Octreotide infusion or emergency sclerotherapy for variceal haemorrhage

Treatment for bleeding oesophageal varices in people with decompensated liver cirrhosis: a network meta-analysis

BACKGROUND

Approximately 40% to 95% of people with liver cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed within about one to three years after diagnosis. Several different treatments are available, including, among others, endoscopic sclerotherapy, variceal band ligation, somatostatin analogues, vasopressin analogues, and balloon tamponade. However, there is uncertainty surrounding the individual and relative benefits and harms of these treatments.

OBJECTIVES

To compare the benefits and harms of different initial treatments for variceal bleeding from oesophageal varices in adults with decompensated liver cirrhosis, through a network meta-analysis; and to generate rankings of the different treatments for acute bleeding oesophageal varices, according to their benefits and harms.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until 17 December 2019, to identify randomised clinical trials (RCTs) in people with cirrhosis and acute bleeding from oesophageal varices.

SELECTION CRITERIA

We included only RCTs (irrespective of language, blinding, or status) in adults with cirrhosis and acutely bleeding oesophageal varices. We excluded RCTs in which participants had bleeding only from gastric varices, those who failed previous treatment (refractory bleeding), those in whom initial haemostasis was achieved before inclusion into the trial, and those who had previously undergone liver transplantation.

DATA COLLECTION AND ANALYSIS

We performed a network meta-analysis with OpenBUGS software, using Bayesian methods, and calculated the differences in treatments using odds ratios (OR) and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. We performed also the direct comparisons from RCTs using the same codes and the same technical details.

MAIN RESULTS

We included a total of 52 RCTs (4580 participants) in the review. Forty-eight trials (4042 participants) were included in one or more comparisons in the review. The trials that provided the information included people with cirrhosis due to varied aetiologies and those with and without a previous history of bleeding. We included outcomes assessed up to six weeks. All trials were at high risk of bias. A total of 19 interventions were compared in the trials (sclerotherapy, somatostatin analogues, vasopressin analogues, sclerotherapy plus somatostatin analogues, variceal band ligation, balloon tamponade, somatostatin analogues plus variceal band ligation, nitrates plus vasopressin analogues, no active intervention, sclerotherapy plus variceal band ligation, balloon tamponade plus sclerotherapy, balloon tamponade plus somatostatin analogues, balloon tamponade plus vasopressin analogues, variceal band ligation plus vasopressin analogues, balloon tamponade plus nitrates plus vasopressin analogues, balloon tamponade plus variceal band ligation, portocaval shunt, sclerotherapy plus transjugular intrahepatic portosystemic shunt (TIPS), and sclerotherapy plus vasopressin analogues). We have reported the effect estimates for the primary and secondary outcomes when there was evidence of differences between the interventions against the reference treatment of sclerotherapy, but reported the other results of the primary and secondary outcomes versus the reference treatment of sclerotherapy without the effect estimates when there was no evidence of differences in order to provide a concise summary of the results. Overall, 15.8% of the trial participants who received the reference treatment of sclerotherapy (chosen because this was the commonest treatment compared in the trials) died during the follow-up periods, which ranged from three days to six weeks. Based on moderate-certainty evidence, somatostatin analogues alone had higher mortality than sclerotherapy (OR 1.57, 95% CrI 1.04 to 2.41; network estimate; direct comparison: 4 trials; 353 participants) and vasopressin analogues alone had higher mortality than sclerotherapy (OR 1.70, 95% CrI 1.13 to 2.62; network estimate; direct comparison: 2 trials; 438 participants). None of the trials reported health-related quality of life. Based on low-certainty evidence, a higher proportion of people receiving balloon tamponade plus sclerotherapy had more serious adverse events than those receiving only sclerotherapy (OR 4.23, 95% CrI 1.22 to 17.80; direct estimate; 1 RCT; 60 participants). Based on moderate-certainty evidence, people receiving vasopressin analogues alone and those receiving variceal band ligation had fewer adverse events than those receiving only sclerotherapy (rate ratio 0.59, 95% CrI 0.35 to 0.96; network estimate; direct comparison: 1 RCT; 219 participants; and rate ratio 0.40, 95% CrI 0.21 to 0.74; network estimate; direct comparison: 1 RCT; 77 participants; respectively). Based on low-certainty evidence, the proportion of people who developed symptomatic rebleed was smaller in people who received sclerotherapy plus somatostatin analogues than those receiving only sclerotherapy (OR 0.21, 95% CrI 0.03 to 0.94; direct estimate; 1 RCT; 105 participants). The evidence suggests considerable uncertainty about the effect of the interventions in the remaining comparisons where sclerotherapy was the control intervention.

AUTHORS' CONCLUSIONS

Based on moderate-certainty evidence, somatostatin analogues alone and vasopressin analogues alone (with supportive therapy) probably result in increased mortality, compared to endoscopic sclerotherapy. Based on moderate-certainty evidence, vasopressin analogues alone and band ligation alone probably result in fewer adverse events compared to endoscopic sclerotherapy. Based on low-certainty evidence, balloon tamponade plus sclerotherapy may result in large increases in serious adverse events compared to sclerotherapy. Based on low-certainty evidence, sclerotherapy plus somatostatin analogues may result in large decreases in symptomatic rebleed compared to sclerotherapy. In the remaining comparisons, the evidence indicates considerable uncertainty about the effects of the interventions, compared to sclerotherapy.

Efficacy of endoscopic treatments for acute esophageal variceal bleeding in cirrhotic patients: systematic review and meta-analysis

Background and aim  Guidelines recommend use of ligation and vasoactive drugs as first-line therapy and as grade A evidence for acute variceal bleeding (AVB), although Western studies about this issue are lacking. Methods  We performed a systematic review and meta-analysis of randomized controlled trials (RCT) to evaluate the efficacy of endoscopic treatments for AVB in patients with cirrhosis. Trials that included patients with hepatocellular carcinoma, use of portocaval shunts or esophageal resection, balloon tamponade as first bleeding control measure, or that received placebo or elective treatment in one study arm were excluded. Results  A total of 8382 publications were searched, of which 36 RCTs with 3593 patients were included. Ligation was associated with a significant improvement in bleeding control (relative risk [RR] 1.08; 95 % confidence interval [CI] 1.02 - 1.15) when compared to sclerotherapy. Sclerotherapy combined with vasoactive drugs showed higher efficacy in active bleeding control compared to sclerotherapy alone (RR 1.17; 95 % CI 1.10 - 1.25). The combination of ligation and vasoactive drugs was not superior to ligation alone in terms of overall rebleeding (RR 2.21; 95 %CI 0.55 - 8.92) and in-hospital mortality (RR 1.97; 95 %CI 0.78 - 4.97). Other treatments did not generate meta-analysis. Conclusions  This study showed that ligation is superior to sclerotherapy, although with moderate heterogeneity. The combination of sclerotherapy and vasoactive drugs was more effective than sclerotherapy alone. Although current guidelines recommend combined use of ligation with vasoactive drugs in treatment of esophageal variceal bleeding, this study failed to demonstrate the superiority of this combined treatment.

