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Zeng A, Li Y, Lyu L, Zhang S, Zhang Y, Ding H, Li L. Risk factors and predictive nomograms for bedside emergency endoscopic treatment following endotracheal intubation in cirrhotic patients with esophagogastric variceal bleeding. Sci Rep 2024; 14:9467. [PMID: 38658605 PMCID: PMC11043454 DOI: 10.1038/s41598-024-59802-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 04/15/2024] [Indexed: 04/26/2024] Open
Abstract
Data on emergency endoscopic treatment following endotracheal intubation in patients with esophagogastric variceal bleeding (EGVB) remain limited. This retrospective study aimed to explore the efficacy and risk factors of bedside emergency endoscopic treatment following endotracheal intubation in severe EGVB patients admitted in Intensive Care Unit. A total of 165 EGVB patients were enrolled and allocated to training and validation sets in a randomly stratified manner. Univariate and multivariate logistic regression analyses were used to identify independent risk factors to construct nomograms for predicting the prognosis related to endoscopic hemostasis failure rate and 6-week mortality. In result, white blood cell counts (p = 0.03), Child-Turcotte-Pugh (CTP) score (p = 0.001) and comorbid shock (p = 0.005) were selected as independent clinical predictors of endoscopic hemostasis failure. High CTP score (p = 0.003) and the presence of gastric varices (p = 0.009) were related to early rebleeding after emergency endoscopic treatment. Furthermore, the 6-week mortality was significantly associated with MELD scores (p = 0.002), the presence of hepatic encephalopathy (p = 0.045) and postoperative rebleeding (p < 0.001). Finally, we developed practical nomograms to discern the risk of the emergency endoscopic hemostasis failure and 6-week mortality for EGVB patients. In conclusion, our study may help identify severe EGVB patients with higher hemostasis failure rate or 6-week mortality for earlier implementation of salvage treatments.
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Affiliation(s)
- Ajuan Zeng
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, 100069, China
| | - Yangjie Li
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, 100069, China
| | - Lingna Lyu
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, 100069, China
| | - Shibin Zhang
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, 100069, China
| | - Yuening Zhang
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, 100069, China
| | - Huiguo Ding
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, 100069, China.
| | - Lei Li
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, 100069, China.
- Department of Gastroenterology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 102208, China.
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Zhang W, Huang Y, Xiang H, Zhang L, Yuan L, Wang X, Dang T, Zhang G, Hu S, Liu C, Zhang X, Peng L, Gao M, Xia D, Li J, Song Y, Zhou X, Qi X, Zeng J, Tan X, Deng M, Fang H, Qi S, He S, He Y, Ye B, Wu W, Shao J, Wei W, Hu J, Yong X, He C, Bao J, Zhang Y, Ji R, Bo Y, Yan W, Li H, Wang Y, Wang Y, Li M, Lian J, Liu C, Wu Y, Gu Y, Wang Y, Cao P, Wu B, Ren L, Pan H, Liang Y, Tian S, Lu L, Fang Y, Jiang P, Liu Z, Liu A, Zhao L, Li S, Qiao J, Sun L, Li M, Fang C, Chen H, Tian Z, Lin G, Huang X, Chen J, Deng Y, Lv M, Liao J, Zhang L, Lu J, Wu S, Yang X, Guo W, Wang J, Chen C, Huang E, Yu Y, Yang M, Cheng S, Yang Y, Wu X, Rang L, Han P, Zhang Y, Li X, Wang F, McAlindon ME, Seto WK, Lv C, Rockey DC, Qi X. Timing of endoscopy for acute variceal bleeding in patients with cirrhosis (CHESS1905): A nationwide cohort study. Hepatol Commun 2023; 7:e0152. [PMID: 37141513 PMCID: PMC10162790 DOI: 10.1097/hc9.0000000000000152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 02/14/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Endoscopy plays an important role in the management of acute variceal bleeding (AVB) in patients with cirrhosis. This study aimed at determining the optimal endoscopy timing for cirrhotic AVB. METHODS Patients with cirrhosis with AVB across 34 university hospitals in 30 cities from February 2013 to May 2020 who underwent endoscopy within 24 hours were included in this study. Patients were divided into an urgent endoscopy group (endoscopy <6 h after admission) and an early endoscopy group (endoscopy 6-24 h after admission). Multivariable analysis was performed to identify risk factors for treatment failure. Primary outcome was the incidence of 5-day treatment failure. Secondary outcomes included in-hospital mortality, need for intensive care unit, and length of hospital stay. A propensity score matching analysis was performed. In addition, we performed an analysis, in which we compared the 5-day treatment failure incidence and the in-hospital mortality among patients with endoscopy performed at <12 hours and 12-24 hours. RESULTS A total of 3319 patients were enrolled: 2383 in the urgent endoscopy group and 936 in the early endoscopy group. After propensity score matching, on multivariable analysis, Child-Pugh class was identified as an independent risk factor for 5-day treatment failure (HR, 1.61; 95% CI: 1.09-2.37). The incidence of 5-day treatment failure was 3.0% in the urgent endoscopy group and 2.9% in the early group ( p = 0.90). The in-hospital mortality was 1.9% in the urgent endoscopy group and 1.2% in the early endoscopy group ( p = 0.26). The incidence of need for intensive care unit was 18.2% in the urgent endoscopy group and 21.4% in the early endoscopy group ( p = 0.11). The mean length of hospital stay was 17.9 days in the urgent endoscopy group and 12.9 days in the early endoscopy group ( p < 0.05). The incidence of 5-day treatment failure in the <12-hour group was 2.3% and 2.2% in the 12-24 hours group ( p = 0.85). The in-hospital mortality was 2.2% in the <12-hour group and 0.5% in the 12-24 hours group ( p < 0.05). CONCLUSIONS The data suggest that performance of endoscopy within 6-12 or within 24 hours of presentation among patients with cirrhosis with AVB led to similar treatment failure outcomes.
