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Larrue H, Allaire M, Weil-Verhoeven D, Barge S, Thabut D, Payance A, Moga L, Jézéquel C, Artru F, Archambeaud I, Elkrief L, Oberti F, Roux C, Laleman W, Rudler M, Dharancy S, Laborde N, Minello A, Mouillot T, Desjonquères E, Wandji LCN, Bourlière M, Ganne-Carrié N, Bureau C. French guidelines on TIPS: Indications and modalities. Liver Int 2024; 44:2125-2143. [PMID: 38758295 DOI: 10.1111/liv.15976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/19/2024] [Accepted: 05/05/2024] [Indexed: 05/18/2024]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) has become essential in the treatment or prevention of portal hypertension-related complications. In the early 1990s, the primary indication was refractory bleeding. It is now proposed for the treatment of ascites for the prevention of bleeding and in patients with vascular diseases of the liver. Thus, there are a growing number of patients being treated with TIPS all over the world. The broadening of indications, the involvement of multiple stakeholders, the need for an accurate selection, the positioning in relation to transplantation and the lack of standardization in pre-therapeutic assessment, in the procedure itself and in the follow-up have led the board of the French Association for the Study of the Liver to establish recommendations.
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Affiliation(s)
- Hélène Larrue
- Service d'Hépatologie Hopital Rangueil CHU Toulouse et Université Paul Sabatier, Toulouse, France
| | - Manon Allaire
- Service d'Hépato-gastroentérologie, Hôpital Universitaire Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
| | - Delphine Weil-Verhoeven
- Service d'Hépatologie et Soins intensifs digestifs, CHU Jean Minjoz, Besançon, France
- Université de Franche-Comté, CHU Besançon, EFS, INSERM, UMR RIGHT, Besançon, France
| | - Sandrine Barge
- Service d'Hépato-gastro-entérologie, Centre Hospitalier Intercommunal de Créteil, Creteil, France
| | - Dominique Thabut
- Service d'Hépato-gastroentérologie, Hôpital Universitaire Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
| | - Audrey Payance
- AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Centre de recherche sur l'inflammation, Inserm, UMR 1149, Université de Paris, Paris, France
| | - Lucile Moga
- AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Centre de recherche sur l'inflammation, Inserm, UMR 1149, Université de Paris, Paris, France
| | | | - Florent Artru
- Service des Maladies du Foie, CHU Rennes, Rennes, France
| | - Isabelle Archambeaud
- Hépato-Gastro-Entérologie et Assistance Nutritionnelle-Institut des Maladies de l'Appareil Digestif (IMAD), CHU Nantes-Inserm CIC 1413, Nantes, France
| | - Laure Elkrief
- Service d'Hépato-Gastroentérologie, Hôpital Trousseau, CHRU de Tours et Faculté de Médecine de Tours, Tours, France
| | - Frédéric Oberti
- Service d'Hépato-Gastroentérologie, CHU Angers, Angers, France
| | - Charles Roux
- Service de Radiologie Intervent.ionnelle, AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Paris, France
| | - Wim Laleman
- Service de Gastroentérologie et Hépatologie, Hôpital Universitaire Gasthuisberg, KU Leuven, Louvain, Belgium
| | - Marika Rudler
- Service d'Hépato-gastroentérologie, Hôpital Universitaire Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
| | - Sébastien Dharancy
- CHU Lille, Hôpital Huriez, Maladies de l'Appareil Digestif, 2 Rue Michel Polonovski, Lille, France
| | - Nolwenn Laborde
- Gastro-Entérologie, Hépatologie, Nutrition, Maladies Héréditaires du Métabolisme Pédiatriques, Centre de Compétence Maladies Rares du Foie, Hôpital des Enfants, CHU, Toulouse, France
| | - Anne Minello
- Service D'hépato-Gastroentérologie et Oncologie Médicale, CHU F. Mitterrand, Dijon, France
| | - Thomas Mouillot
- Service D'hépato-Gastroentérologie et Oncologie Médicale, CHU F. Mitterrand, Dijon, France
| | - Elvire Desjonquères
- AP-HP Sorbonne Paris Nord, Hôpitaux Universitaire Paris Seine Saint-Denis, Service d'Hépatologie, Bobigny, France
| | - Line Caroll Ntandja Wandji
- Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, University of Lille, Lille, France
| | - Marc Bourlière
- Département d'Hépatologie et Gastroentérologie, Hôpital Saint Joseph, Marseille, France
| | - Nathalie Ganne-Carrié
- AP-HP Sorbonne Paris Nord, Hôpitaux Universitaire Paris Seine Saint-Denis, Service d'Hépatologie, Bobigny, France Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris, Paris, France
| | - Christophe Bureau
- Service d'Hépatologie Hopital Rangueil CHU Toulouse et Université Paul Sabatier, Toulouse, France
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Zeng Z, Wang Z, Jin J, Zhang F, Zhang Q, Mei X, Kong D. Comparison of Endoscopic Ultrasound-guided Cyanoacrylate Injection and Transjugular Intrahepatic Portosystemic Shunt in the Prevention of Gastric Varices Rebleeding. Surg Laparosc Endosc Percutan Tech 2024:00129689-990000000-00259. [PMID: 39056236 DOI: 10.1097/sle.0000000000001312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 07/01/2024] [Indexed: 07/28/2024]
Abstract
OBJECTIVE The purpose of this study was to investigate the efficacy and safety of endoscopic ultrasound (EUS)-guided injection of cyanoacrylate (CYA) and transjugular intrahepatic portal shunts (TIPSs) in the treatment of patients with cirrhosis with ruptured gastric varices. METHODS In this retrospective study, 105 patients with liver cirrhosis and gastric varicose veins who were admitted to the First Affiliated Hospital of Anhui Medical University between April 2018 and April 2023 without nonselective β-blockers treatment and no portal vein thrombosis were evaluated. The patients were divided into the transjugular intrahepatic portal shunt (TIPS) group (n = 60) and the EUS-CYA group (n = 45) for the purpose of evaluating postoperative rebleeding rates, complications, survival rates, and other factors. RESULTS During the follow-up, there was no significant difference in the rebleeding rates between the TIPS group and EUS-CYA group within 3 months (5% vs 2.2%; P= 0.825; 10% vs 20%, P= 0.147). However, the TIPS group had significantly lower rebleeding rates than the EUS-CYA group at 6 months (10% vs 33.3%; P= 0.030) and 1 year or longer (11.7% vs 42.2%; P < 0.01). In terms of hepatic encephalopathy, the incidence rate of the TIPS group was significantly higher than that of the EUS-CYA group (20% vs 2.2%; P= 0.006). In addition, there was no difference in the survival rates between the two groups (93.3% vs 97.8%; P= 0.552). CONCLUSIONS TIPS is superior to EUS in preventing rebleeding in patients with ruptured varices of the fundus, but it has a higher incidence of hepatic encephalopathy, and there is no difference in long-term survival between the two groups.
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Affiliation(s)
- Zhuang Zeng
- Department of Gastroenterology, Key Laboratory of Digestive Diseases, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
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Biswas S, Vaishnav M, Gamanagatti S, Swaroop S, Arora U, Aggarwal A, Elhence A, Gunjan D, Kedia S, Mahapatra SJ, Mishra AK, Shalimar. Endoscopic Glue Injection vs Glue Plus BRTO or TIPSS for Preventing Gastric Variceal Bleeding: A Randomized Controlled Trial. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00593-7. [PMID: 38969074 DOI: 10.1016/j.cgh.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 06/18/2024] [Accepted: 06/18/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND AND AIMS The study sought to compare the efficacy of endoscopic injection sclerotherapy with cyanoacrylate glue (EIS-CYA) vs EIS-CYA plus a radiologic intervention (RI) (either transjugular intrahepatic portosystemic shunt or balloon-occluded retrograde transvenous obliteration) for secondary prophylaxis in patients with liver cirrhosis who presented with acute variceal bleeding from cardiofundal varices. Primary outcome measure was gastric varix (GV) rebleed rates at 1 year. METHODS Consecutive cirrhosis patients with acute variceal bleeding from cardiofundal varices were randomized into 2 arms (45 in each) after primary hemostasis by EIS-CYA. In the endoscopic intervention (EI) arm, EIS-CYA was repeated at regular intervals (1, 3, 6, and 12 months), while in the RI arm, patients underwent transjugular intrahepatic portosystemic shunt or balloon-occluded retrograde transvenous obliteration followed by endoscopic surveillance. RESULTS GV rebleed rates at 1 year were higher in the EI arm compared with the RI arm: 11 (24.4%; 95% confidence interval [CI], 12.9%-39.5%) vs 1 (2.2%; 95% CI, 0.1%-11.8%) (P = .004; absolute risk difference: 22.2%; 95% CI, 8.4%-36.6%). GV rebleed-related mortality in the EI arm (8 [17.8%; 95% CI, 8.0%-32.1%]) was significantly higher than in the RI arm (1 [2.2%; 0.1%-11.8%]) (P = .030; absolute risk difference: 15.6; 95% CI, 2.9%-29.2%); however, there was no difference in all-cause mortality between the 2 groups (12 [26.7%; 95% CI, 14.6%-41.9%] vs 7 [15.6%; 95% CI, 6.5%-29.5%]). The number needed to treat to prevent 1 GV-related rebleed at 1 year was 4.5. CONCLUSIONS RI for secondary prophylaxis reduces rebleeding from GV and GV rebleeding-related mortality in patients with GV hemorrhage. (CTRI/2021/02/031396).
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Affiliation(s)
- Sagnik Biswas
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Manas Vaishnav
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Shivanand Gamanagatti
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Shekhar Swaroop
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Umang Arora
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Arnav Aggarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Anshuman Elhence
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Soumya Jagannath Mahapatra
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Ashwani Kumar Mishra
- National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, Delhi, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India.
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Lo GH. Response to Biswas et al. Am J Gastroenterol 2024:00000434-990000000-01187. [PMID: 38874217 DOI: 10.14309/ajg.0000000000002861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Affiliation(s)
- Gin-Ho Lo
- Division of Gastroenterology, Department of Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
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5
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Kaplan DE, Ripoll C, Thiele M, Fortune BE, Simonetto DA, Garcia-Tsao G, Bosch J. AASLD Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology 2024; 79:1180-1211. [PMID: 37870298 DOI: 10.1097/hep.0000000000000647] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/16/2023] [Indexed: 10/24/2023]
Affiliation(s)
- David E Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA USA
| | - Cristina Ripoll
- Internal Medicine IV, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Brett E Fortune
- Department of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Jaime Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS) and CIBERehd, University of Barcelona, Spain
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6
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Shung DL, Laine L. Review article: Upper gastrointestinal bleeding - review of current evidence and implications for management. Aliment Pharmacol Ther 2024; 59:1062-1081. [PMID: 38517201 DOI: 10.1111/apt.17949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/27/2023] [Accepted: 03/04/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Acute upper gastrointestinal bleeding (UGIB) is a common emergency requiring hospital-based care. Advances in care across pre-endoscopic, endoscopic and post-endoscopic phases have led to improvements in clinical outcomes. AIMS To provide a detailed, evidence-based update on major aspects of care across pre-endoscopic, endoscopic and post-endoscopic phases. METHODS We performed a structured bibliographic database search for each topic. If a recent high-quality meta-analysis was not available, we performed a meta-analysis with random effects methods and odds ratios with 95% confidence intervals. RESULTS Pre-endoscopic management of UGIB includes risk stratification, a restrictive red blood cell transfusion policy unless the patient has cardiovascular disease, and pharmacologic therapy with erythromycin and a proton pump inhibitor. Patients with cirrhosis should be treated with prophylactic antibiotics and vasoactive medications. Tranexamic acid should not be used. Endoscopic management of UGIB depends on the aetiology. For peptic ulcer disease (PUD) with high-risk stigmata, endoscopic therapy, including over-the-scope clips (OTSCs) and TC-325 powder spray, should be performed. For variceal bleeding, treatment should be customised by severity and anatomic location. Post-endoscopic management includes early enteral feeding for all UGIB patients. For high-risk PUD, PPI should be continued for 72 h, and rebleeding should initially be evaluated with a repeat endoscopy. For variceal bleeding, high-risk patients or those with further bleeding, a transjugular intrahepatic portosystemic shunt can be considered. CONCLUSIONS Management of acute UGIB should include treatment plans for pre-endoscopic, endoscopic and post-endoscopic phases of care, and customise treatment decisions based on aetiology and severity of bleeding.
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Affiliation(s)
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut, USA
- West Haven Veterans Affairs Medical Center, West Haven, Connecticut, USA
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Ma AS, Thuluvath PJ. The Role of Endoscopy for Primary and Secondary Prophylaxis of Variceal Bleeding. Gastrointest Endosc Clin N Am 2024; 34:231-248. [PMID: 38395481 DOI: 10.1016/j.giec.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Cirrhosis is associated with a high morbidity and mortality. One of the most serious and unpredictable complication of cirrhosis, with a high mortality rate, is bleeding from esophagogastric varices. Endoscopic screening of varices followed by primary prophylactic treatment with beta blockers or band ligation in the presence of large esophageal varices will reduce the variceal bleeding rates and thereby reduce mortality risks in those with advanced cirrhosis. There is a paucity of data on primary prophylaxis of gastric varices but secondary prophylaxis includes glue injection, balloon-occluded retrograde transvenous obliteration, or transjugular intrahepatic portosystemic shunting with coil embolization.