Effects of a Long-Acting Formulation of Octreotide on Patients with Portal Hypertension

Objective

This study aimed to determine whether the treatment of a long-acting formulation of octreotide (OCT-LAR) exerted a similar effect on improving the prognosis of patients with portal hypertension compared with placement of transjugular intrahepatic portosystemic shunts (TIPSs).

Methods

A total of 24 patients with portal hypertension who underwent TIPS placement or OCT-LAR treatment from January 2010 to January 2015 were reviewed. Hemodynamic studies, biological values, live functions, and treatment complications before and during the treatment were evaluated.

Results

Baseline clinical characteristics were similar between two groups. Hepatic venous pressure gradient (HVPG) was improved in OCT-LAR groups (15.9 ± 2.4 to 12.8 ± 1.6 mmHg). Both groups showed a slight decrease in endothelin-1 (ET-1) and urotensin II and a slight increase in oxide metabolite (NOx) concentrations with no significant difference. Aspartate aminotransferase and alanine aminotransferase increased one week after TIPS placement when they improved in the OCT-LAR treatment group. The complications of OCT-LAR treatment were minor and transient. However, one patient who received TIPS placement presented procedure-related complications and required rehospitalization, and 2 patients had developed hepatic encephalopathy during the follow-up period.

Conclusion

Prolonged administration of OCT-LAR exerted a virtually similar effect on improving hemodynamic parameters and liver function in patients with portal hypertension compared with placement of TIPS, with no apparent serious adverse effects.

Common pitfalls in statistical analysis: "No evidence of effect" versus "evidence of no effect"

This article is the first in a series exploring common pitfalls in statistical analysis in biomedical research. The power of a clinical trial is the ability to find a difference between treatments, where such a difference exists. At the end of the study, the lack of difference between treatments does not mean that the treatments can be considered equivalent. The distinction between "no evidence of effect" and "evidence of no effect" needs to be understood.

Successful use of long-acting octreotide for intractable chronic gastrointestinal bleeding in children

BACKGROUND AND AIMS

Octreotide reduces splanchnic blood flow and is effective in controlling gastrointestinal bleeding (GIB) caused by portal hypertension. Monthly long-acting octreotide (OCT-LAR) with an efficacy and safety profile similar to subcutaneous daily administration presents an attractive option for long-term therapy. We report our experience with OCT-LAR for severe/recurrent GIB in children with portal hypertension secondary to chronic liver disease or portal vein thrombosis who were unresponsive to standard interventions.

METHODS

A total of 9 patients, 7 boys, who received OCT-LAR between 2000 and 2009 were studied retrospectively (median age at first bleeding 21 months, range 1 month-14.5 years). The dose (2.5-20 mg intramuscularly monthly) was extrapolated from that used in adult acromegaly and neuroendocrine tumours (10-60 mg/mo). Response to treatment was assessed by comparing the number of bleeding events, hospital admissions for acute bleeding, and number of blood units required during the year before and year after starting OCT-LAR.

RESULTS

OCT-LAR led to a reduction in the number of bleeding episodes in all of the children and to cessation of bleeding in 7. Two children listed for transplantation because of severe GIB were removed from the list. No serious adverse effects immediately attributable to OCT-LAR were observed. One child developed growth hormone deficiency and hypothyroidism during a prolonged period of treatment with subcutaneous octreotide before commencing OCT-LAR.

CONCLUSIONS

OCT-LAR can control severe intractable recurrent GIB in children with portal hypertension. Prospective randomised controlled trials and pharmacokinetic studies are indicated to establish the optimum dose and length of treatment of OCT-LAR and confirm its efficacy and long-term safety in children.

Octreotide infusion for malignant duodenal obstruction in a 12-year-old girl with metastatic peripheral nerve sheath tumor

Malignant bowel obstruction is a common complication of some adult malignancies. In childhood cancer, malignant bowel obstruction is relatively rare. Octreotide, an analogue of the hormone somatostatin, has been shown to be an effective treatment for this condition in adults. However, explicit description of its use for this indication in children was not discovered in the pediatric literature by this group of authors. The following report is that of a 12-year-old female who had copious bilious emesis secondary to malignant obstruction of the distal duodenum, which abated after treatment with a continuous intravenous octreotide infusion.

Medical management of variceal hemorrhage

Gastroesophageal variceal hemorrhage is a major complication of portal hypertension in 50% to 60% of patients with liver cirrhosis and is a frequent cause of mortality in these patients. The prevalence of variceal hemorrhage is approximately 5% to 15% yearly, and early variceal rebleeding has a rate of occurrence of 30% to 40% within the first 6 weeks. More than 50% of patients who survive after the first bleeding episode will experience recurrent bleeding within 1 year. Management of gastroesophageal varices should include prevention of initial and recurrent bleeding episodes and control of active hemorrhage. Therapies used in the management of gastroesophageal variceal hemorrhage may include pharmacologic therapy (vasoactive agents, nonselective b-blockers, and antibiotic prophylaxis), endoscopic therapy, transjugular intrahepatic portosystemic shunt, and shunt surgery. This article focuses primarily on pharmacologic management of acute variceal hemorrhage.

Management of acute esophageal variceal hemorrhage

Acute esophageal variceal hemorrhage (AEVH) is a severe complication of portal hypertension. Its management has rapidly evolved in recent years. Traditional methods included vasoconstrictor and balloon tamponade. Vasoconstrictors were shown to control approximately 80% of the bleeding episodes and are generally used as a first-line therapy. Following the use of vasoconstrictors, endoscopic therapy is often used to arrest the bleeding varices and prevent early rebleeding. A meta-analysis showed that the combination of vasoconstrictor and endoscopic therapy is superior to endoscopic therapy alone for controlling AEVH. Balloon tamponade may be used to achieve temporary control of the hemorrhage in case of severe bleeding. A transjugular intrahepatic portosystemic stent shunt may be needed in patients with refractory acute variceal hemorrhage. Surgical intervention is now widely contraindicated during acute variceal hemorrhage, except for patients with good liver reserve. Conversely, apart from the control of acute variceal hemorrhage, prophylactic antibiotics were shown to be helpful in the prevention of bacterial infection and to prevent early variceal rebleeding. With the introduction of new treatment modalities and the measures taken to manage patients with AEVH, the mortality due to AEVH has significantly decreased in recent years.

Quality of life in children managed for extrahepatic portal venous obstruction

OBJECTIVES

There are no studies on health-related quality of life (HRQOL) in children with extrahepatic portal venous obstruction (EHPVO). The present study evaluated the QOL in children with EHPVO, prevariceal and postvariceal esophageal variceal eradication, and postsurgery in comparison with healthy controls.

METHODS

Children with EHPVO and variceal bleeding were divided into 3 groups: group A, before variceal eradication (n = 50); group B, after variceal eradication (n = 50); and group C, after surgery (n = 12). Group D comprised healthy children (n = 50). Clinical details and investigations were recorded. The Pediatric Quality of Life Inventory parent-proxy HRQOL questionnaire was used for assessment of QOL.