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Affiliation(s)
- Wenhui Zhang
- Digestive System Department, Beijing Daxing District People’s Hospital, Beijing, China
- Diagnosis and Treatment Center, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Yifei Huang
- Department of Radiology, Center of Portal Hypertension, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Huiling Xiang
- Department of Gastroenterology and Hepatology, Tianjin Third Central Hospital, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Institute of Hepatobiliary Disease, Tianjin, China
| | - LiYao Zhang
- CHESS Center, The Sixth People’s Hospital of Shenyang Shenyang, China
| | - Lili Yuan
- Department of Gastroenterology, Shanxi Bethune Hospital, Taiyuan, China
| | - Xing Wang
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Tong Dang
- Inner Mongolia Institute of Digestive Diseases, The Second Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Baotou, China
| | - Guo Zhang
- The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Shengjuan Hu
- Department of Gastroenterology, Endoscopic Center, People’s Hospital of Ningxia Hui Autonomous Region, Yinchuan, China
| | - Chuan Liu
- Department of Radiology, Center of Portal Hypertension, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Xiuping Zhang
- Faculty of Hepato-Biliary-Pancreatic Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Lijun Peng
- Department of Gastroenterology, Linyi People’s Hospital, Linyi, China
| | - Min Gao
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Dongli Xia
- Department of Gastroenterology, Chongqing University Fuling Hospital, Chongqing, China
| | - Jia Li
- Department of Gastroenterology and Hepatology, Tianjin Second People’s Hospital, Tianjin, China
| | - Ying Song
- Department of Gastroenterology, Xi’an GaoXin Hospital, Xi’an, China
| | - Xiqiao Zhou
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xingsi Qi
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jing Zeng
- Department of Emergency, Huizhou Third People’s Hospital, Guangzhou Medical University, Huizhou, China
| | - Xiaoyan Tan
- Department of Gastroenterology, Maoming People’s Hospital, Maoming, China
| | - Mingming Deng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Haiming Fang
- Department of Gastroenterology and Hepatology, The Second Hospital of Anhui Medical University, Hefei, China
| | - Shenglin Qi
- Department of Hepatology, Dalian Sixth People’s Hospital, Dalian, China
| | - Song He
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yongfeng He
- Department of Gastroenterology, Endoscopic Center, Ankang Central Hospital, Ankang, China
| | - Bin Ye
- Department of Gastroenterology, Lishui Hospital of Zhejiang University, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Central Hospital, Lishui, China
| | - Wei Wu
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jiangbo Shao
- Department of Liver Disease, The Third People’s Hospital of Zhenjiang, Zhenjiang, China
| | - Wei Wei
- Gastroenterology Department, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China
| | - Jianping Hu
- Department of Gastroenterology, First People’s Hospital of Yinchuan City, Yinchuan, China
| | - Xin Yong
- Gastroenterology, General Hospital of Western Theater Command, Chengdu, China
| | - Chaohui He
- Department of Gastroenterology and Endoscopy, The Fifth Affiliated Zhuhai Hospital of Zunyi Medical University, Zhuhai, China
| | - Jinlun Bao
- Department of Gastroenterology, Shannan People’s Hospital, Shannan, China
| | - Yuening Zhang
- Center of Hepatology and Gastroenterology, Beijing You’an Hospital, Capital Medical University, Beijing, China
| | - Rui Ji
- Department of Gastroenterology, The First Hospital of Lanzhou University, Lanzhou, China
| | - Yang Bo
- Department of Hepatobiliary Surgery, People’s Hospital of Ningxia Hui Autonomous Region, Yinchuan, China
| | - Wei Yan
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongjiang Li
- Department of Hepatology, Baoding People’s Hospital, Baoding, China
| | - Yong Wang
- Department of Interventional Radiology, Hainan Clinical Research Center for Acute and Critical Diseases, The Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan, China
- Emergency and Trauma College, Hainan Medical University, Haikou, Hainan, China
| | - Yanling Wang
- Diagnosis and Treatment Center, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Mengmeng Li
- Diagnosis and Treatment Center, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Jia Lian
- Department of Gastroenterology and Hepatology, Tianjin Third Central Hospital, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Institute of Hepatobiliary Disease, Tianjin, China
| | - Chang’en Liu
- Department of Gastroenterology and Hepatology, Tianjin Third Central Hospital, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Institute of Hepatobiliary Disease, Tianjin, China
| | - Yunhai Wu
- CHESS Center, The Sixth People’s Hospital of Shenyang Shenyang, China
| | - Ye Gu
- CHESS Center, The Sixth People’s Hospital of Shenyang Shenyang, China
| | - Yan Wang
- CHESS Center, The Sixth People’s Hospital of Shenyang Shenyang, China
| | - Ping Cao
- Department of Gastroenterology, Shanxi Bethune Hospital, Taiyuan, China
| | - Bin Wu
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Limei Ren
- Inner Mongolia Institute of Digestive Diseases, The Second Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Baotou, China
| | - Hongduo Pan
- Inner Mongolia Institute of Digestive Diseases, The Second Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Baotou, China
| | - Yunxiao Liang
- The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Shuni Tian
- Department of Gastroenterology, Linyi People’s Hospital, Linyi, China
| | - Lin Lu
- Department of Gastroenterology, Linyi People’s Hospital, Linyi, China
| | - Yanfei Fang
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Pan Jiang
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhenbei Liu
- Department of Gastroenterology, Chongqing University Fuling Hospital, Chongqing, China
| | - Aimin Liu
- Department of Gastroenterology, Chongqing University Fuling Hospital, Chongqing, China
| | - Lili Zhao
- Department of Gastroenterology and Hepatology, Tianjin Second People’s Hospital, Tianjin, China
| | - Shuang Li
- Department of Gastroenterology and Hepatology, Tianjin Second People’s Hospital, Tianjin, China
| | - Jinggui Qiao
- Department of Gastroenterology, Xi’an GaoXin Hospital, Xi’an, China
| | - Lihui Sun
- Department of Gastroenterology, Xi’an GaoXin Hospital, Xi’an, China
| | - Mengyu Li
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Chengwen Fang
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hao Chen
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zibin Tian
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Gaoyang Lin
- Department of Cardiothoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xuanhui Huang
- Department of Emergency, Huizhou Third People’s Hospital, Guangzhou Medical University, Huizhou, China
| | - Jitao Chen
- Department of Gastroenterology, Maoming People’s Hospital, Maoming, China
| | - Ying Deng
- Department of Gastroenterology, Maoming People’s Hospital, Maoming, China
| | - Muhan Lv
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jingyuan Liao
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Lijiu Zhang
- Department of Gastroenterology and Hepatology, The Second Hospital of Anhui Medical University, Hefei, China
| | - Junyu Lu
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Suhua Wu
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaocui Yang
- Department of Gastroenterology, Endoscopic Center, Ankang Central Hospital, Ankang, China
| | - Wenwei Guo
- Department of Gastroenterology, Endoscopic Center, Ankang Central Hospital, Ankang, China
| | - Jianbo Wang
- Department of Gastroenterology, Lishui Hospital of Zhejiang University, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Central Hospital, Lishui, China
| | - Chao Chen
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Erjiong Huang
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yuehua Yu
- Department of Gastroenterology, First People’s Hospital of Yinchuan City, Yinchuan, China
| | - Ming Yang
- Gastroenterology, General Hospital of Western Theater Command, Chengdu, China
| | - Shuangping Cheng
- Gastroenterology, General Hospital of Western Theater Command, Chengdu, China
| | - Yang Yang
- Department of Gastroenterology and Endoscopy, The Fifth Affiliated Zhuhai Hospital of Zunyi Medical University, Zhuhai, China
| | - Xiaoli Wu
- Department of Gastroenterology, Shannan People’s Hospital, Shannan, China
| | - Limaocai Rang
- Department of Gastroenterology, Shannan People’s Hospital, Shannan, China
| | - Ping Han
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanmin Zhang
- Department of Hepatology, Baoding People’s Hospital, Baoding, China
| | - Xiaoguo Li
- Department of Radiology, Center of Portal Hypertension, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Fengmei Wang
- Department of Gastroenterology and Hepatology, Tianjin Third Central Hospital, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Institute of Hepatobiliary Disease, Tianjin, China
| | - Mark Edward McAlindon
- Academic Department of Gastroenterology and Hepatology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Wai-Kay Seto
- Department of Medicine and State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
- Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Chuanzhu Lv
- Emergency and Trauma College, Hainan Medical University, Haikou, Hainan, China
- Department of Emergency, Hainan Clinical Research Center for Acute and Critical Diseases, The Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan, China
- Research Unit of Island Emergency Medicine, Chinese Academy of Medical Sciences, Hainan Medical University, Haikou, Hainan, China
- Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, Hainan, China
| | - Don C. Rockey
- Division of Gastroenterology and Hepatology, Medical University South Carolina, Charleston, South Carolina, USA
| | - Xiaolong Qi
- Department of Radiology, Center of Portal Hypertension, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
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Jothimani D, Rela M, Kamath PS. Liver Cirrhosis and Portal Hypertension. Med Clin North Am 2023; 107:491-504. [PMID: 37001949 DOI: 10.1016/j.mcna.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
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.