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Affiliation(s)
- Andrew S Ma
- Institute for Digestive Health and Liver Disease Mercy Medical Center, Professional Office Building, 7th Floor 345 St. Paul Place, Baltimore, MD 21202, USA
| | - Paul J Thuluvath
- Institute for Digestive Health and Liver Disease Mercy Medical Center, Professional Office Building, 7th Floor 345 St. Paul Place, Baltimore, MD 21202, USA.
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8
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Kim DS, Yoon YI, Kim BK, Choudhury A, Kulkarni A, Park JY, Kim J, Sinn DH, Joo DJ, Choi Y, Lee JH, Choi HJ, Yoon KT, Yim SY, Park CS, Kim DG, Lee HW, Choi WM, Chon YE, Kang WH, Rhu J, Lee JG, Cho Y, Sung PS, Lee HA, Kim JH, Bae SH, Yang JM, Suh KS, Al Mahtab M, Tan SS, Abbas Z, Shresta A, Alam S, Arora A, Kumar A, Rathi P, Bhavani R, Panackel C, Lee KC, Li J, Yu ML, George J, Tanwandee T, Hsieh SY, Yong CC, Rela M, Lin HC, Omata M, Sarin SK. Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation. Hepatol Int 2024; 18:299-383. [PMID: 38416312 DOI: 10.1007/s12072-023-10629-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 12/18/2023] [Indexed: 02/29/2024]
Abstract
Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.
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Affiliation(s)
- Dong-Sik Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Jun Yong Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jongman Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Hyun Sinn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho Joong Choi
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ki Tae Yoon
- Department of Internal Medicine, Pusan National University College of Medicine, Yangsan, Republic of Korea
| | - Sun Young Yim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Cheon-Soo Park
- Department of Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Deok-Gie Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hae Won Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Won-Mook Choi
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Eun Chon
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Woo-Hyoung Kang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinsoo Rhu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Geun Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yuri Cho
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Ilsan, Republic of Korea
| | - Pil Soo Sung
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Han Ah Lee
- Department of Internal Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Ji Hoon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Si Hyun Bae
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Mo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Soek Siam Tan
- Department of Medicine, Hospital Selayang, Batu Caves, Selangor, Malaysia
| | - Zaigham Abbas
- Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Ananta Shresta
- Department of Hepatology, Alka Hospital, Lalitpur, Nepal
| | - Shahinul Alam
- Crescent Gastroliver and General Hospital, Dhaka, Bangladesh
| | - Anil Arora
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Ashish Kumar
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Pravin Rathi
- TN Medical College and BYL Nair Hospital, Mumbai, India
| | - Ruveena Bhavani
- University of Malaya Medical Centre, Petaling Jaya, Selangor, Malaysia
| | | | - Kuei Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jun Li
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Ming-Lung Yu
- Department of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | | | | | | | | | - H C Lin
- Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Masao Omata
- Department of Gastroenterology, Yamanashi Central Hospital, Yamanashi, Japan
- University of Tokyo, Bunkyo City, Japan
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9
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Jobe K, Henry Z. Endoscopic Treatment of Acute Esophageal and Gastric Variceal Bleeding. Gastrointest Endosc Clin N Am 2024; 34:249-261. [PMID: 38395482 DOI: 10.1016/j.giec.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Acute variceal bleeding is a serious complication of portal hypertension. This most often manifests as bleeding from esophageal varices. Although less likely to occur, bleeding from gastric varices is usually more severe. The best endoscopic management for acute esophageal variceal bleeding is band ligation and this often proves to be definitive therapy for these patients. For gastric variceal bleeding, the best endoscopic therapy is endoscopic cyanoacrylate injection but this can be cumbersome to perform and is not a readily available resource at most centers in the United States.
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Affiliation(s)
- Kendra Jobe
- Department of Medicine, University of Virginia School of Medicine, 1215 Lee Street, PO Box 800708, Charlottesville, VA 22908-0708, USA
| | - Zachary Henry
- Division of Gastroenterology & Hepatology, University of Virginia School of Medicine, 1215 Lee Street, PO Box 800708, Charlottesville, VA 22908-0708, USA.
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10
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Gralnek IM, Garcia-Pagan JC, Hernández-Gea V. Challenges in the Management of Esophagogastric Varices and Variceal Hemorrhage in Cirrhosis - A Narrative Review. Am J Med 2024; 137:210-217. [PMID: 38128860 DOI: 10.1016/j.amjmed.2023.12.001] [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: 07/22/2023] [Revised: 12/02/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
Over the past decade, significant advancements in pharmacological, endoscopic, and radiographic treatments have emerged in the management of patients with cirrhosis and esophagogastric varices or variceal hemorrhage. These advances have been in several areas, including the role of screening and primary prophylaxis (preventing an initial variceal bleed), evaluation and management of acute esophagogastric variceal hemorrhage, and in preventing variceal rebleeding. Therefore, we believe there is a need for an updated, evidence-based "narrative review" on this important clinical topic that will be relevant for internists, hospitalists, intensive care unit physicians, and those in training. We believe the guidance presented in this narrative review will enhance daily medical practice of health care professionals and has the potential to improve quality of care for these complex patients.
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Affiliation(s)
- Ian M Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel; Rappaport Faculty of Medicine Technion Israel Institute of Technology, Haifa, Israel.
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, Universitat de Barcelona University of Barcelona, Barcelona, CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, Universitat de Barcelona University of Barcelona, Barcelona, CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
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11
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Huang JT, Zhong BY, Li WC, Jiang N, Qian D, Hu ZX, Nie H, Zhang S, Shen J, Zhu XL. Emergent TIPS for acute gastroesophageal variceal bleeding in cirrhotic patients with hepatocellular carcinoma. Abdom Radiol (NY) 2024; 49:900-907. [PMID: 38010526 DOI: 10.1007/s00261-023-04088-5] [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: 06/12/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVES To estimate the safety and effectiveness of emergent transjugular intrahepatic portosystemic shunt (TIPS) creation for acute variceal bleeding (AVB) in cirrhotic patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS Data of thirty-three patients with AVB and HCC undergoing emergent TIPS creation from January 2016 to January 2022 were enrolled and were retrospectively analyzed. The primary outcomes were the safety of emergent TIPS creation, the bleeding control rate, and the rebleeding rate. The secondary outcomes included overall survival (OS), liver function, overt hepatic encephalopathy (HE), and shunt dysfunction. RESULTS Emergent TIPS creation was technically successful in 33 patients (100%) and one (3.0%) patient suffered a major procedure-related adverse event. The control rate of bleeding (within 5 days) was 100%. During a median follow-up period of 26.3 months, rebleeding occurred in 6 (18.2%) patients. The median OS was 20.0 months. The 6-week and 1-year survival rates were 87% and 65%, respectively. Laboratory tests showed no significant impairment of liver function following TIPS creation. The incidences of overt HE and shunt dysfunction were 24.2% and 6.1%, respectively. CONCLUSION Emergent TIPS creation is feasible and effective for treatment of AVB in cirrhotic patients with HCC.
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Affiliation(s)
- Jin-Tao Huang
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, No. 188 Shizi Road, Suzhou, 215006, China
| | - Bin-Yan Zhong
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, No. 188 Shizi Road, Suzhou, 215006, China
| | - Wan-Ci Li
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, No. 188 Shizi Road, Suzhou, 215006, China
| | - Nan Jiang
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, No. 188 Shizi Road, Suzhou, 215006, China
| | - Duo Qian
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, No. 188 Shizi Road, Suzhou, 215006, China
| | - Ze-Xin Hu
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, No. 188 Shizi Road, Suzhou, 215006, China
| | - Hong Nie
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, No. 188 Shizi Road, Suzhou, 215006, China
| | - Shuai Zhang
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, No. 188 Shizi Road, Suzhou, 215006, China
| | - Jian Shen
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, No. 188 Shizi Road, Suzhou, 215006, China
| | - Xiao-Li Zhu
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, No. 188 Shizi Road, Suzhou, 215006, China.
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12
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Huang Y, Wang X, Li X, Sun S, Xie Y, Yin X. Comparative efficacy of early TIPS, Non-early TIPS, and Standard treatment in patients with cirrhosis and acute variceal bleeding: a network meta-analysis. Int J Surg 2024; 110:1149-1158. [PMID: 37924494 PMCID: PMC10871647 DOI: 10.1097/js9.0000000000000865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 10/22/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND Cirrhosis is a chronic disease characterized by chronic liver inflammation and diffuse fibrosis. A combination of vasoactive drugs, preventive antibiotics, and endoscopy is the recommended standard treatment for patients with acute variceal bleeding; however, this has been challenged. We compared the effects of early transjugular intrahepatic portosystemic shunt (TIPS), non-early TIPS, and standard treatment in patients with cirrhosis and acute variceal bleeding. MATERIALS AND METHODS The present network meta-analysis was conducted in accordance with the criteria outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Assessing the methodological quality of systematic reviews guidelines. The review has been registered with the International Prospective Register of Systematic Reviews. The PubMed, Embase, Cochrane Library, ClinicalTrials.gov, and World Health Organization-approved trial registry databases were searched for randomized controlled trials (RCTs) evaluating early TIPS, non-early TIPS, and standard treatment in patients with cirrhosis and acute variceal bleeding. RESULTS Twenty-four RCTs (1894 patients) were included in the review. Compared with standard treatment, early TIPS [odds ratio (OR), 0.53; 95% credible interval (Cr), 0.30-0.94; surface under the cumulative ranking curve (SUCRA), 98.3] had a lower risk of all-cause mortality (moderate-to-high-quality evidence), and early TIPS (OR, 0.19; 95% CrI, 0.11-0.28; SUCRA, 98.2) and non-early TIPS (OR, 0.30; 95% CrI, 0.23-0.42; SUCRA, 1.8) were associated with a lower risk of rebleeding (moderate-to-high-quality evidence). Early TIPS was not associated with a reduced risk of hepatic encephalopathy, and non-early TIPS (OR, 2.78; 95% CrI, 1.89-4.23, SUCRA, 0) was associated with an increased incidence of hepatic encephalopathy (moderate-to-high-quality evidence). There was no difference in the incidence of new or worsening ascites (moderate-to-high-quality evidence) among the three interventions. CONCLUSION Based on the moderate-to-high quality evidence presented in this study, early TIPS placement was associated with reduced all-cause mortality [with a median follow-up of 1.9 years (25th-75th percentile range 1.9-2.3 years)] and rebleeding compared to standard treatment and non-early TIPS. Although early TIPS and standard treatment had a comparable incidence of hepatic encephalopathy, early TIPS showed superiority over non-early TIPS in this aspect. Recent studies have also shown promising results in controlling TIPS-related hepatic encephalopathy. However, it is important to consider individual patient characteristics and weigh the potential benefits against the risks associated with early TIPS. Therefore, we recommend that clinicians carefully evaluate the patient's condition, considering factors such as severity of variceal bleeding, underlying liver disease, and overall clinical status, before making a treatment decision. Further well-designed RCTs comparing early TIPS with non-early TIPS are needed to validate these findings and provide more definitive guidance.
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Affiliation(s)
- Ye Huang
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, P.R. China
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, China
- Loudi Center for Diseases Prevention and Control, Loudi, Hunan, China
| | - Xiaokai Wang
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, P.R. China
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Xiangmin Li
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, P.R. China
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Shichang Sun
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, P.R. China
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Yongxiang Xie
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, P.R. China
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Xinbo Yin
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, P.R. China
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, China
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13
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Lee EW, Eghtesad B, Garcia-Tsao G, Haskal ZJ, Hernandez-Gea V, Jalaeian H, Kalva SP, Mohanty A, Thabut D, Abraldes JG. AASLD Practice Guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage. Hepatology 2024; 79:224-250. [PMID: 37390489 DOI: 10.1097/hep.0000000000000530] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/02/2023]
Affiliation(s)
- Edward Wolfgang Lee
- Department of Radiology and Surgery, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Bijan Eghtesad
- Department of General Surgery, Digestive Disease and Surgery Institute Cleveland Clinic, Cleveland, Ohio, USA
| | - Guadalupe Garcia-Tsao
- Yale University School of Medicine, Department of Internal Medicine, Section of Digestive Diseases, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Ziv J Haskal
- Department of Radiology and Medical Imaging/Interventional Radiology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). Universitat de Barcelona (UB). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
| | - Hamed Jalaeian
- Department of Interventional Radiology, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | | | - Arpan Mohanty
- Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Dominique Thabut
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service d'Hépato-gastroentérologie, Paris, France
| | - Juan G Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
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14
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Carroll A, Boike JR. TIPS: indications, Contraindications, and Evaluation. Curr Gastroenterol Rep 2023; 25:232-241. [PMID: 37603109 DOI: 10.1007/s11894-023-00884-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 08/22/2023]
Abstract
PURPOSE OF REVIEW This review summarizes the current and emerging indications, contraindications, and evaluation for TIPS. In the last three decades of use, there have been substantial changes and progress in this field, including the use of controlled-expansion, covered stents, which has broadened the clinical uses of TIPS. RECENT FINDINGS Recent findings have rapidly expanded the indications for TIPS, including emerging uses in hepatorenal syndrome, hepatopulmonary syndrome and before abdominal surgery. The widespread use of controlled-expansion, covered stents has decreased rates of post-TIPS hepatic encephalopathy, opening TIPS to a larger patient population. Overall, with newer stent technology and more research in this area, the clinical utility and potential of TIPS has rapidly expanded. Going forward, a renewed focus on randomized-control trials and long-term outcomes will be a crucial element to selecting appropriate TIPS recipients and recommending emerging indications for this procedure.
