypsin deficiency, and autoimmune hepatitis. Gastroesophageal varices and ascites are two of the complications of portal hypertension likely to cause morbidity and mortality. This review also discusses extrahepatic manifestations of portal hypertension and treatment options.