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Affiliation(s)
- Dinesh Jothimani
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, 7, CLC Works Road, Chrompet, Chennai, India-600044
| | - Mohamed Rela
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, 7, CLC Works Road, Chrompet, Chennai, India-600044
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, 200 First Street Southwest, Rochester, MN 55906, USA.
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Wu K, Fu Y, Guo Z, Zhou X. Analysis of the timing of endoscopic treatment for esophagogastric variceal bleeding in cirrhosis. Front Med (Lausanne) 2022; 9:1036491. [DOI: 10.3389/fmed.2022.1036491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/07/2022] [Indexed: 12/03/2022] Open
Abstract
BackgroundExisting guidelines recommend endoscopic treatment within 12 h or 12–24 h for patients with esophagogastric variceal bleeding (EGVB) in cirrhosis. In addition, research findings on the optimal time for endoscopy are inconsistent.AimThe aim of this study was to investigate the relationship between the timing of endoscopy and clinical outcomes in cirrhotic patients with EGVB and to analyze the risk factors for the composite outcomes after endoscopic treatment.MethodsFrom January 2019 to June 2020, 456 patients with cirrhotic EGVB who underwent endoscopy were matched by a 1:1 propensity score. Finally, 266 patients were divided into two groups, including 133 patients within 12 h (urgent endoscopy group) of admission and after 12 h (non-urgent endoscopy group). Baseline data and clinical outcomes were compared. Logistic regression model analysis was used to determine risk factors for 30 days rebleeding and mortality.ResultsIn 266 patients, the overall 30 days rebleeding rate and mortality were 10.9% (n = 29) and 3.4% (n = 9), respectively. Patients who underwent endoscopic treatment within 12 h had significantly higher 30 days rebleeding outcomes than those who underwent treatment beyond 12 h (15 vs. 6.8%, p = 0.003). However, 30 days mortality did not differ significantly between the two groups (3 vs. 3.8%, p = 0.736). Logistic regression analysis showed that age and shock on admission were independent risk factors for the composite outcome of 30 days rebleeding and mortality in patients with EGVB.ConclusionThe 30 days rebleeding rate in patients with cirrhotic EGVB treated with urgent endoscopy was significantly higher than that in patients treated with non-urgent endoscopy, but there was no significant difference in 30 days mortality.
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Zou X, Xue M, Li J. Combined Use of Transjugular Intrahepatic Portosystemic Shunt and Transarterial Chemoembolization in the Treatment of Esophageal and Gastric Variceal Bleeding: A Retrospective Study of 80 Patients with Hepatocellular Carcinoma and Portal Hypertension. Med Sci Monit 2021; 27:e934436. [PMID: 34840325 PMCID: PMC8641250 DOI: 10.12659/msm.934436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background The main cause of death in patients with hepatocellular carcinoma (HCC) with portal hypertension is esophageal and gastric variceal bleeding caused by severe portal hypertension; therefore, the treatment of portal hypertension is particularly important to prolong the survival of patients. The therapeutic efficacy and safety of transarterial chemoembolization (TACE) combined with a transjugular intrahepatic portosystemic shunt (TIPS) for HCC with esophageal and gastric variceal bleeding has been rarely reported. The aim of this study was to analyze the clinical efficacy of TIPS combined with TACE in the treatment of HCC with esophageal and gastric variceal bleeding. Material/Methods A total of 80 patients with HCC with esophageal and gastric variceal bleeding from July 2015 to November 2019 were retrospectively investigated. Clinical outcomes, biochemical indexes, and complications were compared between TIPS plus TACE and endoscopy plus TACE treatments. Results Gastrointestinal rebleeding and adverse reactions (P<0.05) after TIPS combined with TACE were lower than that after endoscopy combined with TACE treatment. Furthermore, TIPS plus TACE had superior clinical outcomes than endoscopy plus TACE, which was associated with promising progression-free survival, overall survival, objective response rate, and disease control rate, and improved liver function. Conclusions TIPS combined with TACE was better than endoscopy combined with TACE in the treatment of patients with HCC and esophageal and gastric variceal bleeding. TIPS combined with TACE had a better therapeutic effect on improving liver function and prolonging patient survival time.
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Affiliation(s)
- Xinhua Zou
- Department of Interventional Oncology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China (mainland)
| | - Miao Xue
- Department of Interventional Oncology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China (mainland)
| | - Jiaping Li
- Department of Interventional Oncology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China (mainland)
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Yoo JJ, Chang Y, Cho EJ, Moon JE, Kim SG, Kim YS, Lee YB, Lee JH, Yu SJ, Kim YJ, Yoon JH. Timing of upper gastrointestinal endoscopy does not influence short-term outcomes in patients with acute variceal bleeding. World J Gastroenterol 2018; 24:5025-5033. [PMID: 30510377 PMCID: PMC6262253 DOI: 10.3748/wjg.v24.i44.5025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/15/2018] [Accepted: 11/13/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To examine the association between the timing of endoscopy and the short-term outcomes of acute variceal bleeding in cirrhotic patients.