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Affiliation(s)
- Allison Carroll
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, 676 N. St. Clair, Suite 1900, Chicago, IL, 60611, USA
- Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Justin R Boike
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, 676 N. St. Clair, Suite 1900, Chicago, IL, 60611, USA.
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15
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Jagdish RK, Roy A, Kumar K, Premkumar M, Sharma M, Rao PN, Reddy DN, Kulkarni AV. Pathophysiology and management of liver cirrhosis: from portal hypertension to acute-on-chronic liver failure. Front Med (Lausanne) 2023; 10:1060073. [PMID: 37396918 PMCID: PMC10311004 DOI: 10.3389/fmed.2023.1060073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 05/19/2023] [Indexed: 07/04/2023] Open
Abstract
Cirrhosis transcends various progressive stages from compensation to decompensation driven by the severity of portal hypertension. The downstream effect of increasing portal hypertension severity leads to various pathophysiological pathways, which result in the cardinal complications of cirrhosis, including ascites, variceal hemorrhage, and hepatic encephalopathy. Additionally, the severity of portal hypertension is the central driver for further advanced complications of hyperdynamic circulation, hepatorenal syndrome, and cirrhotic cardiomyopathy. The management of these individual complications has specific nuances which have undergone significant developments. In contrast to the classical natural history of cirrhosis and its complications which follows an insidious trajectory, acute-on-chronic failure (ACLF) leads to a rapidly downhill course with high short-term mortality unless intervened at the early stages. The management of ACLF involves specific interventions, which have quickly evolved in recent years. In this review, we focus on complications of portal hypertension and delve into an approach toward ACLF.
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Affiliation(s)
- Rakesh Kumar Jagdish
- Department of Hepatology, Gastroenterology and Liver Transplant Medicine, Metro Hospital, Noida, India
| | - Akash Roy
- Department of Gastroenterology, Institute of Gastrosciences and Liver Transplantation, Apollo Hospitals, Kolkata, India
| | - Karan Kumar
- Department of Hepatology, Mahatma Gandhi Medical College and Hospital, Jaipur, India
| | - Madhumita Premkumar
- Department of Hepatology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Mithun Sharma
- Department of Hepatology, Asian Institute of Gastroenterology (AIG) Hospitals, Hyderabad, India
| | - Padaki Nagaraja Rao
- Department of Hepatology, Asian Institute of Gastroenterology (AIG) Hospitals, Hyderabad, India
| | - Duvvur Nageshwar Reddy
- Department of Hepatology, Asian Institute of Gastroenterology (AIG) Hospitals, Hyderabad, India
| | - Anand V. Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology (AIG) Hospitals, Hyderabad, India
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16
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Escorsell A, Garcia-Pagán JC, Alvarado-Tapia E, Aracil C, Masnou H, Villanueva C, Bosch J. Pre-emptive TIPS for the treatment of bleeding from gastric fundal varices: Results of a randomised controlled trial. JHEP Rep 2023; 5:100717. [PMID: 37284139 PMCID: PMC10240269 DOI: 10.1016/j.jhepr.2023.100717] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/15/2023] [Accepted: 02/18/2023] [Indexed: 06/08/2023] Open
Abstract
Background & Aims Bleeding from gastric fundal varices (isolated gastric varices type 1/gastroesophageal varices type 2) represents a major problem because of a high incidence of rebleeding and death with standard-of-care therapy (endoscopic obliteration with tissue adhesives plus pharmacological therapy). Transjugular intrahepatic portosystemic shunts (TIPSs) are recommended as a rescue therapy. Pre-emptive 'early' TIPS (pTIPS) significantly improves control of bleeding and survival in patients at high-risk of dying or rebleeding from esophageal varices. Methods This randomised controlled trial investigate whether the use of pTIPS improves rebleeding-free survival in patients with gastric fundal varices (isolated gastric varices type 1 and/or gastroesophageal varices type 2) compared with standard therapy. Results The study did not achieve the predefined sample size because of low recruitment. Nevertheless, pTIPS (n = 11) was more effective compared with combined endoscopic and pharmacological therapy (n = 10) in improving rebleeding-free survival (per protocol analysis: 100 vs. 28%; p = 0.017). This was mainly because of a better outcome in patients with Child-Pugh B or C scores. There were no differences in serious adverse events or in the incidence of hepatic encephalopathy among the different cohorts. Conclusion The use of pTIPS should be considered in patients with Child-Pugh B or C scores bleeding from gastric fundal varices. Impact and implications The first-line treatment of gastric fundal varices (GOV2 and/or IGV1) is the combination of pharmacological therapy and endoscopic obliteration with glue. TIPS is considered the main rescue therapy. Recent data suggest that, in patients at high-risk of dying or rebleeding (Child-Pugh C or B scores + active bleeding at endoscopy) from esophageal varices, the use of pTIPS, performed during the first 72 h from admission, results in an increased rate of control of bleeding and survival compared with combined endoscopic and pharmacological therapy. Herein, we present a randomised controlled trial comparing pTIPS with combined endoscopic (injection of glue) and pharmacological therapy (first, somatostatin or terlipressin; carvedilol after discharge) in the treatment of patients bleeding from GOV2 and/or IGV1. Although we were not able to include the calculated sample size because of the scarcity of these patients, our results show that the use of pTIPS is associated with a significantly higher actuarial rebleeding-free survival when analysed as per protocol. This is because of the greater efficacy of this treatment in patients with Child-Pugh B or C scores.
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Affiliation(s)
- Angels Escorsell
- Digestive Diseases Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Madrid, Spain
| | - Juan C. Garcia-Pagán
- CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Madrid, Spain
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
- Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Edilmar Alvarado-Tapia
- Digestive Diseases Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Madrid, Spain
| | - Carles Aracil
- CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Madrid, Spain
- Digestive Diseases Unit, Hospital Arnau de Vilanova, Lleida, Spain
| | - Helena Masnou
- CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Madrid, Spain
- Digestive Diseases Unit, Hospital General Universitari Germans Trias i Pujol, Badalona, Spain
| | - Càndid Villanueva
- Digestive Diseases Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Madrid, Spain
| | - Jaume Bosch
- CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Madrid, Spain
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
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17
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Lo GH. Letter to the Editor: Is embolization of large spontaneous shunt effective in the prevention of HE after TIPS? Hepatology 2023; 77:E80. [PMID: 36626627 DOI: 10.1097/hep.0000000000000007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 09/30/2022] [Indexed: 01/12/2023]
Affiliation(s)
- Gin-Ho Lo
- Division of Gastroenterology, Department of Medicine, E-Da Hospital, Kaohsiung, Taiwan
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18
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Wu L, Fang QQ, Huang XQ, Xue CY, Rao CY, Luo JJ, Xu PJ, Chen Y, Chen S, Li F. Risk factors associated with failure of endoscopic combined treatment to prevent varices rebleeding in patients with liver cirrhosis. Expert Rev Gastroenterol Hepatol 2023; 17:301-308. [PMID: 36795329 DOI: 10.1080/17474124.2023.2181787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
BACKGROUND The aim of this study is to investigate risk factors associated with gastroesophageal variceal rebleeding after endoscopic combined treatment. RESEARCH DESIGN AND METHODS Patients who had liver cirrhosis and underwent endoscopic treatment to prevent variceal rebleeding were retrospectively recruited. Hepatic venous pressure gradient (HVPG) measurement and CT examination of portal vein system were performed before endoscopic treatment. Endoscopic obturation for gastric varices and ligation for esophageal varices were performed simultaneously at the first treatment. RESULTS One hundred and sixty-five patients were enrolled, and after the first endoscopic treatment, recurrent hemorrhage occurred in 39 patients (23.6%) during 1-year follow-up. Compared to the non-rebleeding group, HVPG was significantly higher (18 mmHg vs.14 mmHg, P = 0.024) and more patients had HVPG exceeding 18 mmHg (51.3% vs.31.0%, P = 0.021) in the rebleeding group. No significant difference was found in other clinical and laboratory data between two groups (P > 0.05 for all). By a logistic regression analysis, high HVPG was the only risk factor associated with failure of endoscopic combined therapy (OR = 1.071, 95%CI, 1.005-1.141, P = 0.035). CONCLUSIONS The poor efficacy of endoscopic treatment to prevent variceal rebleeding was associated with high HVPG. Therefore, other therapeutic options should be considered for the rebleeding patients with high HVPG.
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Affiliation(s)
- Ling Wu
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Qing-Qing Fang
- Department of Gastroenterology, Minhang Hospital, Fudan University, Shanghai, P.R. China
| | - Xiao-Quan Huang
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China.,Center of Evidence-Based Medicine, Fudan University, Shanghai, P.R. China
| | - Chun-Yan Xue
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Chen-Yi Rao
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Jian-Jun Luo
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Peng-Ju Xu
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Ying Chen
- Department of Gastroenterology, Minhang Hospital, Fudan University, Shanghai, P.R. China
| | - Shiyao Chen
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China.,Department of Gastroenterology, Minhang Hospital, Fudan University, Shanghai, P.R. China.,Center of Evidence-Based Medicine, Fudan University, Shanghai, P.R. China.,Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Feng Li
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China.,Department of Gastroenterology, Minhang Hospital, Fudan University, Shanghai, P.R. China
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19
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Han JH. Role of endoscopic ultrasound in the secondary prevention of gastric varices. Clin Endosc 2023; 56:50-52. [PMID: 36646421 PMCID: PMC9902684 DOI: 10.5946/ce.2022.301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 12/23/2022] [Indexed: 01/18/2023] Open
Affiliation(s)
- Joung-Ho Han
- Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea,Correspondence: Joung-Ho Han Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, 776 1Sunhwan-ro, Seowon-gu, Cheongju 28644, Korea E-mail:
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20
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Chooklin S, Chuklin S. Comprehensive treatment of patients with gastric variceal bleeding. EMERGENCY MEDICINE 2022; 18:14-21. [DOI: 10.22141/2224-0586.18.8.2022.1539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Gastro-oesophageal varices are the major clinical manifestations of cirrhosis and portal hypertension. Bleeding from gastric varices is usually severe and is associated with higher mortality and a higher risk of rebleeding than from esophageal varices. The management of variceal bleeding is complex, often requiring a multidisciplinary approach involving pharmacological, endoscopic, and radiological interventions. In terms of treatment, three stages can be considered: primary prophylaxis, active bleeding, and secondary prophylaxis. The main goal of primary and secondary prophylaxis is to prevent variceal bleeding. However, active variceal bleeding is a medical emergency that requires prompt intervention to stop it and achieve long-term hemostasis. This review describes the features of pharmacological, endoscopic and interventional radiological prophylactic and treatment options in gastric variceal bleeding. We searched the literature in the MedLine database on the PubMed platform.
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21
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Nardelli S, Bellafante D, Ridola L, Faccioli J, Riggio O, Gioia S. Prevention of post-tips hepatic encephalopathy: The search of the ideal candidate. Metab Brain Dis 2022; 38:1729-1736. [PMID: 36445629 DOI: 10.1007/s11011-022-01131-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 11/22/2022] [Indexed: 11/30/2022]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) has been used since more than 25 years to treat some of the complications of portal hypertension, especially variceal bleeding and ascites refractory to conventional therapy. TIPS establishes a communication between the portal and hepatic veins, inducing the blood to shift from the splanchnic circulation into the systemic vascular bed with the aim of decompressing the portal venous system, and avoids the major complications of portal hypertension. However, the shunt of the portal blood into the systemic circulation is the cause of one of the major complications of the procedure: the post-TIPS hepatic encephalopathy (HE). To date, few pharmacological treatment has been proven effective to prevent this complication and thus, the identification of patients at high risk of post-TIPS hepatic encephalopathy and the patients' carefully selection is the only way to prevent this frequent complication.
