Role and safety of human thrombin injection for the treatment of bleeding gastric varices

Endoscopic Glue Injection Versus Endoscopic Human Thrombin Injection for Bleeding Gastric Varices-A Randomized Controlled Trial

BACKGROUND

Acute gastric variceal bleeding (AGVB) is a potentially fatal consequence of portal hypertension, accounting for 10% to 30% of all variceal bleeding. Although endoscopic cyanoacrylate glue injection is a common treatment for acute hemostasis, it has been linked to significant side effects. In the treatment of AGVB, there is limited evidence of the efficacy and relative safety of endoscopic human thrombin injection over glue injection.

MATERIALS AND METHODS

A total of 52 AGVB patients were randomized to receive either thrombin injection (25 patients) or glue injection (27 patients). The primary outcome was the incidence of any glue or thrombin injection-related post-therapy complications. Initial hemostasis, rebleeding, and mortality were all secondary end goals.

RESULTS

Both groups had comparable baseline data. Hemostasis of active bleeding at endoscopy was 100.0% (10/10) in the thrombin group and 87.5% (7/8) in the glue group ( P =0.44). Treatment failure after 5 days occurred in 2 patients (6.1%) in the glue group compared with none in the thrombin group ( P =0.165). Between 6 and 42 days after index bleeding, rebleeding occurred in 4 patients in the thrombin group compared with 6 patients in the glue group ( P =0.728). In the thrombin group, none of the patients had post-treatment ulcers on gastric varices compared with 14.81% (4/27) that occurred in the glue group ( P =0.045), a statistically significant observation. Overall, complications occurred in 4 (20%) and 11 (40.7%) patients in the thrombin and glue groups, respectively ( P =0.105). Two patients in the glue group died.

CONCLUSION

To achieve successful AGVB hemostasis, endoscopic thrombin injection has been proven efficacious. However, glue injection may be linked to a higher rate of rebleeding and post-therapy gastric variceal ulceration compared with thrombin.

Efficacy and Rationale of Endoscopic Ultrasound-Guided Thrombin Injection in Visceral Artery Pseudoaneurysm Not Amenable to Angioembolization

BACKGROUND

Pseudoaneurysm usually occurs after vascular injuries or erosions such as in trauma or inflammation like pancreatitis and is associated with high morbidity and mortality.

AIM

The aim of study is to assess efficacy and safety of EUS-guided thrombin injection in pseudoaneurysm.

MATERIALS AND METHODS

Prospective data collection was done at SMS Hospital, Jaipur, from January 2015 to March 2023. All patients with pseudoaneurysm were consecutively enrolled.

RESULTS

Twenty patients (M/F, 18:2) with median age of 41 years (25-58 years), were studied. Underlying etiology of pseudoaneurysm was chronic pancreatitis in 75% of the patients, blunt trauma abdomen in 15% of the patients, recurrent acute pancreatitis in 5%, and idiopathic in 5% of the patients. At the time of admission, mean hemoglobin was 6.7 g/dL (3.4-8.2), with median blood transfusion requirement was 2 units (0-6 units). Hemoglobin values after 4-6 weeks showed a significant improvement ( t = 9.21, P < 0.05).Mean dose of human thrombin required for complete obliteration of pseudoaneurysm was 520 ± 188.6 IU per patient (300-800 IU). Amount of thrombin (IU) dose needed to achieve complete obliteration correlated well significantly with the dimension of pseudoaneurysm, P value less than 0.05 ( R = 0.80). Median follow-up duration in this study was 44 months (3-84 months), which was the longest follow-up period by far.

CONCLUSIONS

Endoscopic ultrasound-guided thrombin injection in visceral artery pseudoaneurysm is a safe and effective alternative for patients not amenable for digital subtraction angiography-guided angioembolization.

Comparison of the management of gastric variceal bleeding techniques

Background and Aim

Managing gastric variceal (GV) hemorrhage is more complicated than managing esophageal variceal (EV) bleeding, resulting in significantly higher morbidity and mortality. We aim to compare the outcomes of endoscopic variceal ligation (EVL), transhepatic intrahepatic portosystemic shunt (TIPS), and balloon-occluded retrograde transvenous obliteration (BRTO) in the management of GV bleeding.

Methods

We utilized the National Inpatient Sample (NIS) database from January 2016 to December 2019 to include adult patients with GV hemorrhage.