METHODS This retrospective study included 274 consecutive patients admitted with acute esophageal variceal bleeding of two tertiary hospitals in Korea. We adjusted confounding factors using the Cox proportional hazards model and the inverse probability weighting (IPW) method. The primary outcome was the mortality of patients within 6 wk.
RESULTS A total of 173 patients received urgent endoscopy (i.e., ≤ 12 h after admission), and 101 patients received non-urgent endoscopy (> 12 h after admission). The 6-wk mortality rate was 22.5% in the urgent endoscopy group and 29.7% in the non-urgent endoscopy group, and there was no significant difference between the two groups before (P = 0.266) and after IPW (P = 0.639). The length of hospital stay was statistically different between the urgent group and non-urgent group (P = 0.033); however, there was no significant difference in the in-hospital mortality rate between the two groups (8.1% vs 7.9%, P = 0.960). In multivariate analyses, timing of endoscopy was not associated with 6-wk mortality (hazard ratio, 1.297; 95% confidence interval, 0.806-2.089; P = 0.284).
CONCLUSION In cirrhotic patients with acute variceal bleeding, the timing of endoscopy may be independent of short-term mortality.
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Affiliation(s)
- Jeong-Ju Yoo
- Department of Gastroenterology and Hepatology, Soonchunhyang University school of Medicine, Bucheon 14584, South Korea
| | - Young Chang
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Eun Ju Cho
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Ji Eun Moon
- Department of Biostatistics, Clinical Trial Center, Soonchunhyang University Bucheon Hospital, Bucheon 14584, South Korea
| | - Sang Gyune Kim
- Department of Gastroenterology and Hepatology, Soonchunhyang University school of Medicine, Bucheon 14584, South Korea
| | - Young Seok Kim
- Department of Gastroenterology and Hepatology, Soonchunhyang University school of Medicine, Bucheon 14584, South Korea
| | - Yun Bin Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Su Jong Yu
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Yoon Jun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Jung-Hwan Yoon
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, South Korea
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Barbu LA, Mărgăritescu ND, Şurlin MV. Diagnosis and Treatment Algorithms of Acute Variceal Bleeding. CURRENT HEALTH SCIENCES JOURNAL 2017; 43:191-200. [PMID: 30595875 PMCID: PMC6284844 DOI: 10.12865/chsj.43.03.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 09/09/2017] [Indexed: 12/11/2022]
Abstract
Esophageal varices are about 10%-15% of UGIB. Over 90% of patients with cirrhosis develop portal hypertension (PHT), but not all patients with PHT and liver cirrhosis have esophageal varices. At the time of diagnosis, only 60% of patients with cirrhosis have esophageal varices. In the case of variceal bleeding suspects, vasoactive drugs should be given as soon as possible and before endoscopy. Balloon tamponade is used to obtain temporary hemostasis by direct compression of hemorrhagic varices. The variceal band ligation is already the first place in the treatment and prevention of variceal bleeding, but also in rebleeding prevention. TIPS is used as a rescue therapy after failure of drug and endoscopic therapy. The mortality assigned to the hemorrhagic episode is substantially, estimated at 13-19% of the overall mortality in hepatic cirrhosis. Current recommendations for the treatment of acute variceal bleeding are the use of combination therapy: vasoactive drugs, balloon tamponade, elastic ligation and TIPS, whose staging is done in various diagnosis and treatment algorithms.
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Affiliation(s)
- L A Barbu
- PhD student, Department Surgery, University of Medicine and Pharmacy of Craiova, Romania
| | - N D Mărgăritescu
- Department Surgery, University of Medicine and Pharmacy of Craiova, Romania
| | - M V Şurlin
- Department Surgery, University of Medicine and Pharmacy of Craiova, Romania
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Marot A, Trépo E, Doerig C, Moreno C, Moradpour D, Deltenre P. Systematic review with meta-analysis: self-expanding metal stents in patients with cirrhosis and severe or refractory oesophageal variceal bleeding. Aliment Pharmacol Ther 2015; 42:1250-60. [PMID: 26472616 DOI: 10.1111/apt.13424] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 07/14/2015] [Accepted: 09/14/2015] [Indexed: 01/06/2023]
Abstract
BACKGROUND The prognosis of patients with cirrhosis and acute variceal bleeding is very poor when the standard-of-care fails to control bleeding. New treatment modalities are needed in these patients. AIM To synthesise the available evidence on the efficacy of self-expanding metal stents (SEMS) in patients with cirrhosis and severe or refractory oesophageal variceal bleeding. METHODS Meta-analysis of trials evaluating SEMS in patients with cirrhosis and severe or refractory oesophageal variceal bleeding. RESULTS Thirteen studies were included. The pooled estimate rates were 0.40 (95% confidence interval, CI = 0.31-0.49) for death, 0.41 (95% CI = 0.29-0.53) for liver-related death and 0.36 (95% CI = 0.26-0.47) for death at day 30, with low heterogeneity between studies. The pooled estimate rates were 0.12 (95% CI = 0.07-0.21) for mortality related to variceal bleeding, and 0.18 (95% CI = 0.11-0.29) for failure to control bleeding with SEMS, with no or low heterogeneity between studies. The pooled estimate rate were 0.16 (95% CI = 0.04-0.48) for rebleeding after stent removal and 0.28 (95% CI = 0.17-0.43) for stent migration, with high heterogeneity. A significant proportion of patients had access to liver transplantation or to TIPSS [pooled estimate rate 0.10 (95% CI = 0.04-0.21) and 0.26 (95% CI = 0.18-0.36), respectively]. CONCLUSIONS Fewer than 40% of patients treated with SEMS were dead at 1 month. SEMS can be used as a bridge to TIPSS or to liver transplantation in a significant proportion of patients. Additional studies are required to identify potential risk factors leading to a poor prognosis in patients with acute variceal bleeding in whom the use of SEMS could be considered.
