Sequential variceal pressure measurement by endoscopic needle puncture during maintenance sclerotherapy: the correlation between variceal pressure and variceal rebleeding

Esophageal variceal pressure influence on the effect of ligation

AIM: To explore the effect of in vitro porcine esophageal variceal pressure on complete ligation degree for polycyclic ligators.

METHODS: An in vitro model of experimental porcine venous vessels was used to test various venous pressures. Three treatment groups were designated according to the preset pressure range: P1 = 25-30 cmH₂O; P₂ = 35-40 cmH₂O; P₃ = 45-50 cmH₂O. The effect of pressure on ligation was assessed and compared among the groups.

RESULTS: Complete ligation was achieved at a rate of 56.25% (18/32) in group P₁, 37.5% (12/32) in group P₂, and 33.33% (11/33) in group P₃ (χ² = 3.6126; P = 0.0573).

CONCLUSION: Higher variceal pressures impair the ligation completion rate. Therefore, measuring variceal pressure may help predict the effect of endoscopic ligation and guide treatment choice.

Acute variceal hemorrhage

Variceal bleeding is a frequent and life-threatening complication of portal hypertension. The first episode of variceal bleeding is associated not only with a high mortality, but also with a high recurrence rate in those who survive. Therefore, management should focus on different therapeutic strategies aiming to prevent the first episode of variceal bleeding (primary prophylaxis), to control hemorrhage during the acute bleeding episode (emergency treatment), and to prevent rebleeding (secondary prophylaxis). These strategies involve pharmacological, endoscopic, surgical, and interventional radiological modalities. This article reviews management of acute variceal bleeding.

Prevention of esophageal variceal rebleeding

The rate of rebleeding of esophageal varices remains high after cessation of acute esophageal variceal hemorrhage. Many measures have been developed to prevent the occurrence of rebleeding. When considering their effectiveness in reduction of rebleeding, the associated complications cannot be neglected. Due to unavoidable high incidence of complications, shunt surgery and endoscopic injection sclerotherapy are now rarely used. Transjugular intrahepatic portosystemic stent shunt was developed to replace shunt operation but is now reserved for rescue therapy. Nonselective beta-blockers alone or in combination with isosorbide mononitrate and endoscopic variceal ligation are currently the first choices in the prevention of variceal rebleeding. The combination of nonselective beta-blockers and endoscopic variceal ligation appear to enhance the efficacy. With the advent of newly developed measures, esophageal variceal rebleeding could be greatly reduced and the survival of cirrhotics with bleeding esophageal varices could thereby be prolonged.

Perendoscopic variceal pressure measurement

OBJECTIVES

In patients with cirrhosis, the hepatic venous pressure gradient (HVPG) is the reference method for the assessment of portal hypertension (PHT). Variceal pressure (VP) may be measured at endoscopy, but its relationship to the HVPG remains controversial. The aim of the study was to retrospectively compare HVPG and VP values obtained in a cohort of patients with cirrhosis and PHT.

METHODS

Within 8 days (range: 6-10 days), 64 patients in a stable condition with biopsy-proven cirrhosis [alcoholic: 47; other 17; mean age: 56.5 yrs (35-70); mean Child-Pugh's score: 9.4 +/- 1.9; ascites: 37/64; previous variceal bleeding (="bleeders"): 24/64) and oesophageal varices (grade 2: 49; grade 3: 15)] underwent both measurement of the HVPG during transjugular liver biopsy and VP at endoscopy using a "home made" pressure sensitive gauge in the absence of needle puncture of the varix. Alcoholic hepatitis was present in 28 patients with alcoholic cirrhosis.

RESULTS

The pressure sensitive gauge was well tolerated. The mean HVPG and VP values were 18.5 +/- 3.4 mmHg and 19 +/- 3.7 mmHg, respectively. A significant difference was observed between "bleeders" (n=24) and non "bleeders" (n=40) in terms of VP values (21.4 +/- 3.3 vs 17.2 +/- 3.2 mmHg, P<0.001), but not for HVPG values (19.4 +/- 4.1 vs 17.9 +/- 2.8 mmHg, P=0.075). A positive correlation was observed between VP and HVPG values (r=0.62, P<0.0001).

CONCLUSIONS

In this group of patients with cirrhosis and oesophageal varices, a "home-made" pressure sensitive gauge allowed a non invasive perendoscopic measurement of VP. The positive correlation between VP and HVPG values suggests that measurement of VP may be a reliable estimate of portal pressure in these patients.

Delayed gastrointestinal transit in patients with hepatocellular carcinoma

BACKGROUND AND AIM

Disturbed gastrointestinal (GI) motility exists in cirrhotic patients; however, less is known about the character of GI transit in hepatocellular carcinoma (HCC) patients. It is interesting to study the GI transit in HCC patients and to explore the patient factors modulating GI transit.

METHODS

A non-invasive hydrogen breath test, which measured the orocecal transit time (OCTT), was used to study GI transit in 40 HCC patients, 20 cirrhotics and 40 age- and sex-matched healthy volunteers with normal bowel habits. Meanwhile, their clinical manifestations and various blood parameters, such as platelet count, prothrombin time, erythrocyte sedimentation rate etc. were collected. The plasma endothelin-1 and nitrate/nitrite levels were also measured.