Results

Our study identified 7160 hospitalizations with a primary diagnosis of GV hemorrhage who underwent the interventions of interest. EVL was performed in 69.83%, TIPS in 8.72%, and BRTO in 4.88%. Patients with liver cirrhosis had a higher frequency of undergoing BRTO (68.6%), followed by TIPS (64.0%) and esophagogastroduodenoscopy (EGD) + TIPS (63.7%) (P < 0.001). Patients with cirrhosis secondary to alcoholism had a higher prevalence of TIPS (62.4%), followed by EGD + TIPS (69.4%) and BRTO (52.9%) (P < 0.001). Overall, the inpatient mortality was 6.5%. Overall inpatient mortality was highest in the TIPS cohort (8.8%), followed by BRTO (7.1%), EGD + TIPS (6.5%), EVL (6.2%), and EGD + BRTO (2.8%) (P < 0.001); However, the Kaplan-Meier graph showed endoscopy with BRTO had the most favorable 30-day survival, trailed by TIPS alone and BRTO alone.

Conclusion

EVL remains a prominent therapeutic strategy. Remarkably, the combination of endoscopy with BRTO shows promising 30-day survival outcomes. Considering these observations, although EVL holds its primacy, it is essential to further explore the potential benefits of combined therapies in larger studies to ascertain the best treatment strategies.

Ендоскопічне лікування кровотеч із варикозно розширених вен шлунка

Кровотеча з варикозно розширених вен стравоходу та шлунка є найнебезпечнішим для життя ускладненням цирозу печінки та портальної гіпертензії. Кровотеча з варикозно розширених вен шлунка часто є серйознішою та може призвести до смерті. Для її зупинки спочатку проводиться ендоскопічне лікування. Зараз міжнародні консенсусні рекомендації щодо лікування кровотечі з варикозу шлунка відрізняються залежно від ендоскопічної класифікації. Варикозне розширення вен шлунка має іншу фізіологію та клінічні характеристики порівняно з варикозним розширенням вен стравоходу. Існує мало інформації про способи гемостазу при кровотечі зі шлункових вариксів. Незважаючи на те, що кілька нещодавніх розробок щодо препаратів і методів поліпшили результати при цій патології, консенсус щодо оптимального лікування не досягнутий. У цій статті розглядаються сучасні можливості ендоскопічного втручання при варикозній кровотечі зі шлунка за літературними даними з бази MedLine.

Managing gastric varices

Gastric varices (GV) are a type of ectopic varix, which is a natural portosystemic shunt occurring in response to an increase in intrahepatic vascular resistance, mostly commonly from portal hypertension. GV are present in up to 20% of patients with portal hypertension. Although oesophageal varices are more common than GV, and oesophageal variceal bleeding (EVB) happens more often than gastric variceal bleeding (GVB), GVB tends to be more severe, to have higher associated hospital costs, length of stay, higher rebleeding rates and have higher mortality. Mortality rates associated with variceal bleeding range from 6% in EVB to 20%-55% in GVB. Risk factors for GV haemorrhage include location, size, severity of liver failure, presence of variceal red spots, and presence of HCC (hepatocellular carcinoma). This manuscript will review endoscopic and non-endoscopic treatment of GV.

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.

Safety and Efficacy of Thrombin for Bleeding Gastric Varices: A Systematic Review and Meta-Analysis

INTRODUCTION

The optimal therapy for bleeding-related gastric varices is still a controversial topic. There is a paucity of literature that comprehensively summarizes the available literature regarding safety and efficacy of thrombin in bleeding gastric varices.

METHODS

Four independent reviewers performed a comprehensive review of all original articles published from inception to October 2020, describing the use of thrombin for management of bleeding gastric varices. Primary outcomes were (1) pooled early and late rebleeding rate, (2) pooled gastric variceal related mortality rate, (3) pooled rescue therapy rate, and (4) pooled adverse event rate with the use of thrombin in bleeding gastric varices. The meta-analysis was performed and the statistics were two-tailed. Finally, probability of publication bias was assessed using funnel plots and with Egger's test.

RESULTS

Eleven studies were included in the analysis after comprehensive search. This yielded a pooled early rebleeding rate of 9.3% (95% CI 4.9-17) and late rebleeding rate 13.8% (95% CI 9-20.4). Pooled rescue therapy rate after injecting thrombin in bleeding gastric varices was 10.1% (95% CI 6.1-16.3). The pooled 6-week gastric variceal-related mortality rate after injecting thrombin in bleeding gastric varices was 7.6% (95% CI 4.5-12.5). There were a total of four adverse events out of a total of 222 patients with pooled adverse event rate after injecting thrombin in bleeding gastric varices was 5.6% (95% CI 2.9-10.6).

