Controversies in the management of bleeding esophageal varices (1)

Andrew K. Burroughs: a research hepatologist extraordinaire

Andrew K (Andy) Burroughs passed away in March 2014 at the early age of 60 years. Andy was one of the last of the great all round giants of hepatology. He was a consummate physician, clinical investigator and educator. Over a period of 35 years at the Royal Free Hospital Liver Unit he produced a prodigious quantity of original research and made major contributions in many areas of hepatology including portal hypertension, liver transplantation and chronic liver disease. His work on the methodology of clinical trials is carried on by the Baveno consensus meetings. From bedside clinical mastery to early molecular biology applications to diagnosis and pathology, his contributions left a mark in liver science and advanced medical science in general. He also was praised by his work in medical education particularly in post-graduate mentorship and, an admirable human touch with patients. We will not see his like again.

Fatal hemorrhage from a periumbilical wound: Stabbing or hemorrhage from a caput medusae?

Varices are the main clinical manifestation of portal hypertension, and their bleeding is the predominant cause of mortality from this condition. Periumbilical varices are known as "caput medusae." Reports of their bleeding are rare, with only three fatal cases described in the literature. The antemortem diagnosis is relatively simple, while the postmortem diagnosis is more complex. This paper is the first report of fatal hemorrhage from a caput medusae for which the diagnosis was made postmortem, thanks to a complete diagnostic process including scene and circumstances, medical history, and autopsy with detailed histology. The circumstantial analysis showed the presence of a large amount of blood at the scene, blood which originated from a small abdominal wound; an analysis of the subject's clinical data reported that he was affected by portal hypertension. The autopsy revealed some dilated and convoluted veins in the subcutaneous tissue of the umbilical region; a fistula between these veins and the abdominal wound was detected. The histological study confirmed the presence of periumbilical varices, one of them ruptured and connected with the overlying skin. The cause of death was attributed to a massive hemorrhage generated by a periumbilical varix in a patient affected by portal hypertension.

TIPS for management of portal-hypertension-related complications in patients with cirrhosis

Portal hypertension is primarily due to liver cirrhosis, and is responsible for complications that include variceal bleeding, ascites and hepatorenal syndrome. The transjugular intrahepatic portosystemic shunt (TIPS) is a low-resistance channel between the portal vein and the hepatic vein, created by interventional radiology, that aims to reduce portal pressure. TIPS is a potential treatment for severe portal-hypertension-related complications, including esophageal and gastric variceal bleeding. TIPS is currently indicated as salvage therapy in this setting when patients fail to respond to standard endoscopic and medical treatment. More recently, early TIPS has been shown to be effective in decreasing risk of rebleeding after variceal hemorrhage and mortality in Child-Pugh B patients with active hemorrhage at endoscopy, and in Child-Pugh C patients. TIPS is also an efficient treatment for refractory ascites and hepatic hydrothorax. In contrast, the role of TIPS in the hepatorenal syndrome has not been precisely defined. The aim of this review was to specifically describe the current role of TIPS in management of portal hypertension in patients with cirrhosis.

A case of fatal cutaneous caput medusae hemorrhage

Alcoholic liver cirrhosis leads to portal venous hypertension, which can result in a caput medusae formation. Life-threatening hemorrhage from a ruptured caput medusae vein is a rare complication. It is crucial to stop the bleeding promptly. A transjugular intrahepatic portosystemic shunt is considered potentially lifesaving.

Endoscopic Evaluation in Children With End-Stage Liver Disease-Associated Portal Hypertension Awaiting Liver Transplant

OBJECTIVES

Routine oesophago-gastro-duodenoscopy (OGD) pre-liver transplantation (LT) for evaluation and management of gastrointestinal (GI) pathology, in particular GI varices secondary to portal hypertension, is common practice in adult LT programmes. There is no universal consensus for this practice in children. We report our endoscopic experience in children with end-stage liver disease (ESLD) pre-LT.

METHODS

Retrospective audit of LT database and review of OGD findings of patients who had undergone endoscopy preceding LT.

RESULTS

Of 69 patients with ESLD, 50 (72.4%) had pre-LT OGD, 37 of which were done electively, whereas the remaining 13 were event driven. Forty-eight (96%) patients who underwent OGD had abnormalities, in which 38 (76%) patients had varices and 23 (46%) had portal hypertensive gastropathy. Eleven (22%) patients required therapeutic intervention at initial OGD either with endoscopic variceal band ligation or endoscopic sclerotherapy. Compared with the group who underwent elective OGDs, the group who had event-driven OGDs had a significantly higher requirement for endoscopic intervention (P < 0.0001), occurrence of rebleeding (P < 0.029) and requirement for repeat OGDs (P = 0.014). There was no significant difference in terms of patient (P = 0.2746) or graft survival (P = 0.3192) between the 2 groups.