RESULTS

Compared with controls, patients with EHPVO in groups A, B, and C had lower median QOL scores in physical, emotional, social, and school functioning health domains. Esophageal variceal eradication had no significant effect on QOL (median total QOL score pre- and postvariceal eradication of 87.5 vs 86.3). Increasing size of spleen (mild 92.5, moderate 88.2, and severe 76.2; P < 0.001), presence of hypersplenism (90 vs 73.7, P = 0.001), and growth retardation (90 vs 82.5, P = 0.04) caused significant reduction of the total QOL score. On multivariate regression analysis, splenic size and growth retardation were found to be independent predictors that affect the QOL. After surgery, a trend toward improvement in physical, psychosocial, and total QOL scores was present, but it was not significant.

CONCLUSIONS

Children with EHPVO have a poor QOL that is not affected by variceal eradication. Splenomegaly and growth retardation significantly affect the HRQOL. A trend toward improvement of QOL scores is observed in the postsurgery group.

Emergency sclerotherapy versus vasoactive drugs for bleeding oesophageal varices in cirrhotic patients

BACKGROUND

Emergency sclerotherapy is still widely used as a first line therapy for variceal bleeding in patients with cirrhosis, particularly when banding ligation is not available or feasible. However, pharmacological treatment may stop bleeding in the majority of these patients.

OBJECTIVES

To assess the benefits and harms of emergency sclerotherapy versus vasoactive drugs for variceal bleeding in cirrhosis.

SEARCH STRATEGY

Search of trials was based on The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded through January 2010.

SELECTION CRITERIA

Randomised clinical trials comparing sclerotherapy with vasoactive drugs (vasopressin (with or without nitroglycerin), terlipressin, somatostatin, or octreotide) for acute variceal bleeding in cirrhotic patients.

DATA COLLECTION AND ANALYSIS

Outcome measures were failure to control bleeding, five-day treatment failure, rebleeding, mortality, number of blood transfusions, and adverse events. Data were analysed by a random-effects model according to the vasoactive treatment. Sensitivity analyses included combined analysis of all the trials irrespective of the vasoactive drug, type of publication, and risk of bias.

MAIN RESULTS

Seventeen trials including 1817 patients were identified. Vasoactive drugs were vasopressin (one trial), terlipressin (one trial), somatostatin (five trials), and octreotide (ten trials). No significant differences were found comparing sclerotherapy with each vasoactive drug for any outcome. Combining all the trials irrespective of the vasoactive drug, the risk differences (95% confidence intervals) were failure to control bleeding -0.02 (-0.06 to 0.02), five-day failure rate -0.05 (-0.10 to 0.01), rebleeding 0.01 (-0.03 to 0.05), mortality (17 randomised trials, 1817 patients) -0.02 (-0.06 to 0.02), and transfused blood units (8 randomised trials, 849 patients) (weighted mean difference) -0.24 (-0.54 to 0.07). Adverse events 0.08 (0.03 to 0.14) and serious adverse events 0.05 (0.02 to 0.08) were significantly more frequent with sclerotherapy.

AUTHORS' CONCLUSIONS

We found no convincing evidence to support the use of emergency sclerotherapy for variceal bleeding in cirrhosis as the first, single treatment when compared with vasoactive drugs. Vasoactive drugs may be safe and effective whenever endoscopic therapy is not promptly available and seems to be associated with less adverse events than emergency sclerotherapy. Other meta-analyses and guidelines advocate that combined vasoactive drugs and endoscopic therapy is superior to either intervention alone.

Urgent vs. non-urgent endoscopy in stable acute variceal bleeding

OBJECTIVES

The optimal timing of endoscopy with acute variceal bleeding (AVB) is unknown. The aim of this study was to evaluate the association between the timing of endoscopy and outcomes of stable AVB patients.

METHODS

Patients admitted at two tertiary-care centers with hemodynamically stable AVB from 1997 to 2006 were evaluated retrospectively. The primary outcome was mortality. Other recorded outcomes included stigmata at endoscopy, hemostasis, blood transfusions, rebleeding, renal function, hospitalization length, infection, transjugular intrahepatic portosystemic shunt use, and balloon tamponade use. Logistic regression analysis was used to assess the association of time to endoscopy with mortality. Outcome comparisons were also performed for three different urgency times (< or = vs. > 4 h, < or = vs. > 8 h, and < or = vs. > 12 h).

RESULTS

There were 210 patients with stable AVB, accounting for 52% of the total number of AVB patients. The mean (+/- s.d.) age was 55 (+/- 12) years. The mean presenting systolic blood pressure and heart rate were 121 (+/- 16) mm Hg and 98 (+/- 20) bpm, respectively. Esophageal varices accounted for 91% (n = 191) of variceal bleeding. The mean time to endoscopy was 12 (+/- 12) h. The overall hemostasis rate after endoscopy was 97% (n = 203). The mortality rate was 9.5% (n = 20). There was no significant association of time to endoscopy with mortality (odds ratio, OR, 1.0; 95% confidence interval, CI, 0.92-1.08; P = 0.91). Significant independent predictors for mortality were lower albumin (OR, 0.82; 95% CI, 0.73-0.93; P = 0.001), infection during admission (OR, 8.9; 95% CI, 2.5-31.6; P < 0.001), and higher model end-stage liver disease (MELD) (OR, 1.17; 95% CI, 1.06-1.29; P = 0.002). There was no difference in outcomes with different urgency times.

CONCLUSIONS

For patients who present with hemodynamically stable variceal bleeding, hemostasis after endoscopy is high, and the time to endoscopy does not appear to be associated with mortality.

Avoiding pitfalls: what an endoscopist should know in liver transplantation--part 1

Cirrhosis is associated with global homodynamic changes, but the majority of the complications are usually manifested through the gastrointestinal tract. Therefore, Gastrointestinal Endoscopy has become an important tool in the multidisciplinary approach in the management of these patients. With the ever growing number of cirrhotic patients requiring pre-transplant endoscopic management, it is imperative that the community endoscopists are well aware of the pathologies that can be potentially noted on Gastrointestinal Endoscopy. Their timely management is also considered to have the utmost importance in being able to stabilize the patient until their transfer to a Liver Transplant Center. The aim of this manuscript is to give a comprehensive update and review of various endoscopic findings that a non-transplant endoscopist will encounter in the pre-transplant setting.

A case of an isolated gastric variceal bleed secondary to a pancreatic neuroendocrine tumour

Gastric varices are an important complication of portal hypertension. We present here a case of bleeding gastric varices secondary to a pancreatic neuroendocrine tumour. To our knowledge, there are no other reports in the literature. Such cases are always a timely and important reminder of the importance in considering causes of portal hypertension other than cirrhosis, particularly in patients with limited risk factors for liver disease.

Management of acute bleeding from portal hypertension

Gastrointestinal bleeding is a frequent and severe complication of portal hypertension. The most frequent cause of the bleeding is variceal rupture. Despite improvements in prognosis after variceal bleeding over the past two decades, the 6-week mortality rate remains high, ranging from 15 to 30%. Patients die from uncontrolled bleeding, early rebleeding, infection, or renal failure within the first weeks of a bleeding episode. Poor hepatic function, severe portal hypertension with a hepatic venous pressure gradient (HVPG) >20 mmHg, and active bleeding at endoscopy are independently associated with poor prognosis. First-line treatment includes resuscitation, prophylactic antibiotic therapy, the combined use of vasoactive drugs (started as soon as possible), and an endoscopic procedure. Reconstitution of blood volume should be done cautiously to maintain the haematocrit between 25 and 30%. Terlipressin, somatostatin, or octreotide can be used, and drug therapy is maintained from 48 h to 5 days. Ligation is the endoscopic treatment of choice in bleeding oesophageal varices; in gastric varices, obturation with cyanoacrylate is preferable. Uncontrolled bleeding should be an indication for a salvage transjugular portosystemic shunt (TIPS). In patients with Child-Pugh score A, shunt surgery might be an alternative to TIPS. Trials are currently ongoing into the precise indications of early TIPS in selected patients with an HVPG >20 mmHg, and into the usefulness of administration of recombinant activated factor VII when there is an active bleeding at endoscopy.