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Affiliation(s)
- A Marot
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - E Trépo
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.,Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - C Doerig
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - C Moreno
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.,Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - D Moradpour
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - P Deltenre
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland.,Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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Early transjugular intrahepatic portosystemic shunt in cirrhotic patients with acute variceal bleeding: a systematic review and meta-analysis of controlled trials. Eur J Gastroenterol Hepatol 2015; 27:e1-9. [PMID: 26049710 DOI: 10.1097/meg.0000000000000403] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION There is conflicting evidence on the benefit of early transjugular intrahepatic portosystemic shunt (TIPSS) on the survival of patients with acute variceal bleeding (AVB). AIM To assess the effect of early TIPSS on patient prognosis. MATERIALS AND METHODS We carried out a meta-analysis of trials evaluating early TIPSS in cirrhotic patients with AVB. RESULTS Four studies were included. Early TIPSS was associated with fewer deaths [odds ratio (OR)=0.38, 95% confidence interval (CI)=0.17-0.83, P=0.02], with moderate heterogeneity between studies (P=0.15, I=44%). Early TIPSS was not significantly associated with fewer deaths among Child-Pugh B patients (OR=0.35, 95% CI=0.10-1.17, P=0.087) nor among Child-Pugh C patients (OR=0.34, 95% CI=0.10-1.11, P=0.074). There was no heterogeneity between studies in the Child-Pugh B analysis (P=0.6, I=0%), but there was a high heterogeneity in the Child-Pugh C analysis (P=0.06, I=60%). Early TIPSS was associated with lower rates of bleeding within 1 year (OR=0.08, 95% CI=0.04-0.17, P<0.001) both among Child-Pugh B patients, (OR=0.15, 95% CI=0.05-0.47, P=0.001) and among Child-Pugh C patients (OR=0.05, 95% CI=0.02-0.15, P<0.001), with no heterogeneity between studies. Early TIPSS was not associated with higher rates of encephalopathy (OR=0.84, 95% CI=0.50-1.42, P=0.5). CONCLUSION Cirrhotic patients with AVB treated with early TIPSS had lower death rates and lower rates of clinically significant bleeding within 1 year compared with patients treated without early TIPSS. Additional studies are required to identify the potential risk factors leading to a poor prognosis after early TIPSS in patients with AVB and to determine the impact of the degree of liver failure on the patient's prognosis.
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Kuo MT, Yang SC, Lu LS, Hsu CN, Kuo YH, Kuo CH, Liang CM, Kuo CM, Wu CK, Tai WC, Chuah SK. Predicting risk factors for rebleeding, infections, mortality following peptic ulcer bleeding in patients with cirrhosis and the impact of antibiotics prophylaxis at different clinical stages of the disease. BMC Gastroenterol 2015; 15:61. [PMID: 26268474 PMCID: PMC4533793 DOI: 10.1186/s12876-015-0289-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 05/11/2015] [Indexed: 02/07/2023] Open
Abstract
Background Infections in cirrhotic patients with upper gastrointestinal bleeding are a common event causing severe complication and mortality. This study aimed to identify risk factors that may predict rebleeding, bacterial infections, and the impact of antibiotic prophylaxis on mortality at different stages of cirrhosis following acute peptic ulcer bleeding (PUB). Methods A hospital-based retrospective cohort study was conducted on 235 cirrhotic patients with acute peptic ulcer hemorrhage who underwent therapeutic endoscopic procedures between January 2008 and January 2014 (n = 235); of these, 88 patients received prophylactic intravenous ceftriaxone (antibiotic group) and 147 patients did not (nil-antibiotic group). The recorded outcomes were length of hospital stay, bacterial infection, rebleeding, and in-hospital mortality. Results Forty-eight (20.4 %) patients experienced ulcer rebleeding and 46 (19.6 %) developed bacterial infections. More patients suffered from infection and recurrent bleeding in the nil-antibiotic group than the antibiotic group (25.2 % vs. 10.2 %, p = 0.005 and 30.6 % vs. 3.4 %; p < 0.001, respectively). The predictive risk factors for rebleeding were the Rockall score (p = 0.004), units of blood transfusion (p = 0.031), and no antibiotic prophylaxis (p <0.001); for bacterial infections, they were the Child-Pugh score (p = 0.003), active alcoholism (p = 0.035), and no antibiotic prophylaxis (p = 0.009). Overall, 40 (17 %) patients died during hospitalization. The Rockall score and rebleeding were predictive factors for in-hospital mortality. In subgroup analysis, survival was significantly reduced in decompensated patients (p = 0.034). Conclusions This study suggests that antibiotic prophylaxis after endoscopic hemostasis for acute PUB prevented infections and reduced rebleeding events in cirrhotic patients. Antibiotic prophylaxis improved survival among decompensated cohort following PUB. The Rockall score and rebleeding were predictive risk factors for in-hospital mortality.
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Affiliation(s)
- Ming-Te Kuo
- Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Shih-Cheng Yang
- Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Lung-Sheng Lu
- Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Chien-Ning Hsu
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University; College of Medicine, Kaohsiung, Taiwan.
| | - Yuan-Hung Kuo
- Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Chung-Huang Kuo
- Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Chih-Ming Liang
- Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Chung-Mou Kuo
- Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Cheng-Kun Wu
- Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Wei-Chen Tai
- Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan. .,Division of Hepatogastroenterology, Kaohsiung Chang Gang Memorial Hospital, 123 Ta-Pei Road, Niaosung Hsiang, Kaohsiung City, 833, Taiwan.
| | - Seng-Kee Chuah
- Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan. .,Division of Hepatogastroenterology, Kaohsiung Chang Gang Memorial Hospital, 123 Ta-Pei Road, Niaosung Hsiang, Kaohsiung City, 833, Taiwan.
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GUO SHIBIN, LI QING, DUAN ZHIJUN, WANG QIUMING, ZHOU QIN, SUN XIAOYU. Octreotide attenuates liver fibrosis by inhibiting hepatic heme oxygenase-1 expression. Mol Med Rep 2015; 11:83-90. [PMID: 25338529 PMCID: PMC4237075 DOI: 10.3892/mmr.2014.2735] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 07/21/2014] [Indexed: 01/05/2023] Open
Abstract
The aim of the present study was to investigate the effects of octreotide treatment on hepatic heme oxygenase-1 (HO-1) expression, together with the influence of altered hepatic HO-1 expression levels on hepatic function and fibrosis in bile duct-ligated rats. The rats were divided randomly into sham, cirrhotic, cobalt protoporphyrin and octreotide treatment groups. The expression levels of hepatic HO-1 mRNA were measured by reverse-transcription polymerase chain reaction, while the protein expression was determined by western blotting and immunohistochemical analysis. Hematoxylin and eosin, and Van Gieson's staining, along with determination of the hydroxyproline content in the liver, were performed to determine the degree of liver fibrosis. The serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL) and carboxyhemoglobin (COHb) in arterial blood, and the mean arterial pressure and portal vein pressure were also measured. As compared with the sham group, hepatic HO-1 mRNA and protein expression levels, serum levels of ALT, AST and TBIL, COHb in arterial blood, hydroxyproline and collagen type I content were all significantly increased in the cirrhotic group. As compared with the cirrhotic group, the octreotide-treated group exhibited significantly reduced hepatic HO-1 expression levels, serum levels of ALT, AST and TBIL, COHb in arterial blood and the extent of hepatic fibrosis, whereas the cobalt protoporphyrin group exhibited significantly increased hepatic HO-1 expression levels, as well as aggravated hepatic function and fibrosis (P<0.05). In conclusion, octreotide inhibited hepatic HO-1 overexpression in cirrhotic rats, reduced hepatic HO-1 expression levels to relieve liver injury and attenuated liver fibrosis.