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Affiliation(s)
- Silvia Nardelli
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Viale Dell'Università 37, Rome, Italy.
| | - Daniele Bellafante
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Viale Dell'Università 37, Rome, Italy
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Viale Dell'Università 37, Rome, Italy
| | - Jessica Faccioli
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Viale Dell'Università 37, Rome, Italy
| | - Oliviero Riggio
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Viale Dell'Università 37, Rome, Italy
| | - Stefania Gioia
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Viale Dell'Università 37, Rome, Italy
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22
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Boike JR, Thornburg BG, Asrani SK, Fallon MB, Fortune BE, Izzy MJ, Verna EC, Abraldes JG, Allegretti AS, Bajaj JS, Biggins SW, Darcy MD, Farr MA, Farsad K, Garcia-Tsao G, Hall SA, Jadlowiec CC, Krowka MJ, Laberge J, Lee EW, Mulligan DC, Nadim MK, Northup PG, Salem R, Shatzel JJ, Shaw CJ, Simonetto DA, Susman J, Kolli KP, VanWagner LB. North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension. Clin Gastroenterol Hepatol 2022; 20:1636-1662.e36. [PMID: 34274511 PMCID: PMC8760361 DOI: 10.1016/j.cgh.2021.07.018] [Citation(s) in RCA: 81] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/01/2021] [Accepted: 07/13/2021] [Indexed: 02/07/2023]
Abstract
Complications of portal hypertension, including ascites, gastrointestinal bleeding, hepatic hydrothorax, and hepatic encephalopathy, are associated with significant morbidity and mortality. Despite few high-quality randomized controlled trials to guide therapeutic decisions, transjugular intrahepatic portosystemic shunt (TIPS) creation has emerged as a crucial therapeutic option to treat complications of portal hypertension. In North America, the decision to perform TIPS involves gastroenterologists, hepatologists, and interventional radiologists, but TIPS creation is performed by interventional radiologists. This is in contrast to other parts of the world where TIPS creation is performed primarily by hepatologists. Thus, the successful use of TIPS in North America is dependent on a multidisciplinary approach and technical expertise, so as to optimize outcomes. Recently, new procedural techniques, TIPS stent technology, and indications for TIPS have emerged. As a result, practices and outcomes vary greatly across institutions and significant knowledge gaps exist. In this consensus statement, the Advancing Liver Therapeutic Approaches group critically reviews the application of TIPS in the management of portal hypertension. Advancing Liver Therapeutic Approaches convened a multidisciplinary group of North American experts from hepatology, interventional radiology, transplant surgery, nephrology, cardiology, pulmonology, and hematology to critically review existing literature and develop practice-based recommendations for the use of TIPS in patients with any cause of portal hypertension in terms of candidate selection, procedural best practices and, post-TIPS management; and to develop areas of consensus for TIPS indications and the prevention of complications. Finally, future research directions are identified related to TIPS for the management of portal hypertension.
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Affiliation(s)
- Justin R. Boike
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bartley G. Thornburg
- Department of Radiology, Division of Vascular and Interventional Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Michael B. Fallon
- Department of Medicine, Division of Gastroenterology and Hepatology, Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - Brett E. Fortune
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | - Manhal J. Izzy
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth C. Verna
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Juan G. Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, AB, Canada
| | - Andrew S. Allegretti
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Jasmohan S. Bajaj
- Department of Internal Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA, USA
| | - Scott W. Biggins
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Washington Medical Center, Seattle, WA, USA
| | - Michael D. Darcy
- Department of Radiology, Division of Interventional Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Maryjane A. Farr
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Khashayar Farsad
- Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
| | - Guadalupe Garcia-Tsao
- Department of Digestive Diseases, Yale University, Yale University School of Medicine, and VA-CT Healthcare System, CT, USA
| | - Shelley A. Hall
- Department of Internal Medicine, Division of Cardiology, Baylor University Medical Center, Dallas, TX, USA
| | - Caroline C. Jadlowiec
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Michael J. Krowka
- Department of Pulmonary and Critical Care Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jeanne Laberge
- Department of Radiology and Biomedical Imaging, Division of Interventional Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Edward W. Lee
- Department of Radiology, Division of Interventional Radiology, University of California-Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - David C. Mulligan
- Department of Surgery, Division of Transplantation, Yale University School of Medicine, New Haven, CT, USA
| | - Mitra K. Nadim
- Department of Medicine, Division of Nephrology and Hypertension, University of Southern California, Los Angeles, California, USA
| | - Patrick G. Northup
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Riad Salem
- Department of Radiology, Division of Vascular and Interventional Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joseph J. Shatzel
- Division of Hematology and Medical Oncology, Oregon Health and Science University, Portland, OR, USA
| | - Cathryn J. Shaw
- Department of Radiology, Division of Interventional Radiology, Baylor University Medical Center, Dallas, TX, USA
| | - Douglas A. Simonetto
- Department of Physiology, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jonathan Susman
- Department of Radiology, Division of Interventional Radiology, Columbia University Irving Medical Center, New York, NY, USA
| | - K. Pallav Kolli
- Department of Radiology and Biomedical Imaging, Division of Interventional Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Lisa B. VanWagner
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA,Address for correspondence: Lisa B. VanWagner MD MSc FAST FAHA, Assistant Professor of Medicine and Preventive Medicine, Divisions of Gastroenterology & Hepatology and Epidemiology, Northwestern University Feinberg School of Medicine, 676 N. St Clair St - Suite 1400, Chicago, Illinois 60611 USA, Phone: 312 695 1632, Fax: 312 695 0036,
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23
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Kulkarni AV, Rabiee A, Mohanty A. Management of Portal Hypertension. J Clin Exp Hepatol 2022; 12:1184-1199. [PMID: 35814519 PMCID: PMC9257868 DOI: 10.1016/j.jceh.2022.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/07/2022] [Indexed: 12/12/2022] Open
Abstract
Portal hypertension is the cause of the clinical complications associated with cirrhosis. The primary complications of portal hypertension are ascites, acute variceal bleed, and hepatic encephalopathy. Hepatic venous pressure gradient measurement remains the gold standard test for diagnosing cirrhosis-related portal hypertension. Hepatic venous pressure gradient more than 10 mmHg is associated with an increased risk of complications and is termed clinically significant portal hypertension (CSPH). Clinical, laboratory, and imaging methods can also aid in diagnosing CSPH non-invasively. Recently, deep learning methods have been demonstrated to diagnose CSPH effectively. The management of portal hypertension is always individualized and is dependent on the etiology, the availability of therapies, and the degree of portal hypertension complications. In this review, we discuss the diagnosis and management of cirrhosis-related portal hypertension in detail. Also, we highlight the history of portal hypertension and future research areas in portal hypertension.
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Key Words
- ACLF, acute-on-chronic liver failure
- AKI, acute kidney injury
- APRI, AST to platelet ratio
- AST, aspartate transaminase
- BB, Beta blocker
- BRTO, balloon occluded retrograde transvenous obliteration
- CKD, chronic kidney disease
- CSPH, clinically significant portal hypertension
- CT, computed tomography
- GFR, glomerular filtration rate
- GOV, gastrpoesopahegal varices
- HE, hepatic encephalopathy
- HRS, hepatorenal syndrome
- HVPG, hepatic venous pressure gradient
- ICG, indocyanine green
- LOLA, l-ornithine l-aspartate
- NAFLD, Non-alcoholic fatty liver disease
- SBP, spontaneous bacterial peritonitis
- SGLT2I, sodium glucose co-transporter 2 inhibitors
- SSM, splenic stiffness measurement
- TE, transient elastography
- TIPS, transjugular intrahepatic portosystemic shunt
- VITRO, von Willebrand factor to platelet counts
- acute kidney injury
- ascites
- hemodynamics
- history
- vasoconstrictors
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Affiliation(s)
| | | | - Arpan Mohanty
- Boston University School of Medicine, Boston, MA, USA
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24
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Luo X, Hernández-Gea V. Update on the management of gastric varices. Liver Int 2022; 42:1250-1258. [PMID: 35129288 DOI: 10.1111/liv.15181] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 01/18/2022] [Accepted: 01/27/2022] [Indexed: 02/13/2023]
Abstract
Gastro-oesophageal varices are the major clinical manifestations of cirrhosis and portal hypertension. Although less frequent than oesophageal varices (EV), bleeding from gastric varices (GV) is generally more severe and associated with higher mortality and a greater risk to rebleed. According to Sarin's classification, GVs are categorized into four types based on their location within the stomach and relationship with EV. Currently, treatment options for the management of GV include beta-blockers, endoscopic band ligation, endoscopic cyanoacrylate injection, EUS-guided coil/cyanoacrylate injection, transjugular intrahepatic portosystemic shunts and balloon-occluded retrograde transvenous obliteration. The best treatment strategy of GV remains controversial because of the heterogeneity of GV, lack of high-quality data and suboptimal trial design of the studies available. The proper treatment algorithm may require adequate endoscopic and imaging evaluation by a multidisciplinary team with multiple treatment options available. This review describes the hemodynamic features of GV, pharmacological, endoscopic and interventional radiological treatment options for GV.
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Affiliation(s)
- Xuefeng Luo
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic-IDIBAPS, CIBEREHD, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
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25
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Osman KT, Nayfeh T, Abdelfattah AM, Alabdallah K, Hasan B, Firwana M, Alabaji H, Elkhabiry L, Mousa J, Prokop LJ, Murad MH, Gordon F. Secondary Prophylaxis of Gastric Variceal Bleeding: A Systematic Review and Network Meta-Analysis. Liver Transpl 2022; 28:945-958. [PMID: 34860458 DOI: 10.1002/lt.26383] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/21/2021] [Accepted: 11/26/2021] [Indexed: 12/12/2022]
Abstract
There is no clear consensus regarding the optimal approach for secondary prophylaxis of gastric variceal bleeding (GVB) in patients with cirrhosis. We conducted a systematic review and network meta-analysis (NMA) to compare the efficacy of available treatments. A comprehensive search of several databases from each database's inception to March 23, 2021, was conducted to identify relevant randomized controlled trials (RCTs). Outcomes of interest were rebleeding and mortality. Results were expressed as relative risk (RR) and 95% confidence interval (CI). We followed the Grading of Recommendations Assessment, Development, and Evaluation approach to rate the certainty of evidence. We included 9 RCTs with 647 patients who had histories of GVB and follow-ups >6 weeks. A total of 9 interventions were included in the NMA. Balloon-occluded retrograde transvenous obliteration (BRTO) was associated with a lower risk of rebleeding when compared with β-blockers (RR, 0.04; 95% CI, 0.01-0.26; low certainty), and endoscopic injection sclerotherapy (EIS)-cyanoacrylate (CYA) (RR, 0.18; 95% CI, 0.04-0.77; low certainty). β-blockers were associated with a higher risk of rebleeding compared with most interventions and with increased mortality compared with EIS-CYA (RR, 4.12, 95% CI, 1.50-11.36; low certainty), and EIS-CYA + nonselective β-blockers (RR, 5.61; 95% CI, 1.91-16.43; low certainty). Analysis based on indirect comparisons suggests that BRTO may be the best intervention in preventing rebleeding, whereas β-blocker monotherapy is likely the worst in preventing rebleeding and mortality. Head-to-head RCTs are needed to validate these results.
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Affiliation(s)
- Karim T Osman
- Department of Internal Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Clinic, Burlington, MA
| | - Tarek Nayfeh
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN
| | - Ahmed M Abdelfattah
- Division of Gastroenterology, Lahey Hospital and Medical Center, Beth Israel Lahey Clinic, Burlington, MA.,Department of Medicine, Division of Gastroenterology, University of Massachusetts Medical School, Worcester, MA
| | | | - Bashar Hasan
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN
| | | | - Homam Alabaji
- Department of Internal Medicine, Wertachklinik Schwabmünchen, Bavaria, Germany
| | - Lina Elkhabiry
- Department of Internal Medicine, University of Alexandria, Alexandria, Egypt
| | - Jehan Mousa
- Department of Internal Medicine, Damascus University, Damascus, Syria
| | - Larry J Prokop
- Department of Library Services, Mayo Clinic, Rochester, MN
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN
| | - Fredric Gordon
- Division of Gastroenterology, Lahey Hospital and Medical Center, Beth Israel Lahey Clinic, Burlington, MA.,Department of Transplantation and Hepatobiliary Diseases, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, MA
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26
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Jeyanesan D, Balachandrakumar VK, Hogan B. Guideline review: transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension-a BSG guideline. Frontline Gastroenterol 2022; 13:531-534. [PMID: 36250168 PMCID: PMC9555133 DOI: 10.1136/flgastro-2022-102151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 05/03/2022] [Indexed: 02/04/2023] Open
Abstract
The decision-making around transjugular intrahepatic portosystemic shunt (TIPSS) placement in the management of patients with chronic liver disease and portal hypertension (PH) is a regular challenge for hepatologists. In the UK, access has improved, with more than 35 hospitals now offering this service. However, its role in acute variceal bleeding, refractory ascites and other complications of PH continues to be redefined and expanded. In particular, the role of pre-emptive TIPSS has become more established and requires re-evaluation of pathways to enable equitable access for patients. Here, we summarise the key recommendations from the recently published British Society of Gastroenterology guidelines and expand on the challenges posed.
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Affiliation(s)
- Dhaarica Jeyanesan
- Institute of Liver Studies, King's College Hospital Liver Unit, London, UK
| | | | - Brian Hogan
- Institute of Liver Studies, King's College Hospital Liver Unit, London, UK
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27
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Liu B, Li G. Progress in Endoscopic and Interventional Treatment of Esophagogastric Variceal Bleeding. DISEASE MARKERS 2022; 2022:2940578. [PMID: 35571609 PMCID: PMC9106506 DOI: 10.1155/2022/2940578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 04/22/2022] [Accepted: 04/28/2022] [Indexed: 12/13/2022]
Abstract
Esophagogastric variceal bleeding (EGVB) is one of the main complications of portal hypertension, especially in patients with liver cirrhosis, and has a very high fatality rate. At present, the treatment methods for rupture and bleeding of gastroesophageal varices (GV) include drug therapy, compression hemostasis with three-lumen and two-balloon tube, endoscopic therapy, and interventional and surgical operations. Endoscopy and intervention or their combined application is the mainstream treatment modes in clinical practice, especially their combined application has been increasingly recognized by front-line clinicians. This article intends to discuss the application characteristics of the two treatment methods.