CONCLUSION

In summary, the systematic review and meta-analysis on the use of thrombin for bleeding gastric varices suggest low rates of rebleeding and minimal rates of adverse events. While, early and late rebleeding rate and rescue therapy rate are similar to cyanoacrylate-based therapy, the minimal rates of adverse events are perhaps the most important benefit of thrombin. Thus, the current data suggest that thrombin is a very promising therapeutic alternative with low risk of adverse events for bleeding gastric varices.

Thrombin Is an Effective and Safe Therapy in the Management of Bleeding Gastric Varices. A Real-World Experience

Variceal haemorrhage is a severe complication of liver disease with high mortality. Human recombinant thrombin has gained popularity in the management of variceal haemorrhage. We report on the use of thrombin for gastric and ectopic varices at a regional tertiary care centre. This was a retrospective observational study. Patients with portal hypertension who received endoscopic injection of recombinant thrombin were identified and data collected on haemostasis and rebleeding rates, complications and mortality. Patients were grouped by indication for thrombin injection: gastric/oesophageal/ectopic varices and endoscopic band ligation (EBL)-induced ulceration. 155 patients (96M/59F, mean age 58.3 years) received endoscopic thrombin injection. Mean volume of thrombin injected at index endoscopy was 9.5 ml/2375IU. Initial haemostasis was achieved in 144 patients (92.9%). Rebleeding occurred in a total of 53 patients (36.8%) divided as follows: early rebleeding (<5 days from index endoscopy)-26 patients (18%); rebleeding within 30 days-42 patients (29.1%); delayed rebleeding (> 30 days)-11 patients (7.6%). There was statistically significant difference in rate of initial haemostasis between Child-Pugh A/B patients vs Child-Pugh C (p = 0.046). There was no significant difference in rebleeding rates between different indication groups (p = 0.78), by presence of cirrhosis or by Child-Pugh Score. All-cause mortality at 6 weeks was 18.7%; 1-year mortality 37.4% (median follow-up 48 months). There was no significant difference in mortality between groups (p = 0.37). No significant adverse events or complications were reported. Thrombin is effective and safe for gastric varices and other portal-hypertension-related bleeding including oesophageal varices, ulcers secondary to EBL and ectopic varices.

Beyond the scope and the glue: update on evaluation and management of gastric varices

Gastric varices are encountered less frequently than esophageal varices. Nonetheless, gastric variceal bleeding is more severe and associated with worse outcomes. Conventionally, gastric varices have been described based on the location and extent and endoscopic treatments offered based on these descriptions. With improved understanding of portal hypertension and the dynamic physiology of collateral circulation, gastric variceal classification has been refined to include inflow and outflow based hemodynamic pathways. These have led to an improvement in the management of gastric variceal disease through newer modalities of treatment such as endoscopic ultrasound-guided glue-coiling combination therapy and the emergence of highly effective endovascular treatments such as shunt and variceal complex embolization with or without transjugular intrahepatic portosystemic shunt (TIPS) placement in patients who are deemed ‘difficult’ to manage the traditional way. Furthermore, the decisions regarding TIPS and additional endovascular procedures in patients with gastric variceal bleeding have changed after the emergence of ‘portal hypertension theories’ of proximity, throughput, and recruitment. The hemodynamic classification, grounded on novel theories and its cognizance, can help in identifying patients at baseline, in whom conventional treatment could fail. In this exhaustive review, we discuss the conventional and hemodynamic diagnosis of gastric varices concerning new classifications; explore and illustrate new ‘portal hypertension theories’ of gastric variceal disease and corresponding management and shed light on current evidence-based treatments through a ‘new’ algorithmic approach, established on hemodynamic physiology of gastric varices.

No Benefit of Hemostatic Drugs on Acute Upper Gastrointestinal Bleeding in Cirrhosis

BACKGROUND AND AIMS

Acute upper gastrointestinal bleeding (AUGIB) is one of the most life-threatening emergency conditions. Hemostatic drugs are often prescribed to control AUGIB in clinical practice but have not been recommended by major guidelines and consensus. The aim of this study was to investigate the therapeutic effect of hemostatic drugs on AUGIB in cirrhosis.

METHODS

All cirrhotic patients with AUGIB who were admitted to our hospital from January 2010 to June 2014 were retrospectively included. Patients were divided into hemostatic drugs and no hemostatic drug groups. A 1 : 1 propensity score matching (PSM) analysis was performed by adjusting age, gender, etiology of liver disease, Child-Pugh score, MELD score, hematemesis, red blood cell transfusion, vasoactive drugs, antibiotics, proton pump inhibitors, and endoscopic variceal therapy. Primary outcomes included 5-day rebleeding and in-hospital mortality.