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Affiliation(s)
- SHI-BIN GUO
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 0086-116011, P.R. China
| | - QING LI
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 0086-116011, P.R. China
- Department of Gastroenterology, Dalian Friendship Hospital, Dalian, Liaoning 0086-116011, P.R. China
| | - ZHI-JUN DUAN
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 0086-116011, P.R. China
| | - QIU-MING WANG
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 0086-116011, P.R. China
| | - QIN ZHOU
- Department of Pharmacology, Dalian Medical University, Dalian, Liaoning 0086-116011, P.R. China
| | - XIAO-YU SUN
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 0086-116011, P.R. China
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12
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Epidemiology, diagnosis and early patient management of esophagogastric hemorrhage. Gastroenterol Clin North Am 2014; 43:765-82. [PMID: 25440924 DOI: 10.1016/j.gtc.2014.08.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Acute variceal bleeding (AVB) is a potentially life-threatening complication of cirrhosis and portal hypertension. Combination therapy with vasoactive drugs and endoscopic variceal ligation is the first-line treatment in the management of AVB after adequate hemodynamic resuscitation. Short-term antibiotic prophylaxis, early resuscitation, early use of lactulose for prevention of hepatic encephalopathy, targeting of conservative goals for blood transfusion, and application of early transjugular intrahepatic portosystemic shunts in patients with AVB have further improved the prognosis of AVB. This article discusses the epidemiology, diagnosis, and nonendoscopic management of AVB.
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Narváez-Rivera RM, Cortez-Hernández CA, González-González JA, Tamayo-de la Cuesta JL, Zamarripa-Dorsey F, Torre-Delgadillo A, Rivera-Ramos JFJ, Vinageras-Barroso JI, Muneta-Kishigami JE, Blancas-Valencia JM, Antonio-Manrique M, Valdovinos-Andraca F, Brito-Lugo P, Hernández-Guerrero A, Bernal-Reyes R, Sobrino-Cossío S, Aceves-Tavares GR, Huerta-Guerrero HM, Moreno-Gómez N, Bosques-Padilla FJ. [Mexican consensus on portal hypertension]. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2013; 78:92-113. [PMID: 23664429 DOI: 10.1016/j.rgmx.2013.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Revised: 11/30/2012] [Accepted: 01/21/2013] [Indexed: 02/07/2023]
Abstract
The aim of the Mexican Consensus on Portal Hypertension was to develop documented guidelines to facilitate clinical practice when dealing with key events of the patient presenting with portal hypertension and variceal bleeding. The panel of experts was made up of Mexican gastroenterologists, hepatologists, and endoscopists, all distinguished professionals. The document analyzes themes of interest in the following modules: preprimary and primary prophylaxis, acute variceal hemorrhage, and secondary prophylaxis. The management of variceal bleeding has improved considerably in recent years. Current information indicates that the general management of the cirrhotic patient presenting with variceal bleeding should be carried out by a multidisciplinary team, with such an approach playing a major role in the final outcome. The combination of drug and endoscopic therapies is recommended for initial management; vasoactive drugs should be started as soon as variceal bleeding is suspected and maintained for 5 days. After the patient is stabilized, urgent diagnostic endoscopy should be carried out by a qualified endoscopist, who then performs the corresponding endoscopic variceal treatment. Antibiotic prophylaxis should be regarded as an integral part of treatment, started upon hospital admittance and continued for 5 days. If there is treatment failure, rescue therapies should be carried out immediately, taking into account that interventional radiology therapies are very effective in controlling refractory variceal bleeding. These guidelines have been developed for the purpose of achieving greater clinical efficacy and are based on the best evidence of portal hypertension that is presently available.
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Affiliation(s)
- R M Narváez-Rivera
- Servicio de Gastroenterología, Departamento de Medicina Interna, Hospital Universitario «Dr. José Eleuterio González», Monterrey, N.L., México
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Early TIPS with covered stents in high-risk patients with cirrhosis presenting with variceal bleeding: are we ready to dive into the deep end of the pool? J Hepatol 2011; 55:1148-9. [PMID: 21708107 DOI: 10.1016/j.jhep.2011.05.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Revised: 05/11/2011] [Accepted: 05/12/2011] [Indexed: 12/22/2022]
Abstract
BACKGROUND & AIMS Patients with cirrhosis in Child-Pugh class C or those in class B who have persistent bleeding at endoscopy are at high risk for treatment failure and a poor prognosis, even if they have undergone rescue treatment with a transjugular intrahepatic portosystemic shunt (TIPS). This study evaluated the earlier use of TIPS in such patients. METHODS We randomly assigned, within 24h after admission, a total of 63 patients with cirrhosis and acute variceal bleeding who had been treated with vasoactive drugs plus endoscopic therapy to treatment with a polytetrafluoroethylene-covered stent within 72 h after randomization (early-TIPS group, 32 patients) or continuation of vasoactive-drug therapy, followed after 3-5 days by treatment with propranolol or nadolol and long-term endoscopic band ligation (EBL), with insertion of a TIPS if needed as rescue therapy (pharmacotherapy-EBL group, 31 patients). RESULTS During a median follow-up of 16 months, rebleeding or failure to control bleeding occurred in 14 patients in the pharmacotherapy-EBL group as compared with 1 patient in the early-TIPS group (P = 0.001). The 1-year actuarial probability of remaining free of this composite end point was 50% in the pharmacotherapy-EBL group versus 97% in the early-TIPS group (P < 0.001). Sixteen patients died (12 in the pharmacotherapy-EBL group and 4 in the early-TIPS group, P = 0.01). The 1-year actuarial survival was 61% in the pharmacotherapy-EBL group versus 86% in the early-TIPS group (P < 0.001). Seven patients in the pharmacotherapy-EBL group received TIPS as rescue therapy, but four died. The number of days in the intensive care unit and the percentage of time in the hospital during follow-up were significantly higher in the pharmacotherapy-EBL group than in the early-TIPS group. No significant differences were observed between the two treatment groups with respect to serious adverse events. CONCLUSIONS In these patients with cirrhosis who were hospitalized for acute variceal bleeding and at high risk for treatment failure, the early use of TIPS was associated with significant reductions in treatment failure and in mortality.