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Affiliation(s)
- Bin Liu
- Department of Vascular Surgery, The Second Affiliated Hospital of Shandong First Medical University, Taian 271000, China
| | - Gang Li
- Department of Vascular Surgery, The Second Affiliated Hospital of Shandong First Medical University, Taian 271000, China
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28
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Mukund A, Rana S, Mohan C, Kalra N, Baijal SS. Indian College of Radiology and Imaging Evidence-Based Guidelines for Interventions in Portal Hypertension and Its Complications. Indian J Radiol Imaging 2022; 31:917-932. [PMID: 35136505 PMCID: PMC8817816 DOI: 10.1055/s-0041-1740235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022] Open
Abstract
Portal hypertension is a complication of chronic liver disease. Various radiological interventions are being done to aid in the diagnosis of portal hypertension; further, an interventional radiologist can offer various treatments for the complications of portal hypertension. Diagnosis of portal hypertension in its early stage may require hepatic venous pressure gradient measurement. Measurement of gradient also guides in diagnosing the type of portal hypertension, measuring response to treatment and prognostication. This article attempts to provide evidence-based guidelines on the management of portal hypertension and treatment of its complications.
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Affiliation(s)
- Amar Mukund
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shaleen Rana
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chander Mohan
- Department of Interventional Radiology, BLK Superspecialty Hospital, New Delhi, India
| | - Naveen Kalra
- Department of Radiology, PGIMER, Chandigarh, India
| | - Sanjay Saran Baijal
- Department of Diagnostic and Interventional Radiology, Medanta—The Medicity, Gurugram, Haryana, India
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29
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Wu Y, Chen M, Huang M, Liao G, Tang S, Zheng H, Li Y, Peng B, Zheng X, Pan S, Hou J, Chen B. [Value of purple sign for predicting rebleeding events in cirrhotic patients following endoscopic selective varices devascularization]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2021; 41:1822-1827. [PMID: 35012914 PMCID: PMC8752418 DOI: 10.12122/j.issn.1673-4254.2021.12.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To assess the value of the purple sign for predicting long-term rebleeding events in cirrhotic patients following endoscopic selective varices devascularization. METHODS We retrospectively analyzed the clinical data of 97 patients with liver cirrhosis, who had a history of gastroesophageal variceal bleeding and underwent endoscopic selective varices devascularization. Thirty-two of the patients showed purple sign after endoscopic treatment. We used propensity score matching (PSM) to minimize the selection bias of the patients (purple sign vs no purple sign) and reduce the intergroup differences of clinical characteristics. The primary outcome measure of this study was cumulative rebleeding events after endoscopic selective varices devascularization. RESULTS The 1-year rebleeding rate (27.0% vs 36.7%) or 6-month rebleeding rate (10.9% vs 26.9%) following endoscopic treatment was not significantly different between the purple sign group and no purple sign group before PSM (P=0.2385). But after PSM, the 1-year rebleeding rate (28.2% vs 56.4%) and 6-month rebleeding rate (5.0% vs 37.0%) were significantly lower in the purple sign group than in the no purple sign group (P=0.0304). CONCLUSIONS The presence of purple sign indicates a lower risk of rebleeding after endoscopic treatment of cirrhotic gastroesophageal varices and a potentially favorable treatment response after endoscopic therapy, thus providing a clinical indicator for stratification of the patients for sequential endoscopic sessions.
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Affiliation(s)
- Y Wu
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - M Chen
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - M Huang
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - G Liao
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - S Tang
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - H Zheng
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - Y Li
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - B Peng
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - X Zheng
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - S Pan
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - J Hou
- Department of Gastroenterology and Hepatology of First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - B Chen
- Department of Gastroenterology and Hepatology of First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
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30
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Chandna S, Zarate ER, Gallegos-Orozco JF. Management of Decompensated Cirrhosis and Associated Syndromes. Surg Clin North Am 2021; 102:117-137. [PMID: 34800381 DOI: 10.1016/j.suc.2021.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Patients with cirrhosis account for 3% of intensive care unit admissions with hospital mortality exceeding 50%; however, improvements in survival among patients with acutely decompensated cirrhosis and organ failure have been described when treated in specialized liver transplant centers. Acute-on-chronic liver failure is a distinct clinical syndrome characterized by decompensated cirrhosis associated with one or more organ failures resulting in a significantly higher short-term mortality. In this review, we will discuss the management of common life-threatening complications in the patient with cirrhosis that require intensive care management including neurologic, cardiovascular, gastrointestinal, pulmonary, and renal complications.
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Affiliation(s)
- Shaun Chandna
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Utah School of Medicine, 30 N 1900 E, SOM-4R118, Salt Lake City, UT 84106, USA
| | - Eduardo Rodríguez Zarate
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Utah School of Medicine, 30 N 1900 E, SOM-4R118, Salt Lake City, UT 84106, USA
| | - Juan F Gallegos-Orozco
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Utah School of Medicine, 30 N 1900 E, SOM-4R118, Salt Lake City, UT 84106, USA.
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31
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Yu SY, Wang WH, Xu L. Clip-Assisted Endoscopic Cyanoacrylate Injection: A Novel Technique for Acute Gastroesophageal Variceal Bleeding. J Laparoendosc Adv Surg Tech A 2021. [PMID: 34748420 DOI: 10.1089/lap.2021.0377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background and Aim: Endoscopic injection sclerotherapy is effective for the treatment of gastric variceal bleeding, but may cause fatal ectopic embolism. Spontaneous portosystemic shunts are one of the risk factors for ectopic embolism. This present study aims to evaluate the efficacy and safety of clip-assisted endoscopic cyanoacrylate injection for the treatment of acute gastroesophageal variceal bleeding. Methods: The medical records of patients with gastroesophageal varices (GOVs) who underwent clip-assisted cyanoacrylate injection at the Ningbo First Hospital from March 2017 to August 2020 were reviewed. The outcomes were immediate hemostasis rate, early rebleeding rate, late rebleeding rate, and procedure-related complications. The gastrorenal and splenorenal shunts were evaluated by the computed tomography angiography. Results: A total of 9 patients with GOVs (GOV1 and GOV2) were analyzed, and 4 of the patients had spontaneous portosystemic shunts. The average number of clips used in each patient was 2.11 ± 1.96, and an average of 5.11 ± 1.76 mL of cyanoacrylate was injected into each patient. All patients completed immediate hemostasis. Two patients experienced rebleeding, including 1 case of early rebleeding and 1 case of late rebleeding (both due to cyanoacrylate extrusion) during a median follow-up of 367 days (interquartile range 270-855 days). Five patients underwent follow-up endoscopy; eradicated gastric varices (GVs) were revealed in 1 patient, and shrunken GVs were found in 4 patients. No serious complications, including ectopic embolism, were observed. Conclusion: The present study showed the efficacy and safety of clip-assisted endoscopic cyanoacrylate injection in acute GOV bleeding, but these results require verification by randomized controlled studies with larger sample numbers.
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Affiliation(s)
- Si-Yi Yu
- Department of Gastroenterology, Ningbo First Hospital, Ningbo, China
| | - Wei-Hong Wang
- Department of Gastroenterology, Ningbo First Hospital, Ningbo, China
| | - Lei Xu
- Department of Gastroenterology, Ningbo First Hospital, Ningbo, China
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32
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Singh SP, Wadhawan M, Acharya SK, Bopanna S, Madan K, Sahoo MK, Bhat N, Misra SP, Duseja A, Mukund A, Anand AC, Goel A, Satyaprakash BS, Varghese J, Panigrahi MK, Tandan M, Mohapatra MK, Puri P, Rathi PM, Wadhwa RP, Taneja S, Thomas V, Bhatia V. Management of portal hypertensive upper gastrointestinal bleeding: Report of the Coorg Consensus workshop of the Indian Society of Gastroenterology Task Force on Upper Gastrointestinal Bleeding. Indian J Gastroenterol 2021; 40:519-540. [PMID: 34890020 DOI: 10.1007/s12664-021-01169-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/09/2021] [Indexed: 02/04/2023]
Abstract
Portal hypertensive bleeding is a major complication of portal hypertension (PHT) with high morbidity and mortality. A lot of advances have been made in our understanding of screening, risk stratification, and management strategies for portal hypertensive bleeding including acute variceal bleeding leading to improved overall outcomes in patients with PHT. A number of guidelines on variceal bleeding have been published by various societies in the past few years. The Indian Society of Gastroenterology (ISG) Task Force on Upper Gastrointestinal Bleeding (UGIB) felt that it was necessary to bring out a standard practice guidance document for the use of Indian health care providers especially physicians, gastroenterologists, and hepatologists. For this purpose, an expert group meeting was convened by the ISG Task Force to deliberate on this matter and write a consensus guidance document for Indian practice. The delegates including gastroenterologists, hepatologists, radiologists, and surgeons from different parts of the country participated in the consensus development meeting at Coorg in 2018. A core group was constituted which reviewed all published literature on portal hypertensive UGIB with special reference to the Indian scenario and prepared unambiguous statements on different aspects for voting and consensus in the whole group. This consensus was produced through a modified Delphi process and reflects our current understanding and recommendations for the diagnosis and management of portal hypertensive UGIB in Indians. Intended for use by the health care providers especially gastroenterologists and hepatologists, these consensus statements provide an evidence-based approach to risk stratification, diagnosis, and management of patients with portal hypertensive bleeding.
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Affiliation(s)
- Shivaram P Singh
- Department of Gastroenterology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, 753 001, India.
| | - Manav Wadhawan
- Department of Hepatology and Liver Transplant, Institute of Liver and Digestive Diseases, BLK Super Specialty Hospital, Delhi, 110 005, India
| | - Subrat K Acharya
- Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, 751 024, India
| | - Sawan Bopanna
- Department of Gastroenterology and Hepatology, Fortis Flt. Lt. Rajan Dhall Hospital, Aruna Asaf Ali Marg, Vasant Kunj, New Delhi, 110 070, India
| | - Kaushal Madan
- Department of Gastroenterology and Hepatology, Max Smart Super Specialty Hospital, Saket, New Delhi, 110 017, India
| | - Manoj K Sahoo
- Department of Medical Gastroenterology, IMS and SUM Hospital, K8 Kalinga Nagar, Shampur, Bhubaneswar, 751 003, India
| | - Naresh Bhat
- Department of Gastroenterology and Hepatology, Aster CMI Hospital, Bangalore, 560 092, India
| | - Sri P Misra
- Department of Gastroenterology and Hepatology, Moti Lal Nehru Medical College, Allahabad, 211 001, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Amar Mukund
- Department of Radiology, Institute of Liver and Biliary Sciences, Sector D-1, Vasant Kunj, New Delhi, 110 070, India
| | - Anil C Anand
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Patia, Bhubaneswar, 751 024, India
| | - Ashish Goel
- Department of Hepatology, Christian Medical College, Vellore, 632 004, India
| | | | - Joy Varghese
- Department of Hepatology and Transplant Hepatology, Institute of Liver Disease and Transplantation, Gleneagles Global Health City, 439, Cheran Nagar, Chennai, 600 100, India
| | - Manas K Panigrahi
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, 751 019, India
| | - Manu Tandan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Somajiguda, Hyderabad, 500 082, India
| | - Mihir K Mohapatra
- Department of Surgical Gastroenterology, Srirama Chandra Bhanja Medical College, Cuttack, 753 007, India
| | - Pankaj Puri
- Department of Gastroenterology and Hepatology, Fortis Escorts Liver and Digestive Diseases Institute, Okhla Road, New Delhi, 110 025, India
| | - Pravin M Rathi
- Department of Gastroenterology, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, 400 008, India
| | - Rajkumar P Wadhwa
- Department of Gastroenterology, Apollo BGS Hospital, Adichuchanagiri Road, Kuvempunagar, Mysore, 570 023, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Varghese Thomas
- Department of Gastroenterology, Malabar Medical College Hospital, Modakkallur, Calicut, 673 321, India
| | - Vikram Bhatia
- Department of Hepatology, Institute of Liver and Biliary Sciences, Sector D-1, Vasant Kunj, New Delhi, 110 070, India
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Luo X, Xiang T, Wu J, Wang X, Zhu Y, Xi X, Yan Y, Yang J, García-Pagán JC, Yang L. Endoscopic Cyanoacrylate Injection Versus Balloon-Occluded Retrograde Transvenous Obliteration for Prevention of Gastric Variceal Bleeding: A Randomized Controlled Trial. Hepatology 2021; 74:2074-2084. [PMID: 33445218 DOI: 10.1002/hep.31718] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 12/29/2020] [Accepted: 01/05/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS The optimal treatment for gastric varices (GVs) is a topic that remains open for study. This study compared the efficacy and safety of endoscopic cyanoacrylate injection and balloon-occluded retrograde transvenous obliteration (BRTO) to prevent rebleeding in patients with cirrhosis and GVs after primary hemostasis. APPROACH AND RESULTS Patients with cirrhosis and history of bleeding from gastroesophageal varices type 2 or isolated gastric varices type 1 were randomized to cyanoacrylate injection (n = 32) or BRTO treatment (n = 32). Primary outcomes were gastric variceal rebleeding or all-cause rebleeding. Patient characteristics were well balanced between two groups. Mean follow-up time was 27.1 ± 12.0 months in a cyanoacrylate injection group and 27.6 ± 14.3 months in a BRTO group. Probability of gastric variceal rebleeding was higher in the cyanoacrylate injection group than in the BRTO group (P = 0.024). Probability of remaining free of all-cause rebleeding at 1 and 2 years for cyanoacrylate injection versus BRTO was 77% versus 96.3% and 65.2% versus 92.6% (P = 0.004). Survival rates, frequency of complications, and worsening of esophageal varices were similar in both groups. BRTO resulted in fewer hospitalizations, inpatient stays, and lower medical costs. CONCLUSIONS BRTO is more effective than cyanoacrylate injection in preventing rebleeding from GVs, with similar frequencies of complications and mortalities.