Emergency management of bleeding esophageal varices: drugs, bands or sleep?

Variceal bleeding is a severe complication of cirrhosis leading to significant morbidity and mortality. Treatment of acute variceal bleeding has improved dramatically since the era of the mechanical balloon tamponade. These advances include endoscopic band ligation or sclerotherapy, and vasoactive pharmacological options such as somatostatin, octreotide, vasopressin and terlipressin. Evidence from a multitude of clinical trials and meta-analyses comparing endoscopic and pharmacological treatments suggests near equivalence in efficacy for initial hemostasis, mortality and rate of rebleeding. This raises the question of whether on-call gastroenterologists should be performing emergency endoscopic treatment in the middle of the night or start pharmacological treatment and delay endoscopy until optimal patient and working conditions the next morning. The present review analyzes the available comparative data between endoscopic and pharmacological treatment options. Although the literature cannot yet definitively answer the question posed, the authors suggest that delaying endoscopic treatment until the next morning may be the most reasonable practical approach.

Octreotide in liver cirrhosis: a salvage for variceal bleeding can be a gunshot for kidneys

BACKGROUND

The renal effects of octreotide, used for bleeding esophageal varices in cirrhosis, are controversial.

METHODS

Fourteen cirrhotic patients (Child-Pugh; A/B/C: 1/12/1) were enrolled. Plasma nitrite and endothelin (ET) levels, urinary nitrite output, free water clearance (FWC) and fractional excretion of filtered sodium (FENa) were measured and renal Doppler ultrasound was carried out. Octreotide was infused at a rate of 0.75 microg/kg/h for 3 h after a bolus of 0.75 microg/kg body weight. All the parameters were reevaluated during octreotide administration while the patients acted as their own controls.

RESULTS

Octreotide induced significant reductions in urinary nitrite, FENa and FWC. Plasma ET levels increased (baseline: 6.7 pg/ml, octreotide: 8.4 pg/ml), whereas the plasma nitrite level did not change significantly after octreotide infusion. Overall, no significant change in renal resistive index (RRI) could be demonstrated on Doppler after octreotide administration. However, patients with elevated baseline RRI values had significantly more deterioration in FWC and FENa compared with patients with normal RRI in response to octreotide.

CONCLUSION

A marked decrease in FENa, FWC and urinary nitrite output, together with a significant increase in plasma ET level in response to octreotide, may indicate renal dysfunction in cirrhotic patients. This deleterious renal effect of octreotide may be more enhanced in patients with elevated baseline RRI.

Endoscopic Treatment of Upper Gastrointestinal Bleeding

Endoscopic therapy for nonvariceal bleeding should only be used if major stigmata of hemorrhage such as active bleeding and nonbleeding visible vessel are present. Treatment of peptic ulcers with adherent clots is currently controversial. Combination of epinephrine injection and coaptive coagulation is most effective in achieving endoscopic hemostasis. Hemoclips may be preferable for very deep ulcers and large visible blood vessels if coaptive coagulation is anticipated to have a high risk of perforation or bleeding. Adrenaline injection or hemoclip application should be used in bleeding Mallory-Weiss tears, as the safety of thermal methods is not well established. Argon plasma coagulation is the mainstay of endoscopic treatment for superficial lesions such as angiodysplasia and gastric antral vascular ectasia. Both sclerotherapy and band ligation are effective in acute hemostasis of bleeding esophageal varices. Variceal band ligation is preferred due to its superior safety profile and shorter procedure time. Due to the early recurrence of varices after banding ligation, there may be a role for metachronous combination therapy of ligation followed by sclerotherapy. Histoacryl glue is the preferred method of endoscopic hemostasis in gastric varices.

Gastrointestinal hemorrhage: is the surgeon obsolete?

The management of GI hemorrhage has undergone tremendous evolution in recent decades. Once commonly managed by surgeons, the almost continuous introduction of new technologies and pharmacotherapies has dramatically improved clinicians' ability to identify and control sources of bleeding without surgery. Although a gastroenterologist can successfully manage most cases of GI hemorrhage endoscopically, surgical consultation remains an important consideration for the emergency physician in selected cases.

Somatostatin, somatostatin analogues and other vasoactive drugs in the treatment of bleeding oesophageal varices

Somatostatin and its analogues have been compared with a variety of other treatments for the treatment of variceal bleeding in cirrhotic patients. Meta-analyses of studies comparing somatostatin or octreotide with vasopressin or terlipressin have shown that somatostatin is somewhat superior to vasopressin and equivalent to terlipressin in controlling bleeding and has significantly fewer side effects; no difference in mortality was observed. Octreotide was somewhat better than vasopressin and terlipressin in controlling bleeding, with similar mortality. Meta-analysis of trials comparing somatostatin or octreotide with endoscopic sclerotherapy shows that both drugs are equivalent to sclerotherapy for bleeding control, early rebleeding and survival. Complications are much less frequent with drug treatment. Nine trials have compared endoscopic therapy with therapeutic regimens combining endoscopic treatment with somatostatin, octreotide or vapreotide. Meta-analysis show that the combined regimens increase the 5 days bleeding control rate of endoscopic treatments by over 20%, although there is no difference in mortality. Comparisons of somatostatin and octreotide with combined regimens of sclerotherapy + somatostatin and sclerotherapy + octreotide have shown that the combined regimens were better than drug treatments alone in controlling bleeding and preventing early rebleeding, while complications were significantly less frequent with drug therapy.

Octreotide therapy for control of acute gastrointestinal bleeding in children

OBJECTIVES

To evaluate the outcomes of octreotide use in children with gastrointestinal bleeding with or without portal hypertension.

METHODS

The medical charts of children who received continuous octreotide infusion for the indication of gastrointestinal bleeding from January 1995 to December 2000 were retrospectively reviewed.

RESULTS

Twenty-one children with portal hypertension received octreotide infusions (1-2 microg/kg/h) during 35 gastrointestinal bleeding episodes. The duration of infusion ranged from 19 hours to 7 days. Bleeding ceased in 71% of children. Post-treatment rebleeding occurred in 52%, and the mortality was 19%. Response to octreotide, rebleeding, and mortality did not differ significantly between patients with or without intrinsic liver disease. Twelve children with gastrointestinal bleeding unrelated to portal hypertension received octreotide during 14 episodes. The duration of octreotide ranged from 3 hours to 36 days. Fifty percent of children had resolution of bleeding during the infusion. Post-treatment rebleeding occurred in 29%, and the mortality was 50%. No major adverse events were observed in either group.