RESULTS

Overall, 982 cirrhotic patients with AUGIB were included (870 in hemostatic drugs group and 112 in no hemostatic drug group). In overall analyses, hemostatic drugs group had a significantly higher 5-day rebleeding rate (18.10% versus 5.40%, P = 0.001) than no hemostatic drug group; in-hospital mortality was not significantly different between them (7.10% versus 4.50%, P = 0.293). In PSM analyses, 172 patients were included (86 patients in each group). Hemostatic drugs group still had a significantly higher 5-day rebleeding rate (15.10% versus 5.80%, P = 0.046); in-hospital mortality remained not significantly different (7.00% versus 3.50%, P = 0.304) between them. Statistical results remained in PSM analyses according to the type of hemostatic drugs.

CONCLUSIONS

The use of hemostatic drugs did not improve the in-hospital outcomes of cirrhotic patients with AUGIB.

Gastric variceal bleeding

PURPOSE OF REVIEW

There are no well-established guidelines for the management of gastric variceal bleeding. Endoscopic management of acute gastric variceal bleeding has been premised on the injection of sclerosants and synthetic glue. However, these therapies are associated with various complications including systemic embolization and recurrent bleeding. Recently, endoscopic ultrasound (EUS)-guided interventions including coil injection have emerged as promising modalities with high technical and clinical success rates and low rates of recurrence.

RECENT FINDINGS

In this review we discuss the classification, natural history, prognosis, and treatment options of gastric variceal. Discussion of treatment is further subdivided into primary and secondary prophylaxis and the management of acute gastric variceal bleeding with a focus on emerging endoscopic interventions.

SUMMARY

Cyanoacrylate injection may have a role in the primary and secondary prophylaxis of gastric variceal. Endoscopic band ligation should be considered for GOV1. EUS-guided injection of synthetic glues like cyanoacrylate is superior to direct injection. However, EUS-guided coil injections with or without cyanoacrylate should be considered first-line endoscopic treatment in all bleeding gastric variceal except for GOV1. Balloon retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunts (TIPS) remain important interventional radiologic therapeutic options as primary therapy in centers without EUS expertise or as salvage therapy.

Current Approaches to the Treatment of Gastric Varices: Glue, Coil Application, TIPS, and BRTO

Gastric varices are less common than esophageal varices, and their treatment is quite challenging. Gastric varix bleedings (GVB) occur less frequently than esophageal varix (EV) bleedings and represent 10% to 30% of all variceal bleedings. They are; however, more severe and are associated with high mortality. Re-bleeding may occur in 35% to 90% of cases after spontaneous hemostasis. GV bleedings represent a serious clinical problem compared with esophageal varices due to their location. Sclerotherapy and band ligation, in particular, are less effective. Based on the anatomic site and location, treatment differs from EV and is categorized into two groups (i.e., endoscopic or radiologic treatment). Surgical management is used less frequently. Balloon-occluded retrograde transvenous obliteration (BRTO) and cyanoacrylate are safe but there is a high risk of re-bleeding. Portal pressure elevates following BRTO and leads to worsening of esophageal varix pressure. Other significant complications may include hemoglobinuria, abdominal pain, fever, and pleural effusion. Shock and atrial fibrillation are major complications. New and efficient treatment modalities will be possible in the future.

Update on management of gastric varices

Gastric varices (GV) have different physiology and clinical characteristics compared to oesophageal varices (OV). There is little information about the management of GV. Most part of the recommendations is extrapolated from studies where the majority of participants had OV. Thus, most recommendations lack of strong evidence. This is a comprehensive review on all aspects of management of GV, i.e., primary, secondary prophylaxis and management of acute bleeding. The papers on which international societies’ recommendations are based are scrutinised in this review and areas of research are identified.

Blood, blood components, plasma, and plasma products

This review of 2018 publications identifies side effects of blood, blood components, and plasma products. In addition, albumin, blood transfusion (erythrocytes, granulocytes, and platelets), blood substitutes (hemoglobin-based oxygen carriers), plasma products (alpha1-antitrypsin, C1 esterase inhibitor concentrate, cryoprecipitate, and fresh frozen plasma), plasma substitutes (etherified starches, and gelatin), globulins (intravenous immunoglobulin, subcutaneous immunoglobulin, and anti-D immunoglobulin), coagulation proteins (factor I, factor II, factor VIIa, factor VIII, factor IX, prothrombin complex concentrate, antithrombin III, and von Willebrand factor/factor VIII concentrates), erythropoietin and derivatives, thrombopoietin and receptor agonists, transmission of infectious agents through blood donation, and stem cells are reviewed. This chapter informs the reader about newly recognized and published data in the blood product domain.