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Affiliation(s)
- Xuefeng Luo
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Tong Xiang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Junchao Wu
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoze Wang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Yongjun Zhu
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaotan Xi
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
| | - Yuling Yan
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Jinlin Yang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, Barcelona, Spain
| | - Li Yang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
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34
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Lee HL, Lee SW. The role of transjugular intrahepatic portosystemic shunt in patients with portal hypertension: advantages and pitfalls. Clin Mol Hepatol 2021; 28:121-134. [PMID: 34571587 PMCID: PMC9013617 DOI: 10.3350/cmh.2021.0239] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/25/2021] [Indexed: 12/31/2022] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an effective interventional procedure to relieve portal hypertension, which is a main mechanism for the development of complications of liver cirrhosis (LC), such as variceal hemorrhage, ascites, and hepatorenal syndrome. However, the high incidence of adverse events after TIPS implementation limits its application in clinical practice. Esophageal variceal hemorrhage is one of the major indications for TIPS. Recently, preemptively performed TIPS has been recommended, as several studies have shown that TIPS significantly reduced mortality as well as rebleeding or failure to control bleeding in patients who are at high risk of treatment failure for bleeding control with endoscopic variceal ligation and vasoactive drugs. Meanwhile, recurrent ascites is another indication for TIPS with a proven survival benefit. TIPS may also be considered as an effective treatment for other LC complications, usually as an alternative therapy. Although there are concerns about the development of hepatic encephalopathy and hepatic dysfunction after TIPS implementation, careful patient selection using prognostic scores can lead to excellent outcomes. Assessments of cardiac and renal function prior to TIPS may also be considered to improve patient prognosis.
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Affiliation(s)
- Hae Lim Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,The Catholic Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung Won Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,The Catholic Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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35
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Yao Q, Chen W, Yan C, Yu J, Jiang T, Cao H. Efficacy and Safety of Treatments for Patients With Portal Hypertension and Cirrhosis: A Systematic Review and Bayesian Network Meta-Analysis. Front Med (Lausanne) 2021; 8:712918. [PMID: 34540867 PMCID: PMC8446274 DOI: 10.3389/fmed.2021.712918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/12/2021] [Indexed: 12/19/2022] Open
Abstract
Background and Aims: Viral hepatitis are one of the main causes of liver cirrhosis. The treatment of portal hypertension caused by liver cirrhosis is difficult and diverse, and the therapeutic effect is unknown. Bayesian network meta-analysis was performed to compare the efficacy and safety of treatments for patients with portal hypertension and cirrhosis, including a transjugular intrahepatic portosystemic shunt (TIPS), endoscopic therapy, surgical therapy and medications. Methods: Eligible articles were searched for in PubMed, Embase, Cochrane Library and Web of Science databases from their inception until June 2020. Using the "gemtc-0.8.4" package in R v.3.6.3 software and the Just Another Gibbs Sampler v.4.2.0 program, network meta-analysis was performed using a random effects model within a Bayesian framework. The odds ratios for all-cause rebleeding, bleeding-related mortality, overall survival (OS), treatment failure and hepatic encephalopathy were determined within the Bayesian framework. Results: Forty randomized controlled trials were identified, including 4,006 adult patients and nine treatment strategies. Our results showed that distal splenorenal shunt and TIPS provided the best control of hemorrhage. Endoscopic variceal ligation with medication resulted in the highest OS rate. Medication alone resulted in poor OS and treatment failure. Conclusions: We performed a systematic comparison of diverse treatments for cirrhotic patients with portal hypertension. Our meta-analysis indicated that a TIPS and distal splenorenal shunt resulted in lower rates of rebleeding than did other therapies. Furthermore, drugs are more suitable for combination therapy than monotherapy.
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Affiliation(s)
- Qigu Yao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Clinical Research Center for Infectious Diseases, Hangzhou, China
| | - Wenyi Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Clinical Research Center for Infectious Diseases, Hangzhou, China
| | - Cuilin Yan
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiong Yu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Clinical Research Center for Infectious Diseases, Hangzhou, China
| | - Tian'an Jiang
- National Clinical Research Center for Infectious Diseases, Hangzhou, China.,Department of Ultrasound, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hongcui Cao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Clinical Research Center for Infectious Diseases, Hangzhou, China.,Zhejiang Provincial Key Laboratory for Diagnosis and Treatment of Aging and Physic-Chemical Injury Diseases, Hangzhou, China
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36
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Portal Hypertension and Ascites: Patient-and Population-centered Clinical Practice Guidelines by the Italian Association for the Study of the Liver (AISF). Dig Liver Dis 2021; 53:1089-1104. [PMID: 34321192 DOI: 10.1016/j.dld.2021.06.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/30/2021] [Accepted: 06/20/2021] [Indexed: 02/06/2023]
Abstract
Portal hypertension and ascites are two crucial events in the natural history of liver cirrhosis, whose appearance marks a downward shift in the prognosis of the disease. Over the years, several international and national societies have issued clinical practice guidelines for the diagnosis and management of portal hypertension and ascites. The present document addresses the needs of an updated guidance on the clinical management of these conditions. Accordingly, the AISF Governing Board appointed a multi-disciplinary committee of experts for drafting an update of the most recent EASL Clinical Practice Guidelines. The aim of this work was to adapt the EASL recommendations to national regulations and resources, local circumstances and settings, infrastructure, and cost/benefit strategies to avoid duplication of efforts and optimize resource utilization. The committee defined the objectives, the key issues and retrieved the relevant evidence by performing a systematic review of the literature. Finally, the committee members (chosen on the basis of their specific expertise) identified the guidelines' key questions and developed them following the PICO format (Population, Intervention, Comparison, Outcomes). For each of the PICO questions, the systematic review of the literature was made on the most important scientific databases (Pubmed, Scopus, Embase).
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37
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Vaz K, Efthymiou M, Vaughan R, Testro AG, Lew HB, Pu LZCT, Chandran S. Unpacking the challenge of gastric varices: A review on indication, timing and modality of therapy. World J Hepatol 2021; 13:868-878. [PMID: 34552693 PMCID: PMC8422918 DOI: 10.4254/wjh.v13.i8.868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/09/2021] [Accepted: 07/29/2021] [Indexed: 02/06/2023] Open
Abstract
Upper gastrointestinal bleeding from oesophageal or gastric varices is an important medical condition in patients with portal hypertension. Despite the emergence of a number of novel endoscopic and radiologic therapies for oesophagogastric varices, controversy exists regarding the indication, timing and modality of therapy. The aim of this review is to provide a concise and practical evidence-based overview of these issues.
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Affiliation(s)
- Karl Vaz
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Marios Efthymiou
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
- University of Melbourne, Parkville 3052, Victoria, Australia
| | - Rhys Vaughan
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
- University of Melbourne, Parkville 3052, Victoria, Australia
| | - Adam G Testro
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Hin-Boon Lew
- Department of Radiology, Austin Health, Heidelberg 3084, Victoria, Australia
| | | | - Sujievvan Chandran
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
- University of Melbourne, Parkville 3052, Victoria, Australia
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38
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Henry Z, Patel K, Patton H, Saad W. AGA Clinical Practice Update on Management of Bleeding Gastric Varices: Expert Review. Clin Gastroenterol Hepatol 2021; 19:1098-1107.e1. [PMID: 33493693 DOI: 10.1016/j.cgh.2021.01.027] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 01/13/2021] [Accepted: 01/18/2021] [Indexed: 02/07/2023]
Abstract
Management of bleeding gastric varices (GV) presents a unique challenge for patients with portal hypertension. Despite over thirty years of diagnostic and treatment advances standardized practices for bleeding GV are lacking and unsupported by adequate evidence. There are no definitive natural history studies to help with risk assessment or prospective clinical trials to guide clinical decision making. Available literature on the natural history and management of gastric varices consists of case series, restricted cohort studies, and a few small randomized trials, all of which have significant selection biases. This review summarizes the available data and recommendations based on expert opinion on how best to diagnose and manage bleeding from gastric varices. Table 1 summarizes our recommendations.
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Affiliation(s)
- Zachary Henry
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia, Charlottesville, Virginia.
| | - Kalpesh Patel
- Division of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Heather Patton
- Gastroenterology Section, VA San Diego Healthcare System, San Diego, California
| | - Wael Saad
- Interventional Radiology, Radiology and Imaging Sciences, National Institutes of Health, Washington, DC
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39
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Chevallier O, Guillen K, Comby PO, Mouillot T, Falvo N, Bardou M, Midulla M, Aho-Glélé LS, Loffroy R. Safety, Efficacy, and Outcomes of N-Butyl Cyanoacrylate Glue Injection through the Endoscopic or Radiologic Route for Variceal Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10112298. [PMID: 34070534 PMCID: PMC8198169 DOI: 10.3390/jcm10112298] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 05/17/2021] [Accepted: 05/17/2021] [Indexed: 12/12/2022] Open
Abstract
We performed a systematic review and meta-analysis of published studies to assess the efficacy, safety, and outcomes of N-butyl cyanoacrylate (NBCA) injection for the treatment of variceal gastrointestinal bleeding (GIB). The MEDLINE/PubMed, EMBASE, and SCOPUS databases were searched for English-language studies published from January 1980 to December 2019 and including patients who had injection of NBCA for variceal GIB. Two independent reviewers extracted and evaluated the data from eligible studies. Exclusion criteria were sample size < 5, article reporting the use of NBCA with other embolic agents, no extractable data, and duplicate reports. NBCA was injected during endoscopy in 42 studies and through a direct percutaneous approach for stomal varices in 1 study. The study’s endpoints were: Technical success, 30-day rebleeding, and 30-day overall and major complications. The estimated overall rates were computed with 95% confidence intervals, based on each study rate, weighted by the number of patients involved in each study. In total, 43 studies with 3484 patients were included. The technical success rate was 94.1% (95% CI: 91.6–96.1%), the 30-day rebleeding rate was 24.2% (18.9–29.9%), and 30-day overall and major complications occurred in 15.9% (11.2–21.3%) and 5.3% (3.3–7.8%) of patients, respectively. For treating variceal GIB, NBCA injection is a safe and effective method that demonstrates high technical success rate and very low major complication rate.
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Affiliation(s)
- Olivier Chevallier
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (O.C.); (K.G.); (N.F.); (M.M.)
| | - Kévin Guillen
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (O.C.); (K.G.); (N.F.); (M.M.)
| | - Pierre-Olivier Comby
- Department of Neuroradiology and Emergency Radiology, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France;
| | - Thomas Mouillot
- Department of Gastroenterology and Hepatology, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (T.M.); (M.B.)
| | - Nicolas Falvo
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (O.C.); (K.G.); (N.F.); (M.M.)
| | - Marc Bardou
- Department of Gastroenterology and Hepatology, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (T.M.); (M.B.)
| | - Marco Midulla
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (O.C.); (K.G.); (N.F.); (M.M.)
| | - Ludwig-Serge Aho-Glélé
- Department of Biostatistics and Epidemiology, François-Mitterrand University Hospital, 14 Rue Paul, Gaffarel, BP 77908, 21079 Dijon, France;
| | - Romaric Loffroy
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (O.C.); (K.G.); (N.F.); (M.M.)
- Correspondence: ; Tel.: +33-380-293-358
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40
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Baiges A, Magaz M, Turon F, Hernández-Gea V, García-Pagán JC. Treatment of Acute Variceal Bleeding in 2021-When to Use Transjugular Intrahepatic Portosystemic Shunts? Clin Liver Dis 2021; 25:345-356. [PMID: 33838854 DOI: 10.1016/j.cld.2021.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Variceal bleeding in patients with cirrhosis is associated with high mortality if not adequately managed. Treatment of acute variceal bleeding with adequate resuscitation maneuvers, restrictive transfusion policy, antibiotic prophylaxis, pharmacologic therapy, and endoscopic therapy is highly effective at controlling bleeding and preventing death. There is a subgroup of high-risk cirrhotic patients in whom this strategy fails, however, and who have a high-mortality rate. Placing a preemptive transjugular intrahepatic portosystemic shunt in these high-risk patients, as soon as possible after admission, to achieve early control of bleeding has proved not only to control bleeding but also to improve survival.