CONCLUSIONS

A high rate of bleeding control was achieved with octreotide during acute gastrointestinal bleeding in children with portal hypertension. However, controlled studies are needed for more definitive description of its clinical effects. The role of octreotide is less clear in gastrointestinal bleeding unrelated to portal hypertension.

An assessment of the management of acute bleeding varices: a multicenter prospective member-based study

OBJECTIVE

Bleeding from esophagogastric varices is a major complication of portal hypertension. Despite recent practice guidelines for the management of bleeding esophageal or gastric varices, the widespread application of these measures by gastroenterologists has not been evaluated. The purpose of this study was to continue the concept of membership-based research within diverse practice settings by expanding the American College of Gastroenterology (ACG) GI Bleeding Registry to assess the management and outcome of acute variceal bleeding.

METHODS

All ACG members (domestic and foreign) were invited to participate during the 1997 Annual Fall meeting and by mail. Data were collected over 12 months. Information obtained included physician training, practice demographics, patient demographics, disease etiology and severity, clinical presentation, medications, transfusion needs, therapy, complications, and rebleeding within 2 wk.

RESULTS

A total of 93 physicians/centers (79.6% domestic, 26.9% university and affiliated, 3.2% Veterans Affairs) participated. Complete demographic data were available for 725 of the 741 patients enrolled with index bleeding. The median age of these 725 patients was 52 yr and 73.3% were male. The most common single etiology for portal hypertension was cirrhosis (94.3%). The most common causes of cirrhosis were alcohol (56.7%), hepatitis C virus (30.3%), and hepatitis B virus (10.0%). Hemodynamic instability was noted in 60.7% of the patients (22.3% tachycardic, 9.7% orthostatic, 28.7% hypotensive). Index interventions included banding (40.8%; median five bands), sclerotherapy (36.3%), combination banding/sclerotherapy (6.2%), octreotide (52.6%; median 3 days), balloon tamponade (5.5%), transjugular intrahepatic portosystemic shunt (TIPS) (6.6%), liver transplantation (1.1%), surgical shunt (0.7%), and embolization (0.1%). Transfusion of packed red blood cells, fresh frozen plasma, and platelets was given in 83.4%, 44.7%, and 24.6% of the patients with index bleeding, respectively. Median transfusion was four units of packed red blood cells, three units of fresh frozen plasma, and 1.5 units of platelets. Rebleeding occurred in 92 of the 741 patients (12.6%) at a median of 7 days (mean 11 days) and was treated by banding (18.5%; median six bands), sclerotherapy (30.4%), octreotide (63%; median 2 days), balloon tamponade (17.4%), TIPS (15.2%), and surgical shunt (3.3%). Complications from the index bleeding and rebleeding within 2 wk included ulceration (2.6%, 2.2%), aspiration (2.4%, 3.3%), medication side effects (0.8%, 0%), dysphagia (2.3%, 0%), odynophagia (2.2%,0%), encephalopathy (13%,17.4%), and hepatorenal syndrome (2.4%, 2.2%), respectively. After the index bleeding, 46.2% of patients were treated with beta-blockers and 8.2% with nitrates. The majority of patients with index bleeding had Child's B cirrhosis (61.5%). Patients presenting with recurrent bleeding had mostly Child's B (46.7%) or Child's C cirrhosis (44.6%). The overall short-term mortality after index bleeding was 12.9%.

CONCLUSIONS

Acute variceal hemorrhage occurs more often in patients with Child's B and C cirrhosis. Endoscopic banding is the most common single endoscopic intervention. Adjunctive pharmacotherapy is prevalent acutely and after stabilization. Both morbidity and mortality may be lower than reported in previous studies.

Effectiveness of octreotide in a case of refractory sulfonylurea-induced hypoglycemia

The use of sulfonylurea medications in the treatment of type 2 diabetes mellitus is common. Patients who present to the Emergency Department after ingestion of excessive amounts of suflonylurea medications often have hypoglycemia refractory to dextrose administration. Standard care includes the administration of dextrose, glucagon, and diazoxide. Recently, the use of octreotide has been described as an alternative treatment in these patients. We present a case of a 20-year-old woman who ingested 900 mg of glyburide causing refractory hypoglycemia resistant to treatment with intravenous dextrose, glucagon, and diazoxide. Octreotide administration rapidly reversed hypoglycemia allowing patient stabilization and eventual discharge without any significant adverse events.

Review article: the management of acute variceal bleeding

Variceal haemorrhage is a common medical emergency with a high mortality (30-50%). Adequate resuscitation is vital, and once stabilised the patient should be moved to a high-dependency area. Antibiotics reduce mortality, and the vasoactive drug terlipressin should be administered if early endoscopy is unavailable. Early endoscopy is essential both to make the diagnosis and to allow therapeutic measures to be performed. The evidence suggests that variceal band ligation is the most effective therapy for oesophageal varices. If gastric varices are found at the index endoscopy the evidence at present is inadequate to be certain which is the best treatment, but both endoscopic therapy with cyanoacrylate or thrombin and transjugular intrahepatic portosystemic stent shunt (TIPSS) have been reported to be of benefit. When initial treatments fail, rescue therapy should be initiated. Most authorities agree that TIPSS is the rescue therapy of choice. Many questions remain concerning the treatment of acute variceal bleeding, particularly the ideal therapy for gastric varices and the role of combination vasoactive and endoscopic therapy. Randomised controlled trials are required to answer these important issues.

Role of acute elevation of portal venous pressure by exogenous glucagon on gastric mucosal injury in rats with portal hypertension

Time-course studies revealed the increased susceptibility of the gastric mucosa to noxious injury in portal hypertension correlates with the level of elevated portal venous pressure and hyperglucagonemia. Whether acute elevation of portal venous pressure by exogenous glucagon aggravates such injury is not known. We tested the hypothesis that glucagon in a dose sufficient to acutely elevate portal venous pressure aggravates noxious injury of the gastric mucosa in rats with portal hypertension. Infusion of a portal hypotensive dose of somatostatin should reverse these changes. In anesthetized rats with portal vein ligation, glucagon, somatostatin or the combination was administered intravenously in a randomized, coded fashion. Acidified ethanol-induced gastric mucosal injury was determined. Portal venous pressure and gastric mucosal perfusion and oxygenation (reflectance spectrophotometry) were monitored to confirm the effects of the respective intravenous treatments. Exogenous glucagon exacerbated acidified ethanol-induced gastric mucosal injury. The exacerbation was attenuated by somatostatin. These changes paralleled the portal hypertensive and hypotensive effects of glucagon and somatostatin, respectively. Our data suggest that a unique mechanism is triggered with the onset of portal hypertension. In an antagonistic manner, glucagon and somatostatin modulate this novel mechanism that controls portal venous pressure and susceptibility of the gastric mucosa to noxious injury.