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Inoue H, Nakagawa Y, Ikemura M, Shinone K, Okada K, Nata M. A subacute epidural haematoma extending over the occipital region and posterior cranial fossa due to a laceration in the transverse sinus. Int J Legal Med 2011; 126:467-71. [PMID: 22008787 DOI: 10.1007/s00414-011-0635-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 10/07/2011] [Indexed: 01/07/2023]
Abstract
A 6-year-old male was found dead on his stomach with massive reddish vomiting from his mouth and nose. Postmortem cranial CT revealed an epidural haematoma in the left occipital region, but the cause and origin of the haematoma were unclear. An autopsy revealed that the epidural haematoma expanded over the left temporal region and the left side of the occipital region and posterior cranial fossa, and its origin was a laceration in the left transverse sinus induced by diastases in the left lambdoidal and occipitomastoid sutures. A pathohistological examination revealed that one portion of the haematoma was an early-stage hemorrhage, while the other portion extended approximately 1 week after the hemorrhage. Moreover, approximately 1 week elapsed after the laceration of the transverse sinus. Thus, we believe that the primary haematoma was induced by the laceration in the transverse sinus approximately 1 week before death, but the haematoma ceased to enlarge due to hemostasis. However, later, the size of the haematoma rapidly increased again due to rebleeding from the laceration, which led to intracranial hypertension. Consequently, we diagnosed the direct cause of death as choking due to vomit aspiration that resulted from intracranial hypertension induced by a subacute epidural haematoma.
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Affiliation(s)
- Hiromasa Inoue
- Department of Forensic Medicine and Sciences, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan.
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Classen CF, Haffner D, Hauenstein C, Wolf R, Kyank U. Long-time octreotide in an adolescent with severe haemorrhagic gastrointestinal vascular malformation. BMJ Case Rep 2011; 2011:bcr.05.2011.4291. [PMID: 22688939 DOI: 10.1136/bcr.05.2011.4291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Gastrointestinal vascular malformations are a rare cause of acute or chronic blood loss. Usually they are treated by endoscopic obliteration or surgical resection. When such a therapy is inapplicable, pharmacotherapy may be required. At the age of 15 years, our female patient suffered from transfusion dependent recurrent gastrointestinal haemorrhage due to multiple gastrointestinal vascular malformations. Gastroscopy, coloscopy and capsule endoscopy revealed numerous foci making both endoscopic obliteration and complete surgical resection impossible. Neither regular transfusions nor substitution with coagulation factors were helpful. However, subcutaneous octreotide resulted in immediate stop of bleeding. Initial treatment by daily subcutaneous injections was followed by monthly depot application. Over 3 years only 2 transfusions had to be given. The patient required thyroxin substitution, otherwise, no side effects occurred and the girl had a good quality of life. The authors conclude that octreotide is safe and effective in gastrointestinal angiodysplasias inaccessible to endoscopy or surgery.
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Somatostatin Receptors in Lung Cancer: From Function to Molecular Imaging and Therapeutics. ACTA ACUST UNITED AC 2011; 10:69-76. [PMID: 25663834 DOI: 10.6058/jlc.2011.10.2.69] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Lung cancer is a deadly disease that is difficult to diagnose and even more difficult to treat effectively. Many pathways are known to affect tumor growth, and targeting these pathways provides the cornerstone by which cancer is treated. Somatostatin receptors (SSTR) are a family of G protein coupled receptors that signal to alter hormonal secretion, increase apoptosis, and decrease cellular proliferation. These receptors are expressed in many normal and malignant cells, including both small cell and non-small cell lung cancer. Synthetic analogs of SSTRs are commercially available, but their effects in lung cancer are still largely uncertain. Signaling pathway studies have shown that SSTRs signal through phosphotyrosine phosphatases to induce apoptosis as well as to decrease cell proliferation. Radiolabeled SSTR2 analogs are utilized for radiographic imaging of tumors, which, when combined with positron emission tomography-computed tomography (PET-CT) may improve detection of lung cancer. These radiolabeled SSTR2 analogs also hold promise for targeted chemotherapy as well as radiotherapy. In this review, we summarize what is known about SSTRs and focus our discussion on the knowledge as it relates to lung cancer biology, as well as discuss current and future uses of these receptors for imaging and therapy of lung cancer.
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Krige JEJ, Kotze UK, Distiller G, Shaw JM, Bornman PC. Predictive factors for rebleeding and death in alcoholic cirrhotic patients with acute variceal bleeding: a multivariate analysis. World J Surg 2009; 33:2127-35. [PMID: 19672651 DOI: 10.1007/s00268-009-0172-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Bleeding from esophageal varices is a leading cause of death in alcoholic cirrhotic patients. The aim of the present single-center study was to identify risk factors predictive of variceal rebleeding and death within 6 weeks of initial treatment. METHODS Univariate and multivariate analyses were performed on 310 prospectively documented alcoholic cirrhotic patients with acute variceal hemorrhage (AVH) who underwent 786 endoscopic variceal injection treatments between January 1984 and December 2006. All injections were administered during the first 6 weeks after the patients were treated for their first variceal bleed. RESULTS Seventy-five (24.2%) patients experienced a rebleed, 38 within 5 days of the initial treatment and 37 within 6 weeks of their initial treatment. Of the 15 variables studied and included in a multivariate analysis using a logistic regression model, a bilirubin level >51 mmol/l and transfusion of >6 units of blood during the initial hospital admission were predictors of variceal rebleeding within the first 6 weeks. Seventy-seven (24.8%) patients died, 29 (9.3%) within 5 days and 48 (15.4%) between 6 and 42 days after the initial treatment. Stepwise multivariate logistic regression analysis showed that six variables were predictors of death within the first 6 weeks: encephalopathy, ascites, bilirubin level >51 mmol/l, international normalized ratio (INR) >2.3, albumin <25 g/l, and the need for balloon tube tamponade. CONCLUSIONS Survival was influenced by the severity of liver failure, with most deaths occurring in Child-Pugh grade C patients. Patients with AVH and encephalopathy, ascites, bilirubin levels >51 mmol/l, INR >2.3, albumin <25 g/l and who require balloon tube tamponade are at increased risk of dying within the first 6 weeks. Bilirubin levels >51 mmol/l and transfusion of >6 units of blood were predictors of variceal rebleeding.
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Affiliation(s)
- Jake E J Krige
- Department of Surgery J45OMB, Groote Schuur Hospital, Anzio Road, Observatory 7925, Cape Town, South Africa.