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Affiliation(s)
- Anna Baiges
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), HealthCare Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Marta Magaz
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), HealthCare Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Fanny Turon
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), HealthCare Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), HealthCare Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), HealthCare Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver).
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41
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Prevention of variceal rebleeding in cirrhotic patients with spontaneous portosystemic shunts: transjugular intrahepatic portosystemic shunt versus endoscopic treatment. Eur J Gastroenterol Hepatol 2021; 33:752-761. [PMID: 33731589 DOI: 10.1097/meg.0000000000002079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Spontaneous portosystemic shunts(SPSSs) in cirrhotic patients indicate higher incidence of gastric varices, which increases the risk for bleeding and death. However, few studies compared endoscopic therapy with transjugular intrahepatic portosystemic shunt (TIPS) in preventing variceal rebleeding in cirrhotic patients with SPSSs. This research aims to evaluate the effectiveness of the two methods in this group of patients. METHODS We reviewed consecutive cirrhotic patients with SPSSs who underwent either TIPS or endoscopic treatment to prevent variceal rebleeding between January 2015 and December 2018 in our institution. Outcomes including rebleeding, overt hepatic encephalopathy (OHE), complications and survival were compared. Meanwhile, subgroup analyses were conducted to screen relevant factors affecting the results. RESULTS A total of 97 patients were included in the study. The TIPS arm contained 50 patients and the endoscopy arm contained 47 patients. Rebleeding rate in TIPS group was statistically lower than endoscopic group [16.0 vs 38.3%, hazard ratio (HR) = 0.37, 95% confidence interval (CI): 0.16-0.84, P = 0.01], while OHE was more frequent (16.0 vs 2.1%, HR = 7.59, 95% CI: 0.94-61.2, P = 0.025), the survival rate (92 vs 89.4%, HR = 0.88, 95% CI: 0.22-3.60, P = 0.87) and frequency of complications were comparable between two groups. In the subgroups of GOV2/IGV1 and splenorenal shunt/gastrorenal shunt, compared with endoscopic treatments, TIPS reduced the rate of rebleeding without significantly increasing overt hepatic encephalopathy; however, it did not improve survival rate. CONCLUSIONS For cirrhotic patients with SPSSs, TIPS brought a lower rebleeding rate but a higher incidence of OHE. However, in the subgroups of GOV2/IGV1 and splenorenal shunt/gastrorenal shunt, TIPS was considered more reasonable due to the lower rebleeding rate and comparable OHE incidence.
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Zhou J, Liu C, Ma L, Chen J, Luo T, Li F, Wang J, Zeng X, Chen S. Complications and management of elective endoscopic cyanoacrylate injection with lauromacrogol for gastric varices. Eur J Gastroenterol Hepatol 2021; 33:680-685. [PMID: 33731585 DOI: 10.1097/meg.0000000000002099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To report the complications and evaluate the risk factors of elective endoscopic cyanoacrylate injection with lauromacrogol for gastric varices in cirrhotic patients. METHODS A total of 583 elective endoscopic tissue adhesives procedures were performed in 439 patients in our hospital from January 2015 to December 2016. The clinical characteristics and complications were retrospectively collected and evaluated. RESULTS The median age was 56 ± 11 years, and 290 (66.1%) patients were male. The main etiology of liver cirrhosis was hepatitis virus (63.3%). Two hundred fifty-nine (59.0%) patients were classified as Child-Pugh Class A. Bleeding occurred in 44 patients (7.5%) during procedures. Two patients developed distant embolism (0.5%; one pulmonary, one cerebra). In perioperative period, fever was a common complication; however, only 16 cases had high fever and one case had sepsis. Bleeding was observed in 7 (1.2%) patients. Overall incidence of the major perioperative complication was 3.8%. The major postoperative complication rate was 10.4% (60/582, 26 rebleeds, 27 ascites increase, 12 new-onset portal vein thrombosis). The complication-related death was 1.6% (one death from embolism, five deaths from rebleeding, one death from refractory ascites). Injection point was the only factor related to the major perioperative complications [odds ratio (OR) = 1.581, 95% CI, 1.086-2.301; P < 0.05]. Etiology of cirrhosis and injection point were independent risk factors of major postoperative complications (OR = 1.830, 95% CI, 1.005-3.331, P = 0.048; OR = 1.373, 95% CI, 1.089-1.731, P = 0.007). CONCLUSION The incidence of complications after elective endoscopic cyanoacrylate injection with lauromacrogol for gastric varices was low. The injection point was the risk factor for both perioperative and postoperative complications.
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Affiliation(s)
- Ji Zhou
- Department of Gastroenterology and Hepatology
| | - Chengfeng Liu
- Department of Gastroenterology and Hepatology
- Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lili Ma
- Department of Endoscopy Center
| | - Jie Chen
- Department of Gastroenterology and Hepatology
| | | | - Feng Li
- Department of Gastroenterology and Hepatology
| | - Jian Wang
- Department of Gastroenterology and Hepatology
| | | | - Shiyao Chen
- Department of Gastroenterology and Hepatology
- Department of Endoscopy Center
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Tsauo J, Tie J, Xue H, Zhao JB, Li JJ, Fang ZT, Guo WH, Li X. Transjugular Intrahepatic Portosystemic Shunt Creation for the Prevention of Gastric Variceal Rebleeding in Patients with Hepatocellular Carcinoma: A Multicenter Retrospective Study. J Vasc Interv Radiol 2021; 32:963-969. [PMID: 33864909 DOI: 10.1016/j.jvir.2021.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/28/2021] [Accepted: 04/03/2021] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To evaluate the effectiveness and safety of transjugular intrahepatic portosystemic shunt (TIPS) creation for the prevention of gastric variceal rebleeding in patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS This multicenter retrospective study included 126 cirrhotic patients (mean age, 54.1 ± 10.2 years; 110 men) with HCC who underwent TIPS creation for the prevention of gastric variceal rebleeding. Of these, 110 (87.3%) patients had gastroesophageal varices and 16 (12.7%) patients had isolated gastric varices. Thirty-five (27.8%) patients had portal vein tumor thrombus. RESULTS TIPS creation was technically successful in 124 (98.4%) patients. Rebleeding occurred in 26 (20.6%) patients during the follow-up period. The 6-week and 1-year actuarial probabilities of patients remaining free of rebleeding were 98.3% ± 1.2% and 81.2% ± 3.9%, respectively. Forty-nine (38.8%) patients died during the follow-up period. The 6-week and 1-year actuarial probabilities of survival were 98.4 ± 1.1% and 65.6 ± 4.4%, respectively. Two (1.6%) patients had major procedure-related complications, including acute liver failure (n = 1) and intra-abdominal bleeding (n = 1). Thirty-three (26.2%) patients had at least 1 episode of overt hepatic encephalopathy during the follow-up period. Shunt dysfunction occurred in 15 (11.9%) patients after a median follow-up time of 11.4 months (range, 1.4-41.3 months). Lung metastasis occurred in 3 (2.4%) patients, 3.9-32.9 months after TIPS creation. CONCLUSIONS TIPS creation may be effective and safe for the prevention of gastric variceal rebleeding in patients with HCC.
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Affiliation(s)
- Jiaywei Tsauo
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Tie
- National Clinical Research Center for Digestive Diseases, State Key Laboratory of Cancer Biology and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Military Medical University, Xi'an, Shaanxi, China
| | - Hui Xue
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Jian-Bo Zhao
- Division of Vascular and Interventional Radiology, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Jian-Jun Li
- Hepatic Disease and Tumor Interventional Therapy Center, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Zhu-Ting Fang
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China; Department of Interventional Radiology, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Wu-Hua Guo
- Department of Interventional Radiology, Mengchao Hepatobiliary Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Xiao Li
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Shah KY, Ren A, Simpson RO, Kloster ML, Mikolajczyk A, Bui JT, Lipnik AJ, Niemeyer MM, Ray CE, Gaba RC. Combined Transjugular Intrahepatic Portosystemic Shunt Plus Variceal Obliteration versus Transjugular Intrahepatic Portosystemic Shunt Alone for the Management of Gastric Varices: Comparative Single-Center Clinical Outcomes. J Vasc Interv Radiol 2021; 32:282-291.e1. [PMID: 33485506 DOI: 10.1016/j.jvir.2020.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/11/2020] [Accepted: 10/11/2020] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To compare the safety and clinical outcomes of combined transjugular intrahepatic portosystemic shunt (TIPS) plus variceal obliteration to those of TIPS alone for the treatment of gastric varices (GVs). MATERIALS AND METHODS A single-center, retrospective study of 40 patients with bleeding or high-risk GVs between 2008 and 2019 was performed. The patients were treated with combined therapy (n = 18) or TIPS alone (n = 22). There were no significant differences in age, sex, model for end-stage liver disease score, or GV type between the groups. The primary outcomes were the rates of GV eradication and rebleeding. The secondary outcomes included portal hypertensive complications and hepatic encephalopathy. RESULTS The mean follow-up period was 15.4 months for the combined therapy group and 22.9 months for the TIPS group (P = .32). After combined therapy, there was a higher rate of GV eradication (92% vs 47%, P = .01) and a trend toward a lower rate of GV rebleeding (0% vs 23%, P = .056). The estimated rebleeding rates were 0% versus 5% at 3 months, 0% versus 11% at 6 months, 0% versus 18% at 1 year, and 0% versus 38% at 2 years after combined therapy and TIPS, respectively (P = .077). There was no difference in ascites (13% vs 11%, P = .63), hepatic encephalopathy (47% vs 55%, P = .44), or esophageal variceal bleeding (0% vs 0%, P > .999) after the procedure between the groups. CONCLUSIONS The GV eradication rate is significantly higher after combined therapy, with no associated increase in portal hypertensive complications. This translates to a clinically meaningful trend toward a reduction in GV rebleeding. The value of a combined treatment strategy should be prospectively studied in a larger cohort to determine the optimal management of GVs.
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Affiliation(s)
- Ketan Y Shah
- Department of Radiology, University of Illinois at Chicago, 1740 West Taylor Street, MC 931, Chicago, IL, 60612.
| | - Albert Ren
- University of Illinois College of Medicine, Chicago, IL
| | | | | | - Adam Mikolajczyk
- Department of Medicine, University of Illinois Health, Chicago, IL
| | - James T Bui
- Department of Radiology, University of Illinois at Chicago, 1740 West Taylor Street, MC 931, Chicago, IL, 60612
| | - Andrew J Lipnik
- Department of Radiology, University of Illinois at Chicago, 1740 West Taylor Street, MC 931, Chicago, IL, 60612
| | - Matthew M Niemeyer
- Department of Radiology, University of Illinois at Chicago, 1740 West Taylor Street, MC 931, Chicago, IL, 60612
| | - Charles E Ray
- Department of Radiology, University of Illinois at Chicago, 1740 West Taylor Street, MC 931, Chicago, IL, 60612
| | - Ron C Gaba
- Department of Radiology, University of Illinois at Chicago, 1740 West Taylor Street, MC 931, Chicago, IL, 60612
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Carrion AF, Martin P. Keeping Patients with End-Stage Liver Disease Alive While Awaiting Transplant: Management of Complications of Portal Hypertension. Clin Liver Dis 2021; 25:103-120. [PMID: 33978573 DOI: 10.1016/j.cld.2020.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Complications of portal hypertension such as gastroesophageal variceal hemorrhage, ascites, and spontaneous bacterial peritonitis, as well as pulmonary complications, are often responsible for diminished quality of life, excess morbidity and mortality, increased health care resource use and expenditure, and dropout from the liver transplant (LT) waiting list. Therefore, the care of LT candidates on the waiting list must be centered on anticipation and prompt intervention for these complications.
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Affiliation(s)
- Andres F Carrion
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, Office 1189, Miami, FL 33136, USA.
| | - Paul Martin
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1120 Northwest 14th #1115, Miami, FL 33136, USA
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Thiruvengadam SS, Sedarat A. The Role of Endoscopic Ultrasound (EUS) in the Management of Gastric Varices. Curr Gastroenterol Rep 2021; 23:1. [PMID: 33389241 PMCID: PMC7778619 DOI: 10.1007/s11894-020-00801-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Gastric varices (GV) are an important complication of portal hypertension, and the current recommendation for management is beta-blocker therapy for primary prophylaxis and transjugular intrahepatic portosystemic shunt (TIPS) for active bleeding or secondary prophylaxis. Direct endoscopic injection of cyanoacrylate (CYA) glue has been investigated but has drawbacks including limited endoscopic characterization of GV and possible distal glue embolism. To this end, endoscopic ultrasound (EUS) has been pursued to help in characterization of GV, visualization of treatment in real time, and confirmation of obliteration with Doppler. RECENT FINDINGS In this paper, we review treatments for GV involving EUS, including EUS-guided injection of CYA and coils, either alone or in combination. We also discuss less common methods, including EUS-guided injection of thrombin and absorbable gelatin sponge. We then review literature comparing EUS-guided methods with direct endoscopic therapy and comparing individual EUS-guided methods with one another. We conclude by highlighting drawbacks of EUS in this field, including the unproven benefit over conventional therapy, lack of a standardized approach, and limited availability of expertise and necessary materials. Novel EUS-based methods offer a unique opportunity to directly visualize and access gastric varices for treatment and obliteration. This may provide key advantages over current endoscopic or angiographic treatments. Comparative studies investigating the benefit of EUS over conventional therapy are needed.