Update on treatment of variceal hemorrhage

Variceal hemorrhage accounts for one third of all deaths related to cirrhosis. To date, many modalities of treating variceal bleeding have been devised, including pharmacological therapy. Treatment of variceal hemorrhage includes resuscitation, initial hemostasis, and prevention of complications and recurrent bleeding. Intravenous vasoactive agents such as terlipressin, somatostatin, octreotide, or vapreotide should be administered in patients with suspected variceal bleeding. Endoscopic treatment remains the mainstay of treatment. Endoscopic variceal ligation is safer and more efficacious than sclerotherapy as initial treatment of bleeding esophageal varices, whereas cyanoacrylate injection is the endoscopic treatment of choice for gastric varices. An adjuvant vasoactive agent is useful for the prevention of early rebleeding. Prophylactic antibiotics are increasingly used for prevention of infection, notably spontaneous bacterial peritonitis. Follow-up endoscopic treatment is necessary in order to obliterate residual varices. The combination of a beta blocker and nitrate is an essential component of secondary prophylaxis for recurrent variceal bleeding. Transjugular intrahepatic portosystemic shunt or surgery offers the best salvage therapy in patients with failed hemostasis or breakthrough recurrent bleeding despite medical and endoscopic therapy. Endoscopic ultrasonography is useful in the prediction of recurrence of varices and facilitates visualization and guidance of further treatment of gastric varices. Despite advances in the treatment of variceal bleeding, liver function remains the determining factor of patient survival. Liver transplantation is the only definitive treatment that can alter the course of the disease.

Emergency sclerotherapy versus vasoactive drugs for variceal bleeding in cirrhosis: a Cochrane meta-analysis

BACKGROUND & AIMS

Emergency sclerotherapy is used as a first-line therapy for variceal bleeding in cirrhosis, although pharmacologic treatment stops bleeding in most patients. We performed a meta-analysis comparing emergency sclerotherapy with pharmacologic treatment.

METHODS

MEDLINE (1968-2002), EMBASE (1986-2002), and the Cochrane Library (2002;4) were searched to retrieve randomized controlled trials comparing sclerotherapy with vasopressin (+/- nitroglycerin), terlipressin, somatostatin, or octreotide for variceal bleeding in cirrhosis. Outcome measures were failure to control bleeding, rebleeding, blood transfusions, adverse events, and mortality.

RESULTS

Fifteen trials were identified. Sclerotherapy was not superior to terlipressin, somatostatin, or octreotide for any outcome and to vasopressin for rebleeding, blood transfusions, death, and adverse events; it was superior to vasopressin for the control of bleeding in a single trial flawed by a potential detection bias. Sclerotherapy was associated with significantly more adverse events than somatostatin. In a predefined sensitivity analysis, combining all of the trials irrespective of the control treatment, risk differences (sclerotherapy minus control) and confidence intervals (CIs) were as follows: failure to control bleeding, -0.03 (-0.06 to 0.01); mortality, -0.035 (-0.07 to 0.008); adverse events, 0.08 (0.02 to 0.14). Mortality risk difference was -0.01 (-0.07 to 0.04) in good-quality trials and -0.08 (-0.14 to -0.02) in poor-quality trials.

CONCLUSIONS

Available evidence does not support emergency sclerotherapy as the first-line treatment of variceal bleeding in cirrhosis when compared with vasoactive drugs, which control bleeding in 83% of patients. Therefore, endoscopic therapy might be added only in pharmacologic treatment failures.

[Acute upper gastrointestinal hemorrhage. Diagnosis and management]

Upper gastrointestinal hemorrhage calls for a team approach. Early endotracheal intubation of unconscious patients helps to prevent aspiration. Erythromycin i.v. 20 min. before emergency endoscopy improves the diagnostic yield. Patients without increased risk of rebleeding may be treated on an outpatient basis. Band ligation is the gold standard for acute variceal bleeding. Terlipressin, somatostatin and octreotide are equally effective but require additional measures for prevention of late recurrence. Somatostatin and analogues used as adjunct to ligation slightly reduce the risk of rebleeding but not of death. Three to seven days of prophylactic antibiotics decrease the risk of uncontrolled or recurrent bleeding. Therapeutic failures are rescued by transjugular intrahepatic portosystemic shunting (TIPS). Patients with nonvaricose bleeding should only be treated when active hemorrhage or a "visible vessel" is found. First line treatment is endoscopic injection of diluted adrenalin or isotonic saline. Thermal coagulation is an alternative. Tissue-destructing sclerosants should be avoided. Clipping and injection of fibrin glue are second and third line measures. Proton pump inhibitors improve endoscopic hemostasis, however, it is unclear whether high i.v. doses are required. H. pylori must be eradicated to prevent late recurrence. Rebleeding is treated endoscopically with angiographic intervention or surgery as rescue measures.

Treatment of Variceal Bleeding

Mortality due to variceal bleeding secondary to portal hypertension has decreased significantly in the past 2 decades. Endoscopic therapy has been the mainstay of treatment for acute variceal bleeding. Variceal banding ligation has superceded injection sclerotherapy as the most popular treatment modality for acute bleeding. Multiple banding ligators are widely used with high success in restoring hemostasis. The combination of banding and sclerotherapy may be useful in preventing the early recurrence of varices and rebleeding after initial obliteration of varices. Selective vasoactive agents such as somatostatin analogs also improve the outcome of patients. Radiologic shunting has proven to be an effective salvage procedure when endoscopic treatments fail and may be a good intermediate-stage therapy while the patient is waiting for liver transplantation.

Recent advances in the endoscopic diagnosis and therapy of upper gastrointestinal, small intestinal, and colonic bleeding

Endoscopy has become the first and primary diagnostic and therapeutic modality in the management of patients with severe gastrointestinal bleeding. Panendoscopy, push enteroscopy, and colonoscopy provide the diagnostic, prognostic, and therapeutic elements to improve patient outcomes and to reduce morbidity and mortality from severe GI hemorrhage. Recent improvements in endoscopic hemostatic techniques and in imaging modalities using wireless capsule endoscopy suggest that diagnostic and therapeutic endoscopy will be even more important in determining patient outcomes in the future.

Management of portal hypertension

Portal hypertension (PHT) is common in children and a majority of cases in India are constituted by extrahepatic portal venous obstruction or cirrhosis of liver. Morbidity and mortality in this condition is related to variceal bleeding, most commonly from esophageal varices. Acute variceal bleeding is best controlled by endoscopic therapy. Somatostatin and octreotide are useful in acute variceal bleeding as a supplementary therapy. Acute variceal bleeding uncontrolled by medical therapy merits preferably a shunt surgery or devascularization depending upon etiology of PHT and expertise of the surgeon. Acute variceal bleeding originating from gastric varices can be effectively controlled by endoscopic injection of tissue adhesive agent (n-butyl 2 cyanoacrylate). Eradication of esophageal varices by endoscopic measures (sclerotherapy or band ligation) is successful in prevention of recurrence of bleeding. Surgical portosystemic shunts especially in non-cirrhotic PHT are successful in achieving portal decompression and significant reduction in recurrence of variceal bleeding. Role of beta-blockers in primary prophylaxis of variceal bleeding in children still remains to be substantiated.