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Hsu YC, Chung CS, Tseng CH, Lin TL, Liou JM, Wu MS, Hu FC, Wang HP. Delayed endoscopy as a risk factor for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage. J Gastroenterol Hepatol 2009; 24:1294-9. [PMID: 19682197 DOI: 10.1111/j.1440-1746.2009.05903.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Risk factors for mortality in acute variceal hemorrhage remain incompletely understood. Whether endoscopy timing is associated with risk of mortality has not been investigated. We aimed to investigate risk factors for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage, with emphasis on endoscopy timing. METHODS Three hundred and eleven (73% male and 23% female) consecutive cirrhotic patients presenting with acute variceal hemorrhage from July 2004 to July 2007 were investigated. The univariate association of endoscopy timing as the predictor for in-hospital mortality was examined. Independent risk factors for mortality were determined by multivariate logistic regression analysis consisting of clinical, laboratory and endoscopic parameters. RESULTS Twenty-five (8.04%) patients died within admission. By plotting the receiver operating curve of endoscopy timing for mortality, we selected 15 h as the optimal cut-off point to define delayed endoscopy. Multivariate regression analysis revealed that independent risk factors predictive for in-hospital mortality included delayed endoscopy performed 15 h after admission (adjusted odds ratio [aOR] = 3.67; 95% confidence interval [CI], 1.27-10.39), every point increment of model for end-stage liver disease (MELD) score (aOR = 1.16; 95% CI, 1.07-1.25), failure of the first endoscopy (aOR = 4.36; 95% CI, 1.54-12.30) and hematemesis as the chief complaint (compared with melena, aOR = 8.66; 95% CI, 1.06-70.94). CONCLUSION Delayed endoscopy for more than 15 h, high MELD score, failure of the first endoscopy and hematemesis are independent risk factors for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage.
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Affiliation(s)
- Yao-Chun Hsu
- Division of Gastroenterology, Department of Internal Medicine, Lotung Poh-Ai Hospital, Yilan, Taiwan
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Successful Treatment of Parastomal Varices Bleeding With Percutaneous N-butyl-2-cyanoacrylate Glue Injection. Surg Laparosc Endosc Percutan Tech 2008; 18:520-2. [DOI: 10.1097/sle.0b013e31817739d3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Percutaneous injection of hemostatic agents for severe blunt hepatic trauma: an experimental study. Eur Radiol 2008; 18:2848-53. [DOI: 10.1007/s00330-008-1096-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2007] [Revised: 04/24/2008] [Accepted: 04/25/2008] [Indexed: 01/16/2023]
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Abstract
PURPOSE OF REVIEW Esophageal variceal bleeding is a life-threatening complication of liver cirrhosis. The aim of this review is to discuss the most important studies published in 2007 concerning diagnosis of esophageal varices, primary and secondary prophylaxis and treatment of variceal bleeding. RECENT FINDINGS The specific areas reviewed are the noninvasive or minimally invasive diagnosis of oesophageal varices, prevention of the formation of varices and their progression from small to large, prevention of the first variceal hemorrhage, treatment of acute bleeding episodes and prevention of rebleeding, assessment of costs related to prophylaxis and treatment of variceal bleeding. Multidetector computed tomographic esophagography was found to identify the presence and grade the size of esophageal varices. Portal vein thrombosis was found to be an independent predictor of the aggravation of esophageal varices in patients with cirrhosis and hepatocellular carcinoma. The role of hepatic vein pressure gradient measurement in the prediction of decompensation of cirrhosis has been elucidated. SUMMARY Relevant studies are reviewed on the diagnosis and the natural history of esophageal varices, prevention of their formation and growth, prevention of the first variceal bleed, use of hepatic vein pressure gradient to predict the evolution of portal hypertension and to estimate the response to pharmacological treatment, prediction of bleeding, treatment of variceal bleeding and prevention of rebleeding, and cost strategies.
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Cappell MS, Friedel D. Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. Med Clin North Am 2008; 92:491-509, xi. [PMID: 18387374 DOI: 10.1016/j.mcna.2008.01.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Acute upper gastrointestinal bleeding is a relatively common, potentially life-threatening medical emergency responsible for more than 300,000 hospital admissions and about 30,000 deaths per annum in America. The initial assessment focuses on bleeding activity, bleeding severity, hemodynamic compromise from the bleeding, and differentiating upper from lower gastrointestinal bleeding. The initial supportive therapy includes fluid resuscitation to reverse the hypovolemia, blood transfusions to replete the lost blood, respiratory support as necessary, and proton pump inhibitor therapy to stabilize mucosal blood clots and promote hemostasis. Esophagogastroduodenoscopy is the best test to determine the bleeding site and cause.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, William Beaumont Hospital, MOB 233, 3601 West Thirteen Mile Road, Royal Oak, MI 48073, USA.
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Cappell MS, Friedel D. Acute nonvariceal upper gastrointestinal bleeding: endoscopic diagnosis and therapy. Med Clin North Am 2008; 92:511-50, vii-viii. [PMID: 18387375 DOI: 10.1016/j.mcna.2008.01.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute upper gastrointestinal bleeding is a relatively common,potentially life-threatening condition that causes more than 300,000 hospital admissions and about 30,000 deaths per annum in America. Esophagogastroduodenoscopy is the procedure of choice for the diagnosis and therapy of upper gastrointestinal bleeding lesions. Endoscopic therapy is indicated for lesions with high risk stigmata of recent hemorrhage, including active bleeding, oozing, a visible vessel, and possibly an adherent clot. Endoscopic therapies include injection therapy, such as epinephrine or sclerosant injection; ablative therapy, such as heater probe or argon plasma coagulation; and mechanical therapy, such as endoclips or endoscopic banding. Endoscopic therapy reduces the risk of rebleeding,the need for blood transfusions, the requirement for surgery, and patient morbidity.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, William Beaumont Hospital, MOB 233, 3601 West Thirteen Mile Road, Royal Oak, MI 48073, USA.
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[Medical therapy of complications in liver cirrhosis]. Internist (Berl) 2007; 48:1349-57. [PMID: 17992496 DOI: 10.1007/s00108-007-1965-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Patients with liver cirrhosis bear a considerable risk of a variety of complications that involve virtually all organ systems. They can be addressed with a wide spectrum of drugs for acute interventions as well as for prophylactic purposes. At the same time treatment of the underlying disease, the identification and treatment of triggering factors and the possibility of liver transplantation should be kept in mind.
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Szabo S, Oikonomopoulos T, Hoffmeister HM. Prevention and treatment of major blood loss. N Engl J Med 2007; 357:1260; author reply 1261. [PMID: 17881761 DOI: 10.1056/nejmc071849] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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