CONCLUSIONS

The role of pre-LT OGDs in patients with ESLD associated with portal hypertension is possibly limited to control of bleeding during episodes of GI bleed, where the aim would be to stabilize the patient until eventual LT. Multicentre prospective studies are required to provide more evidence on the use of routine endoscopy for pre-LT assessment in children.

Management of portal hypertension in children

Portal hypertension can be caused by a wide variety of conditions. It frequently presents with bleeding from esophageal varices. The approach to acute variceal hemorrhage in children is a stepwise progression from least invasive to most invasive. Management of acute variceal bleeding is straightforward. But data on primary prophylaxis and long term management prevention of recurrent variceal bleeding in children is scarce, therefore prospective multicenter trials are needed to establish best practices.

Liver transplantation in a randomized controlled trial of emergency treatment of acutely bleeding esophageal varices in cirrhosis

BACKGROUND

Bleeding esophageal varices (BEV) in cirrhosis has been considered an indication for liver transplantation (LT). This issue was examined in a randomized controlled trial (RCT) of unselected, consecutive patients with advanced cirrhosis and BEV that compared endoscopic sclerotherapy (EST; n = 106) to emergency direct portacaval shunt (EPCS; n = 105).

METHODS

Diagnostic work-up and treatment were initiated within 8 hours. Patients were evaluated for LT on admission and repeatedly thereafter; 96% underwent over 10 years of regular follow-up. The analysis was supplemented by 1300 unrandomized cirrhotic patients who previously underwent portacaval shunt (PCS) with 100% follow-up.

RESULTS

In the RCT long-term bleeding control was 100% following EPCS, only 20% following EST. Also, 3-, 5-, 10-, and 15-year survival rates were 75%, 73%, 46%, and 46%, respectively, following EPCS compared with 44%, 21%, 9%, and 9% following EST, respectively (P < .001). Only 13 RCT patients (6%) were ultimately referred for LT mainly because of progressive liver failure; only 7 (3%) were approved for LT and only 4 (2%) underwent LT. The 1- and 5-year LT survival rates were 0.68% and 0, respectively, compared with 81% and 73%, respectively, after EPCS. In the 1300 unrandomized PCS patients, 50 (3.8%) were referred and 19 (1.5%) underwent LT. The 5-year survival rate was 53% compared with 72% for all 1300 patients.

CONCLUSIONS

If bleeding is permanently controlled, as occurred invariably following EPCS, cirrhotic patients with BEV seldom require LT. PCS is effective first-line and long-term treatment. Should LT be required in patients with PCS, although technically more demanding, numerous studies have shown that PCS does not increase mortality or complications. EST is not effective emergency or long-term therapy.

Emergency portacaval shunt versus rescue portacaval shunt in a randomized controlled trial of emergency treatment of acutely bleeding esophageal varices in cirrhosis--part 3

BACKGROUND

Emergency treatment of bleeding esophageal varices in cirrhosis is of singular importance because of the high mortality rate. Emergency portacaval shunt is rarely used today because of the belief, unsubstantiated by long-term randomized trials, that it causes frequent portal-systemic encephalopathy and liver failure. Consequently, portacaval shunt has been relegated solely to salvage therapy when endoscopic and pharmacologic therapies have failed.

QUESTION

Is the regimen of endoscopic sclerotherapy with rescue portacaval shunt for failure to control bleeding varices superior to emergency portacaval shunt? A unique opportunity to answer this question was provided by a randomized controlled trial of endoscopic sclerotherapy versus emergency portacaval shunt conducted from 1988 to 2005.

METHODS

Unselected consecutive cirrhotic patients with acute bleeding esophageal varices were randomized to endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Diagnostic workup was completed and treatment was initiated within 8 h. Failure of endoscopic sclerotherapy was defined by strict criteria and treated by rescue portacaval shunt (n = 50) whenever possible. Ninety-six percent of patients had more than 10 years of follow-up or until death.

RESULTS

Comparison of emergency portacaval shunt and endoscopic sclerotherapy followed by rescue portacaval shunt showed the following differences in measurements of outcomes: (1) survival after 5 years (72% versus 22%), 10 years (46% versus 16%), and 15 years (46% versus 0%); (2) median post-shunt survival (6.18 versus 1.99 years); (3) mean requirements of packed red blood cell units (17.85 versus 27.80); (4) incidence of recurrent portal-systemic encephalopathy (15% versus 43%); (5) 5-year change in Child's class showing improvement (59% versus 19%) or worsening (8% versus 44%); (6) mean quality of life points in which lower is better (13.89 versus 27.89); and (7) mean cost of care per year ($39,200 versus $216,700). These differences were highly significant in favor of emergency portacaval shunt (all p < 0.001).