Management of bleeding in the cirrhotic patient

Important advances have been made in the management of variceal bleeding. Despite these advances, bleeding in the patient with cirrhosis remains one of the most demanding clinical challenges that a gastroenterologist or gastrointestinal surgeon may face. The aim is to identify the source of bleeding, control active bleeding and prevent rebleeding. This requires a multidisciplinary team, and the optimal management algorithm depends on the clinical circumstance of the patient and the local availability of endoscopic, radiological and surgical expertise. Injection sclerotherapy is effective in stopping acute variceal bleeding, but has the drawback of a high incidence of complications. Endoscopic variceal ligation is just as effective, and is associated with fewer complications. An overtube allows repeated introductions of the endoscope to be more tolerable for the patient and protects the airway against aspiration of blood; its use should be encouraged in patients with massive bleeding. Newer ligators can deliver multiple bands without removal of the scope but the high cost of these disposable devices limits their widespread use. Bleeding from gastric varices is even more challenging; the treatment of choice is injection with cyanoacrylate glue. To prevent rebleeding, beta-blockers are recommended for all patients with large varices (including those which have never bled). Injection sclerotherapy or band ligation, conducted at weekly intervals after the initial control of bleeding, is equally effective at obliterating varices and decreasing the risk of further hemorrhage; band ligation results in fewer complications. Other newer treatment modalities for variceal bleeding, such as somatostatin analogs, transjugular intrahepatic portasystemic shunt and liver transplantation, offer more optimal approaches to control bleeding and prevent rebleeding, but may be prohibitively expensive. Even for the most affluent communities, affordability, cost-effectiveness, and resource rationing are important considerations in management of patients with cirrhosis complicated by gastrointestinal bleeding.

Emergency sclerotherapy versus medical interventions for bleeding oesophageal varices in cirrhotic patients

BACKGROUND

Emergency sclerotherapy is widely used as a first line therapy for variceal bleeding in cirrhosis, although pharmacological treatment may stop bleeding in the majority of patients.

OBJECTIVES

To assess whether emergency sclerotherapy is superior to pharmacological treatment for variceal bleeding in cirrhosis.

SEARCH STRATEGY

Electronic and manual searches were combined until April 2001.

SELECTION CRITERIA

Randomised clinical trials comparing sclerotherapy with vasoactive treatments (vasopressin (plus minus nitroglycerin), terlipressin, somatostatin, or octreotide) for acute variceal bleeding in cirrhotic patients.

DATA COLLECTION AND ANALYSIS

Two independent reviewers identified eligible trials and extracted data. Outcome measures were failure to control bleeding, five-day treatment failure, rebleeding before other elective treatments, 42-day rebleeding, mortality before other elective treatments, 42-day mortality, number of blood transfusions, and adverse events. Data were analysed by a random effects model according to the vasoactive treatment. Sensitivity analyses included combined analysis of all the trials irrespective of the vasoactive drug, fixed effects model analyses, type of publication, methodological quality, and adequacy of generation of the randomisation list and of allocation concealment.

MAIN RESULTS

Twelve trials including 1146 patients (pts) were identified. One trial compared sclerotherapy with vasopressin, one with terlipressin, four with somatostatin, and six with octreotide. No significant differences were found comparing sclerotherapy with each vasoactive drug for any outcomes. Combining all the trials irrespective of the vasoactive drug, risk differences (95% confidence intervals) were: failure to control bleeding (11 RCTs, 977 pts) -0.03 (-0.07 to 0.01); five-day failure rate (7 RCTs, 759 pts) -0.05 (-0.12 to 0.01); rebleeding (11 RCTs, 1082 pts) -0.01(-0.06 to 0.04); rebleeding before other elective treatments (9 RCTs, 975 pts) -0.02 (-0.06 to 0.03); mortality (12 RCTs, 1146 pts) -0.04 (-0.08 to 0.00); mortality before other elective treatments (5 RCTs, 474 pts) -0.02 (-0.07 to 0.04); transfused blood units (7 RCTs, 793 pts) (weighted mean difference) -0.17 (-0.52 to 0.19). Adverse events (11 RCTs, 1082 pts) and serious adverse events (5 RCTs, 602 pts) were significantly more frequent with sclerotherapy: risk differences 0.08 (0.02 to 0.14) and 0.05 (0.02 to 0.08), respectively. Results were consistent across all the other sensitivity analyses.

REVIEWER'S CONCLUSIONS

We found no convincing evidence to support the use of emergency sclerotherapy for variceal bleeding in cirrhosis as the first, single treatment when compared with vasoactive drugs.

Management of portal hypertension after variceal hemorrhage

Each variceal bleed is associated with 20% to 30% risk of dying. Management of portal hypertension after a bleed consists of (1) control of bleeding and (2) prevention of rebleeding. Effective control of bleeding can be achieved either pharmacologically by administering somatostatin or octreotide or endoscopically via sclerotherapy or variceal band ligation. In practice, both pharmacologic and endoscopic therapy are used concomitantly. Rebleeding can be prevented by endoscopic obliteration of varices. In this setting, variceal ligation is the preferred endoscopic modality. B-blockade is as effective as endoscopic therapy and, in combination, the two modalities may be additive.

Effects of different octreotide dosages on splanchnic hemodynamics and glucagon in patients with TIPS

OBJECTIVE

The aim of this study was to evaluate the hemodynamic effects of octreotide in patients treated with transjugular intrahepatic portosystemic stent shunt in relation to plasma levels of octreotide and glucagon and the correlation between portal pressure and noninvasive Doppler parameters.

METHODS

In 15 fasting patients, we i.v. administered isotonic sodium chloride followed by octreotide 25 microg/h and 100 microg/h, each over 1 h. We measured portal pressure (PP) directly and portal vein blood flow velocity by Doppler ultrasound simultaneously and calculated portal vascular resistance (PVR) and portal venous flow (PVF). Blood samples were taken for glucagon and octreotide (mean +/- SE).

RESULTS

Octreotide reduced PP (120': -7.7+/-2.2%, p < 0.01 vs baseline; 180': - 11.4+/-2.1%, p < 0.01 vs baseline) and PVF (120': -21.7+/-31.7%, p < 0.01 vs baseline; 180': -11.6+/-18.1%, p < 0.05 vs baseline). Glucagon decreased with the increase in octreotide levels and showed a correlation with the decrease in PP and with PVF. In patients with a high PVR, we found a close inverse correlation between PP and portal vein blood flow velocity (r = -0.83, p = 0.03) as well as Cl (r = 0.81, p = 0.05), whereas poor correlation was found in patients with low PVR.

CONCLUSIONS

Octreotide caused a dose-related, moderate but sustained reduction in PP in patients with transjugular intrahepatic portosystemic stent shunt. PVR seems to be an important parameter that influences the efficacy of octreotide and the relation between PP and noninvasive Doppler parameters.

Review article: current endoscopic therapeutic options in the management of variceal bleeding

Variceal bleeding is a frequent and life-threatening complication of portal hypertension. The first episode of variceal bleeding is not only associated with a high mortality, but also with a high recurrence rate in those who survive. Therefore, many studies and randomized clinical trials have focused on different therapeutic strategies aiming to prevent the first episode of variceal bleeding (primary prophylaxis), to control haemorrhage during the acute bleeding episode (emergency treatment), and to prevent re-bleeding (secondary prophylaxis). These strategies involve pharmacological, endoscopic, surgical, and interventional radiological modalities. This review concentrates on the clinical aspects of the endoscopic modalities used to treat oesophageal variceal haemorrhage, including variceal injection sclerotherapy, variceal band ligation, and the use of tissue adhesives (glue) and their substitutes. We also draw conclusions from the available literature regarding the use of endoscopic modalities in primary prophylaxis, emergency treatment, and secondary prophylaxis of variceal re-bleeding. The management of gastric varices and variceal bleeding during pregnancy is also addressed.