RESULTS

The OCTT were delayed in HCC and cirrhotic patients compared with controls (116.3 +/- 7.8 and 104.5 +/- 10.6 vs 75.3 +/- 5.1 min, P < 0.05). Neither the severity of liver damage, presence of ascites, tumor size, portal hypertension, nor various blood parameters, such as nitrate/nitrite, endothelin-1, platelet count etc., had any influence on GI transit. Only serum alpha-fetoprotein levels exhibited a trend toward positive correlation with the OCTT (r = 0.271, P = 0.091).

CONCLUSIONS

Hepatocellular carcinoma patients have delayed GI transit. The confounding factor responsible for the disturbance of GI transit in HCC patients needs further exploration.

Pharmacologic efficacy in gastric variceal rebleeding and survival: including multivariate analysis

BACKGROUND

Therapy with beta-blocker and nitrate has been reported to improve survival of patients with bleeding esophageal varices and to decrease esophageal rebleeding. However, there is little information available concerning the efficacy of these medications on rebleeding risk and survival in gastric variceal bleeding after initial hemostasis.

METHODS

We conducted an open trial to observe the roles of beta-blocker and nitrate in the long-term outcome of bleeding gastric varices. Eighty-three patients were included and evaluated on the basis of age, gender, gastric variceal size, associated esophageal variceal size, Child-Pugh classification, existence of hepatoma and portal vein thrombosis, beta-blocker or nitrate therapy, and follow-up histoacryl injection. Survival analysis and multivariate analysis with the Cox proportional hazards model were performed to evaluate independent risk factors.

RESULTS

Larger gastric varices have been shown to be the only risk factor for rebleeding (adjusted odds ratio, 4.50; 95% CI, 1.30-15.59). beta-Blocker and nitrate did not significantly reduce the incidence of rebleeding (adjusted odds ratio, 0.37; 95% CI, 0.08-1.66). Although medical treatment was shown to improve the overall survival by Kaplan-Meier method (p < 0.01), multivariate analysis showed Child-Pugh class B or C and advanced hepatoma with portal vein thrombosis to be the real independent risk factors that influence survival (Child-Pugh class B or C odds ratio, 2.72; 95% CI, 1.53-4.84; portal vein thrombosis odds ratio, 6.99; 95% CI, 2.42-20.16). beta-Blocker and nitrate did not significantly prolong survival independently.

CONCLUSIONS

beta-Blocker and nitrate did not decrease the risk of rebleeding and did not improve the overall survival independently. The poor prognosis was correlated with Child-Pugh class B or C, and the advance hepatoma, with portal vein thrombosis.

Variceal bleeding and portal hypertensive gastropathy

Cirrhosis can be the end stage of any chronic liver disease. At the time of diagnosis of cirrhosis varices are present in about 60% of decompensated and 30% of compensated patients. The risk factors for the first episode of variceal bleeding in cirrhotic patients are the severity of liver dysfunction, large size of varices and the presence of endoscopic red colour signs but only one-third of patients who have variceal haemorrhage have the above risk factors. Recent interest has been directed at identifying haemodynamic factors that may reflect the pathophysiological changes which lead to variceal bleeding, e.g. it has been confirmed that no bleeding occurs if HVPG falls below 12 mmHg and also a hypothesis has been put forward in which bacterial infection is considered a trigger for bleeding. Pharmacological treatment with beta-blockers is safe, effective and is the standard long-term treatment for the prevention of recurrence of variceal bleeding. Combination of beta-blockers with isosorbide-5-mononitrate needs further testing in randomized controlled trials. The use of haemodynamic targets for reduction in HVPG response needs further study, and surrogate markers of pressure response need evaluation. If endoscopic treatment is chosen, variceal ligation is the modality of choice. The combination of simultaneous variceal ligation and sclerotherapy does not offer any benefit. However, the use of additional sclerotherapy for the complete eradication of small varices after variceal ligation needs to be evaluated. The results of current prospective randomized controlled trials comparing variceal ligation with pharmacological treatment are awaited with great interest. Finally, the use of transjugular intrahepatic portosystemic shunt (TIPS) for the secondary prevention of variceal bleeding is not substantiated by current data, as survival is not improved and because of its worse cost-benefit profile compared to other treatments. In contrast, there still is a role for the selective surgical shunts in the modern management of portal hypertension. The ideal patients should be well compensated cirrhotics, who have had troublesome bleeding - either who have failed at least one other modality of therapy (drugs or ligation), have bled from gastric varices despite medical or endoscopic therapy, or live far from suitable medical services. Recently, ligation has been compared to beta-blockers for primary prophylaxis but so far there is no good evidence to recommend banding for primary prophylaxis, if beta-blockers can be given.

Delayed liquid gastric emptying in patients with hepatocellular carcinoma

OBJECTIVE

Liver cirrhotic patients sometimes have disturbed gastric emptying (GE). Apparently there is no study addressing the issue of whether patients with hepatocellular carcinoma (HCC) have similarly impaired GE. Using impedance tomography to measure liquid GE, we attempted to assess the characteristics of GE in HCC patients.