CONCLUSIONS

Emergency portacaval shunt was strikingly superior to endoscopic sclerotherapy as well as to the combination of endoscopic sclerotherapy and rescue portacaval shunt in regard to all outcome measures, specifically bleeding control, survival, incidence of portal-systemic encephalopathy, improvement in liver function, quality of life, and cost of care. These results strongly support the use of emergency portacaval shunt as the first line of emergency treatment of bleeding esophageal varices in cirrhosis.

Pharmacotherapy plus endoscopic intervention is more effective than pharmacotherapy or endoscopy alone in the secondary prevention of esophageal variceal bleeding: a meta-analysis of randomized, controlled trials

BACKGROUND

Previous clinical trials on the treatment of esophageal variceal bleeding yielded mixed results regarding the efficacy of endoscopic procedures compared with pharmacotherapy only.

OBJECTIVE

To compare the efficacy of endoscopic procedures with that of pharmacotherapy in the prevention of mortality and rebleeding.

DESIGN AND SETTING

A systematic literature review was performed to identify randomized, controlled trials of the efficacy of pharmacotherapy and endoscopic therapy. A meta-analysis was performed by using the Comprehensive MetaAnalysis software package. A 2-sided alpha error <.05 was considered statistically significant (P < .05).

PATIENTS

Twenty-five clinical trials with a total of 2159 patients were eligible for meta-analysis.

OUTCOME MEASUREMENTS

Relative risk (RR) with 95% confidence interval (CI) was computed for all-cause mortality, mortality from rebleeding, all-cause rebleeding, and rebleeding caused by varices.

RESULTS

Pharmacotherapy was as effective as endoscopic procedures in preventing rebleeding (RR 1.067; 95% CI, 0.865-1.316; P = .546), variceal rebleeding (RR 1.143; 95% CI, 0.791-1.651; P = .476), all-cause mortality (RR 0.997; 95% CI, 0.827-1.202, P = .978), and mortality from rebleeding (RR 1.171; 95% CI, 0.816-1.679; P = .39). Pharmacotherapy combined with endoscopic procedures did not reduce all-cause mortality (RR 0.787; 95% CI, 0.587-1.054; P = .108) or mortality caused by rebleeding (RR 0.786; 95% CI, 0.445-1.387; P = .405) compared with endoscopic procedures. However, combination therapy (endoscopic procedure plus pharmacotherapy) significantly reduced the incidence of all rebleeding (RR 0.623; 95% CI, 0.523-0.741; P < .001) and variceal rebleeding (RR 0.601; 95% CI, 0.440-0.820; P < .001).

LIMITATIONS

Heterogeneity of patient population and different treatment protocols may have affected our meta-analysis.

CONCLUSION

Pharmacotherapy may be as effective as endoscopic therapy in reducing rebleeding rates and all-cause mortality. Pharmacotherapy plus endoscopic intervention is more effective than endoscopic intervention alone.

Randomized trial of emergency endoscopic sclerotherapy versus emergency portacaval shunt for acutely bleeding esophageal varices in cirrhosis

BACKGROUND

The mortality rate of bleeding esophageal varices in cirrhosis is highest during the period of acute bleeding. This is a report of a randomized trial that compared endoscopic sclerotherapy (EST) with emergency portacaval shunt (EPCS) in cirrhotic patients with acute variceal hemorrhage.

STUDY DESIGN

A total of 211 unselected consecutive patients with cirrhosis and acutely bleeding esophageal varices who required at least 2 U of blood transfusion were randomized to EST (n=106) or EPCS (n=105). Diagnostic workup was completed within 6 hours and EST or EPCS was initiated within 8 hours of initial contact. Longterm EST was performed according to a deliberate schedule. Ninety-six percent of patients underwent more than 10 years of followup, or until death.

RESULTS

The percent of patients in Child's risk classes were A, 27.5; B, 45.0; and C, 27.5. EST achieved permanent control of bleeding in only 20% of patients; EPCS permanently controlled bleeding in every patient (p< or =0.001). Requirement for blood transfusions was greater in the EST group than in the EPCS patients. Compared with EST, survival after EPCS was significantly higher at all time intervals and in all Child's classes (p< or =0.001). Recurrent episodes of portal-systemic encephalopathy developed in 35% of EST patients and 15% of EPCS patients (p< or =0.01).

CONCLUSIONS

EPCS permanently stopped variceal bleeding, rarely became occluded, was accomplished with a low incidence of portal-systemic encephalopathy, and compared with EST, produced greater longterm survival. The widespread practice of using surgical procedures mainly as salvage for failure of endoscopic therapy is not supported by the results of this trial (clinicaltrials.gov #NCT00690027).

[Treatment of extra-esophageal variceal bleeding with cyanoacrylate]

BACKGROUND AND AIMS

Endoscopic obliteration of bleeding extra-esophageal varices using N-butyl-2-cyanoacrylate (Histoacryl) has been validated by several authors. The aim of the present paper is to describe the intravariceal injection technique using cyanoacrylate and to present the own results and complications observed in conjunction with the haemostatic treatment.