Octreotide for acute variceal bleeding

OBJECTIVE

To review the use o f octreotide for acute variceal bleeding.

DATA SOURCES

Articles were obtained through computerized searches involving MEDLINE (from 1997 to October 2000). Additionally, several textbooks containing information on the diagnosis and management of acute variceal bleeding were reviewed. The bibliographies of retrieved publications and textbooks were reviewed for additional references.

STUDY SELECTION

All randomized studies and pharmacoeconomic evaluations that used octreotide therapy for acute variceal bleeding were considered. Randomized controlled trials and meta-analyses involving other therapies for treating variceal bleeding were also reviewed for possible inclusion.

DATA EXTRACTION

The primary outcomes extracted from the literature were persistent or recurrent bleeding, need for endoscopic intervention or balloon tamponade, and mortality.

DATA SYNTHESIS

Although both endoscopic therapies and medications are used to control bleeding and rebleeding episodes, the endoscopic approach has the additional goal of obliterating the varix. Since rebleeding episodes are common as long as the varix is present, endoscopic and medication therapies cannot be considered interchangeable based on bleeding control alone. However, octreotide by continuous intravenous infusion has demonstrated effectiveness in reducing blood loss and transfusion requirements as both an initial intervention (until definitive sclerotherapy can be performed) or as adjunctive therapy to endoscopic measures. Octreotide can be started quickly, has a relatively rapid onset of action, and does not require someone with endoscopy training to initiate. Additionally, octreotide is relatively free of significant adverse effects.

CONCLUSIONS

While additional investigations are needed, particularly in the area of pharmacoeconomics, there is substantial evidence that octreotide is an efficacious therapy with relatively few adverse effects when used in the management of acute variceal bleeding.

Management of acute variceal haemorrhage

Endoscopic therapy and in particular endoscopic variceal banding ligation, in experienced hands, is the treatment of choice for acute variceal bleeding which remains a major cause of death in patients with cirrhosis and portal hypertension. Pharmacological therapy with Glypressin or somatostatin can be useful to gain time when the endoscopic expertise is not available or to help to obtain a clearer endoscopic view. Transjugular intrahepatic porto-systemic stent shunt is currently used for endoscopic failures, producing similar results with the surgical portacaval shunts. Which one of the two should be preferred, since they both work best in relatively compensated patients, should be a balance between the available surgical and radiological expertise, the urgency of the situation and the expected course of the disease.

Octreotide for acute esophageal variceal bleeding: a meta-analysis

BACKGROUND & AIMS

Studies of octreotide have not demonstrated a consistent benefit in efficacy or safety compared with conventional therapies. This study statistically pooled existing trials to evaluate the safety and efficacy of octreotide for esophageal variceal hemorrhage.

METHODS

We identified randomized trials of octreotide for variceal hemorrhage from computerized databases, scientific meeting abstracts, and the manufacturer of octreotide. Blinded reviewers abstracted the data, and a meta-analysis was performed.

RESULTS

Octreotide improved control of esophageal variceal hemorrhage compared with all alternative therapies combined (relative risk [RR], 0.63; 95% confidence interval [CI], 0.51-0.77); vasopressin/terlipressin (RR, 0.58; 95% CI, 0.42-0.81); or no additional intervention/placebo (among patients that received initial sclerotherapy/banding before randomization) (RR, 0.46; 95% CI, 0.32-0.67). Octreotide had comparable efficacy to immediate sclerotherapy for control of bleeding (RR, 0.94; 95% CI, 0.55-1.62), fewer major complications than vasopressin/terlipessin (RR, 0.31; 95% CI, 0.11-0.87), and a complication profile comparable to no intervention/placebo (RR, 1.06; 95% CI, 0.72-1.55). No specific alternative therapy demonstrated a mortality benefit.

CONCLUSIONS

These results favor octreotide over vasopressin/terlipressin in the control of esophageal variceal bleeding and suggest it is a safe and effective adjunctive therapy after variceal obliteration techniques. Trials are needed to determine the optimal dose, route, and duration of octreotide treatment.

Octreotide potentiates PKC-dependent vasoconstrictors in portal-hypertensive and control rats

BACKGROUND & AIMS

The effect of octreotide on vascular tone in the superior mesenteric artery (SMA) was studied in portal-hypertensive (portal vein-ligated) and sham-operated rats.

METHODS

In vitro-perfused SMA vascular beds were tested for the cumulative dose-response to octreotide at baseline conditions and after preconstriction with different vasoconstrictors (alpha1-agonist methoxamine, endothelin [ET-1], phorbol ester [PdBu], and potassium chloride [KCl]).

RESULTS

Octreotide did not affect baseline perfusion pressures (without preconstriction). alpha1-Adrenergic-, ET-1-, and PdBu-, but not KCl-, induced vasoconstriction was significantly potentiated by octreotide. This effect was dose-dependent and not different in portal vein-ligated and sham rats. Amplification of alpha1-adrenergic vasoconstriction by octreotide was significantly enhanced by nitric oxide inhibition (N(W)-nitro-L-arginine, 10(-4) mol/L) as well as by removal of the endothelium, and was completely suppressed by inhibition of protein kinase C (calphostin C, 1 micromol/L), phospholipase A2 (quinacrine, 5 micromol/L), and cyclooxygenase (indomethacin, 20 micromol/L).

CONCLUSIONS

Not directly, but in the presence of vasoconstrictors involving activation of protein kinase C, octreotide exerts a local vasoconstrictive effect on vascular smooth muscle of SMA. This potentiation is equipotent in portal vein-ligated and sham rats, immediate in onset, and mediated via phospholipase A2 and cyclooxygenase-derived prostanoids. This indicates that in preprandial conditions octreotide enhances the vasoconstrictive effect of dependent vasoconstrictors.

[Sclerotherapy versus somatostatin in the treatment of upper digestive hemorrhage caused by rupture of esophageal varices]

The aim of this study was to compare the efficacy of somatostatin versus endoscopic sclerotherapy in the management of digestive bleeding caused by rupture of esophageal varices. Forty patients were evaluated; 21 were randomly assigned to receive somatostatin (initial 250 micrograms followed by a 48-hour continuous infusion of 250 micrograms/h and 250 micrograms 6/6 h bolus in the first 24 hours) and 19 to receive endoscopic sclerotherapy with ethanolamine oleate 5%. The patients were evaluated after 48 hours and after 7 days of treatment. Both groups of patients were similar in sex, age, gravity of the hemorrhage and liver dysfunction. Therapeutic failure occurred in 26.3% and 35.7% in the group of endoscopic sclerotherapy (48 h and 7 days respectively), and in 23.8% and 21.4% in the group of somatostatin. The need of blood transfusion (3.38 U in the group of endoscopic sclerotherapy and 2.42 U in the group of somatostatin) and the mortality rate (31.6% in the group of endoscopic sclerotherapy and 28.6% in the group of somatostatin) were also similar (P > 0.05). The authors conclude that somatostatin is as effective as endoscopic sclerotherapy and that it should be considered in the treatment of acute esophageal variceal bleeding.