METHODS

We enrolled 34 healthy controls and 45 HCC patients in the current study, and compared their GE according to certain defined criteria. After each subject drank 500 ml of water, 12 electrodes were placed in a circular array around the subject's upper abdomen. One pair of electrodes was applied with electrical current, and the remaining 10 electrodes recorded signals consecutively in a rotating order. Based on tomographic calculation, serial changes in the averaged signals of altered resistivities were constructed to display liquid GE. Meanwhile, the demographic and clinical data, various blood parameters, and gut peptide levels of the patients were recorded.

RESULTS

The half-emptying times in controls and HCC patients were 15.14 +/- 1.56 and 21.38 +/- 1.84 min, respectively (p < 0.05), whereas the areas under the emptying curve were 1732.2 +/- 106.4 and 2246.6 +/- 109.8 arbitrary units, respectively (p < 0.05). Delayed GE was observed in the HCC patients, as demonstrated by vomiting and anorexia. The cirrhotic component in HCC patients only resulted in a shorter period needed for full distention of the stomach after drinking (4.33 +/- 1.02 vs 8.78 +/- 2.1 min; p < 0.05). Other characteristics, including demographics, clinical state, tumor size, ascites, blood parameters, and gut peptides, had no influence on GE.

CONCLUSIONS

Liquid GE is inhibited in HCC patients, particularly in those mainly showing symptoms of vomiting and anorexia. Other demographic and tumor characteristics are not responsible for delayed liquid GE; however, the cirrhotic component may promote stomach distention.

Clinical aspects of bleeding complications in cirrhotic patients

Liver disease is a frequent cause of haemostatic abnormalities, which may lead to overt or occult bleeding. Clinical manifestations of hepatic coagulopathy include upper and lower gastrointestinal haemorrhage, easy bruising and bleeding from gums, nose or the female genital tract. The most significant bleeding problem among patients with chronic liver disease is blood loss due to portal hypertension. About 30% of subjects with oesophageal or gastric varices resulting from cirrhosis have an episode of gastrointestinal bleeding in their lifetime. Risk factors for the first episode of variceal bleeding include the severity of liver dysfunction, large varices, and the presence of endoscopic red colour signs. Bacterial infection in patients with variceal haemorrhage may be critical in triggering bleeding. Nongastrointestinal bleeding events, either spontaneous or induced by minor trauma, are also a common complication of advanced cirrhosis. In women, for instance, dysfunctional uterine bleeding may become so severe that hysterectomy is required. In addition, invasive diagnostic tests (mostly solid tissue biopsies) and surgical procedures have a high risk of haemorrhage and are sometimes withheld in cirrhotic patients for fear of complications. In patients with portal hypertension, surgical procedures aggravate the injury of the hepatic parenchyma and may worsen the condition.

Recurrence of esophageal varices following endoscopic treatment and its impact on rebleeding: comparison of sclerotherapy and ligation

BACKGROUND/AIMS

Endoscopic variceal ligation is superior to sclerotherapy because of its lower rebleeding and complication rates. However, ligation is not without drawbacks due to a higher tendency to variceal recurrence. We conducted a randomized cohort study to delineate the long-term history of variceal recurrence following ligation and sclerotherapy, and to clarify the impact of recurrence on rebleeding and on the consumption of endoscopic treatment resources.

METHODS

Two hundred cirrhotic patients with esophageal variceal bleeding were randomized to undergo maintenance endoscopic variceal sclerotherapy or ligation.

RESULTS

One hundred and forty-one patients achieved variceal eradication and were regularly followed up for 2.2 to 6.7 (mean: 5.1 +/- 1.2) years. The demographic data, hepatic reserve, bleeding severity, and endoscopic features of both sclerotherapy (n=70) and ligation (n=71) showed no difference. Forty (57.1%) patients who underwent sclerotherapy experienced 58 recurrences of esophageal varices, in contrast to the 46 (64.8%) patients who underwent ligation and experienced 81 episodes of recurrence. Kaplan-Meier analysis showed that within 2 years variceal recurrence was more frequent for ligation than sclerotherapy, and the difference decreased thereafter. Multiple recurrence appeared more common with ligation (1/2/3/4/5 episodes of recurrence: 46/23/8/3/1 vs. 40/14/3/1/0, p=0.08). On multifactorial analysis, the endoscopic treatment method and red wale markings were the two factors determining variceal recurrence. Rebleeding from recurrent esophageal varices was unusual and showed no difference between the two groups (7/58 vs. 6/81, p>0.05). Rebleeding from gastric varices was more common after eradication by sclerotherapy (7/19 vs. 1/16, p=0.085) than by ligation. The number of sessions required for eradication of recurrent varices was no different between the two groups.

CONCLUSIONS

Early recurrence and multiple recurrence of esophageal varices are more likely in patients undergoing endoscopic ligation, compared to sclerotherapy; however, the recurrence did not lead to a higher risk of rebleeding or require more endoscopic treatment.