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Affiliation(s)
| | - Alireza Sedarat
- Division of Digestive Diseases, UCLA Vatche and Tamar Manoukian, Los Angeles, CA USA
- Santa Monica, USA
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Zanetto A, Barbiero G, Battistel M, Sciarrone SS, Shalaby S, Pellone M, Battistella S, Gambato M, Germani G, Russo FP, Burra P, Senzolo M. Management of portal hypertension severe complications. Minerva Gastroenterol (Torino) 2020; 67:26-37. [PMID: 33140623 DOI: 10.23736/s2724-5985.20.02784-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Portal hypertension is a clinical syndrome characterized by an increase in the portal pressure gradient, defined as the gradient between the portal vein at the site downstream of the site of obstruction and the inferior vena cava. The most frequent cause of portal hypertension is cirrhosis. In patients with cirrhosis, portal hypertension is the main driver of cirrhosis progression and development of hepatic decompensation (ascites, variceal hemorrhage and hepatic encephalopathy), which defines the transition from compensated to decompensated stage. In decompensated patients, treatments aim at lowering the risk of death by preventing further decompensation and/or development of acute-on-chronic liver failure. Decompensated patients often pose a complex challenge which typically requires a multidisciplinary approach. The aims of the present review were to discuss the current knowledge regarding interventional treatments for patients with portal hypertension complications as well as to highlight useful information to aid hepatologists in their clinical practice. Specifically, we discussed the indications and contraindications of transjugular intra-hepatic portosystemic shunt and for the treatment of gastro-esophageal variceal hemorrhage in patients with decompensated cirrhosis (first section); we reviewed the use of interventional treatments in patients with hepatic vein obstruction (Budd-Chiari Syndrome) and in those with portal vein thrombosis (second section); and we briefly comment on the most frequent applications of selective splenic embolization in patients with and without underlying cirrhosis (third section).
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Affiliation(s)
- Alberto Zanetto
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Giulio Barbiero
- Department of Medicine, Institute of Radiology, University Hospital of Padua, Padua, Italy
| | - Michele Battistel
- Department of Medicine, Institute of Radiology, University Hospital of Padua, Padua, Italy
| | - Salvatore S Sciarrone
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Sarah Shalaby
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Monica Pellone
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Sara Battistella
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Martina Gambato
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Giacomo Germani
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Francesco P Russo
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Patrizia Burra
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Marco Senzolo
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy -
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Transjugular intrahepatic portosystemic shunt placement: portal vein puncture guided by 3D/2D image registration of contrast-enhanced multi-detector computed tomography and fluoroscopy. Abdom Radiol (NY) 2020; 45:3934-3943. [PMID: 32451673 PMCID: PMC7593285 DOI: 10.1007/s00261-020-02589-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Background To assess the technical feasibility, success rate, puncture complications and procedural characteristics of transjugular intrahepatic portosystemic shunt (TIPS) placement using a three-dimensional vascular map (3D-VM) overlay based on image registration of pre-procedural contrast-enhanced (CE) multi-detector computed tomography (MDCT) for portal vein puncture guidance. Materials and methods Overall, 27 consecutive patients (59 ± 9 years, 18male) with portal hypertension undergoing elective TIPS procedure were included. TIPS was guided by CE-MDCT overlay after image registration based on fluoroscopic images. A 3D-VM of the hepatic veins and the portal vein was created based on the pre-procedural CE-MDCT and superimposed on fluoroscopy in real-time. Procedural characteristics as well as hepatic vein catheterization time (HVCT), puncture time (PT), overall procedural time (OPT), fluoroscopy time (FT) and the dose area product (DAP) were evaluated. Thereafter, HVCT, PT, OPT and FT using 3D-VM (61 ± 9 years, 14male) were compared to a previous using classical fluoroscopic guidance (53 ± 9 years, 21male) for two interventional radiologist with less than 3 years of experience in TIPS placement. Results All TIPS procedure using of 3D/2D image registered 3D-VM were successful with a significant reduction of the PSG (p < 0.0001). No clinical significant complication occurred. HVCT was 14 ± 11 min, PT was 14 ± 6 min, OPT was 64 ± 29 min, FT was 21 ± 12 min and DAP was 107.48 ± 93.84 Gy cm2. HVCT, OPT and FT of the interventionalist with less TIPS experience using 3D/2D image registered 3D-VM were statistically different to an interventionalist with similar experience using fluoroscopic guidance (pHVCT = 0.0022; pOPT = 0.0097; pFT = 0.0009). PT between these interventionalists was not significantly different (pPT = 0.2905). Conclusion TIPS placement applying registration-based CE-MDCT vessel information for puncture guidance is feasible and safe. It has the potential to improve hepatic vein catherization, portal vein puncture and radiation exposure.
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Simonetti RG, Perricone G, Robbins HL, Battula NR, Weickert MO, Sutton R, Khan S. Portosystemic shunts versus endoscopic intervention with or without medical treatment for prevention of rebleeding in people with cirrhosis. Cochrane Database Syst Rev 2020; 10:CD000553. [PMID: 33089892 PMCID: PMC8095029 DOI: 10.1002/14651858.cd000553.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND People with liver cirrhosis who have had one episode of variceal bleeding are at risk for repeated episodes of bleeding. Endoscopic intervention and portosystemic shunts are used to prevent further bleeding, but there is no consensus as to which approach is preferable. OBJECTIVES To compare the benefits and harms of shunts (surgical shunts (total shunt (TS), distal splenorenal shunt (DSRS), or transjugular intrahepatic portosystemic shunt (TIPS)) versus endoscopic intervention (endoscopic sclerotherapy or banding, or both) with or without medical treatment (non-selective beta blockers or nitrates, or both) for prevention of variceal rebleeding in people with liver cirrhosis. SEARCH METHODS We searched the CHBG Controlled Trials Register; CENTRAL, in the Cochrane Library; MEDLINE Ovid; Embase Ovid; LILACS (Bireme); Science Citation Index - Expanded (Web of Science); and Conference Proceedings Citation Index - Science (Web of Science); as well as conference proceedings and the references of trials identified until 22 June 2020. We contacted study investigators and industry researchers. SELECTION CRITERIA Randomised clinical trials comparing shunts versus endoscopic interventions with or without medical treatment in people with cirrhosis who had recovered from a variceal haemorrhage. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. When possible, we collected data to allow intention-to-treat analysis. For each outcome, we estimated a meta-analysed estimate of treatment effect across trials (risk ratio for binary outcomes). We used random-effects model meta-analysis as our main analysis and as a means of presenting results. We reported differences in means for continuous outcomes without a meta-analytic estimate due to high variability in their assessment among all trials. We assessed the certainty of evidence using GRADE. MAIN RESULTS We identified 27 randomised trials with 1828 participants. Three trials assessed TSs, five assessed DSRSs, and 19 trials assessed TIPSs. The endoscopic intervention was sclerotherapy in 16 trials, band ligation in eight trials, and a combination of band ligation and either sclerotherapy or glue injection in three trials. In eight trials, endoscopy was combined with beta blockers (in one trial plus isosorbide mononitrate). We judged all trials to be at high risk of bias. We assessed the certainty of evidence for all the outcome review results as very low (i.e. the true effects of the results are likely to be substantially different from the results of estimated effects). The very low evidence grading is due to the overall high risk of bias for all trials, and to imprecision and publication bias for some outcomes. Therefore, we are very uncertain whether portosystemic shunts versus endoscopy interventions with or without medical treatment have effects on all-cause mortality (RR 0.99, 95% CI 0.86 to 1.13; 1828 participants; 27 trials), on rebleeding (RR 0.40, 95% CI 0.33 to 0.50; 1769 participants; 26 trials), on mortality due to rebleeding (RR 0.51, 95% CI 0.34 to 0.76; 1779 participants; 26 trials), and on occurrence of hepatic encephalopathy, both acute (RR 1.60, 95% CI 1.33 to 1.92; 1649 participants; 24 trials) and chronic (RR 2.51, 95% CI 1.38 to 4.55; 956 participants; 13 trials). No data were available regarding health-related quality of life. Analysing each modality of portosystemic shunts individually (i.e. TS, DSRS, and TIPS) versus endoscopic interventions with or without medical treatment, we are very uncertain if each type of shunt has effect on all-cause mortality: TS, RR 0.46, 95% CI 0.19 to 1.13; 164 participants; 3 trials; DSRS, RR 0.93, 95% CI 0.65 to 1.33; 352 participants; 4 trials; and TIPS, RR 1.10, 95% CI 0.92 to 1.31; 1312 participants; 19 trial; on rebleeding: TS, RR 0.28, 95% CI 0.14 to 0.56; 127 participants; 2 trials; DSRS, RR 0.26, 95% CI 0.11 to 0.65; 330 participants; 5 trials; and TIPS, RR 0.44, 95% CI 0.36 to 0.55; 1312 participants; 19 trials; on mortality due to rebleeding: TS, RR 0.25, 95% CI 0.06 to 0.96; 164 participants; 3 trials; DSRS, RR 0.31, 95% CI 0.13 to 0.74; 352 participants; 5 trials; and TIPS, RR 0.65, 95% CI 0.40 to 1.04; 1263 participants; 18 trials; on acute hepatic encephalopathy: TS, RR 1.66, 95% CI 0.70 to 3.92; 115 participants; 2 trials; DSRS, RR 1.70, 95% CI 0.94 to 3.08; 287 participants; 4 trials, TIPS, RR 1.61, 95% CI 1.29 to 1.99; 1247 participants; 18 trials; and chronic hepatic encephalopathy: TS, Fisher's exact test P = 0.11; 69 participants; 1 trial; DSRS, RR 4.87, 95% CI 1.46 to 16.23; 170 participants; 2 trials; and TIPS, RR 1.88, 95% CI 0.93 to 3.80; 717 participants; 10 trials. The proportion of participants with shunt occlusion or dysfunction was overall 37% (95% CI 33% to 40%). It was 3% (95% CI 0.8% to 10%) following TS, 7% (95% CI 3% to 13%) following DSRS, and 47.1% (95% CI 43% to 51%) following TIPS. Shunt dysfunction in trials utilising polytetrafluoroethylene-covered stents was 17% (95% CI 11% to 24%). Length of inpatient hospital stay and cost were not comparable across trials. Funding was unclear in 16 trials; 11 trials were funded by government, local hospitals, or universities. AUTHORS' CONCLUSIONS Evidence on whether portosystemic shunts versus endoscopy interventions with or without medical treatment in people with cirrhosis and previous hypertensive portal bleeding have little or no effect on all-cause mortality is very uncertain. Evidence on whether portosystemic shunts may reduce bleeding and mortality due to bleeding while increasing hepatic encephalopathy is also very uncertain. We need properly conducted trials to assess effects of these interventions not only on assessed outcomes, but also on quality of life, costs, and length of hospital stay.
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Affiliation(s)
- Rosa G Simonetti
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Giovanni Perricone
- S.C. Epatologia e Gastroenterologia, Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Helen L Robbins
- Department of Surgery, University Hospital Coventry and Warwickshire, Coventry, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Narendra R Battula
- Division of Hepatobiliary and Abdominal Transplant surgery, University of Florida, Gainesville, Florida, USA
| | - Martin O Weickert
- The ARDEN NET Centre, ENETS Centre of Excellence, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Robert Sutton
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Saboor Khan
- Surgery, University Hosptial Coventry and Warwickshire, Coventry, UK
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Lesmana CRA, Raharjo M, Gani RA. Managing liver cirrhotic complications: Overview of esophageal and gastric varices. Clin Mol Hepatol 2020; 26:444-460. [PMID: 33053928 PMCID: PMC7641566 DOI: 10.3350/cmh.2020.0022] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 07/23/2020] [Indexed: 02/07/2023] Open
Abstract
Managing liver cirrhosis in clinical practice is still a challenging problem as its progression is associated with serious complications, such as variceal bleeding that may increase mortality. Portal hypertension (PH) is the main key for the development of liver cirrhosis complications. Portal pressure above 10 mmHg, termed as clinically significant portal hypertension, is associated with formation of varices; meanwhile, portal pressure above 12 mmHg is associated with variceal bleeding. Hepatic vein pressure gradient measurement and esophagogastroduodenoscopy remain the gold standard for assessing portal pressure and detecting varices. Recently, non-invasive methods have been studied for evaluation of portal pressure and varices detection in liver cirrhotic patients. Various guidelines have been published for clinicians’ guidance in the management of esophagogastric varices which aims to prevent development of varices, acute variceal bleeding, and variceal rebleeding. This writing provides a comprehensive review on development of PH and varices in liver cirrhosis patients and its management based on current international guidelines and real experience in Indonesia.
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Affiliation(s)
- Cosmas Rinaldi Adithya Lesmana
- Division of Hepatobiliary, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia.,Digestive Disease & GI Oncology Centre, Medistra Hospital, Jakarta, Indonesia
| | - Monica Raharjo
- Division of Hepatobiliary, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia
| | - Rino A Gani
- Division of Hepatobiliary, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia
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