PATIENTS AND METHODS

A total of 11 intravariceal injection treatments of N-butil-2-cyanoacrylate were performed in 8 patients (3 males, 5 females, mean age 65.5 years) with extra-esophageal variceal bleeding. In 7 cases the bleeding varices were located in the gastric fundus and in one case the varix was found in the duodenum. Variceal bleeders under subintensive care were treated early electively with 1:1 ratio cyanoacrylate-lipiodol intravariceal injection solutions. The injection needle was inserted trough a standard endoscope.

RESULTS

Early haemostasis was achieved in all patients (11/11) and no early rebleeding occurred. In one case because of repeated episodes of late recurrent bleedings 3 more injection treatments were performed. In another case several hours after the injection a transitional cerebral ischemic attack developed. Injection needle sticking occurred during one treatment. There was no mortality due to acute bleeding while two patients died because of hepatic failure during the follow up period.

CONCLUSIONS

Endoscopic injection of diluted cyanoacrylate and lipiodol appears to be an effective and safe treatment method of the extra-esophageal variceal bleeding. Injection treatment in an early elective fashion can be performed with the standard sclerotherapy equipment.

Transabdominal gastro-esophageal devascularization and esophageal transection for bleeding esophageal varices after failed injection sclerotherapy: long-term follow-up report

BACKGROUND

Management of continued bleeding from esophageal varices despite adequate injection sclerotherapy remains one of the medical and surgical dilemmas. Transabdominal gastroesophageal devascularization and esophageal transection (TGDET) is considered an effective and safe procedure for such patients.

AIM

This study aimed at presenting continued evaluation of TGDET. Various problems influencing the early outcome are discussed, and long-term outcome is analyzed.

DESIGN

This was a prospective clinical descriptive study.

METHODS

Prospective data was collected on 142 consecutive patients managed by one group of surgeons over a 5 year-period and 15 years follow-up after failed injection sclerotherapy for variceal bleeding. Evaluation was made in terms of effectiveness in controlling the acute bleeding, postoperative morbidity and mortality, recurrent bleeding, encephalopathy, and long-term survival.

RESULTS

There were 133 men and 9 women. Mean age was 41.8 years. Etiology of portal hypertension was bilharziasis in 54.9% and posthepatitic in 14.8%. Child-Pugh grading on admission was A: 47.2%, B: 28.8%, and C: 14%. Hemorrhage was controlled in all cases. Clinical leak was observed in 5.6%, portal vein thrombosis in 6.3%, and staple line erosion in 2.1% of cases. No patient developed encephalopathy. In-hospital mortality was 12.7%. Complete eradication of varices was observed in 70.6% patients. Recurrent variceal bleeding was noticed in 6.9% of cases. Actuarial 15-year survival for Child-Pugh A patients was 44%, B was 22.5%, and none for C.

CONCLUSION

TGDET remains a safe and effective procedure after failure of sclerotherapy when other alternatives are either not indicated or not available.

Variceal recurrence, rebleeding, and survival after endoscopic injection sclerotherapy in 287 alcoholic cirrhotic patients with bleeding esophageal varices

OBJECTIVE

This study tested the validity of the hypothesis that eradication of esophageal varices by repeated injection sclerotherapy would reduce recurrent variceal bleeding and death from bleeding varices in a high-risk cohort of alcoholic patients with cirrhosis.

SUMMARY BACKGROUND DATA

Although banding of esophageal varices is now regarded as the most effective method of endoscopic intervention, injection sclerotherapy is still widely used to control acute esophageal variceal bleeding as well as to eradicate varices to prevent recurrent bleeding. This large single-center prospective study provides data on the natural history of alcoholic cirrhotic patients with bleeding varices who underwent injection sclerotherapy.

METHODS

Between 1984 and 2001, 287 alcoholic cirrhotic patients (225 men, 62 women; mean age, 51.9 years; range, 24-87 years; Child-Pugh grades A, 39; B, 116; C, 132) underwent a total of 2565 upper gastrointestinal endoscopic sessions, which included 353 emergency and 1015 elective variceal injection treatments. Variceal rebleeding, eradication, recurrence, and survival were recorded.

RESULTS

Before eradication of varices was achieved, 104 (36.2%) of the 287 patients had a total of 170 further bleeding episodes after the first endoscopic intervention during the index hospital admission. Rebleeding was markedly reduced after eradication of varices. In 147 (80.7%) of 182 patients who survived more than 3 months, varices were eradicated after a mean of 5 injection sessions and remained eradicated in 69 patients (mean follow-up, 34.6 months; range, 1-174 months). Varices recurred in 78 patients and rebled in 45 of these patients. Median follow-up was 32.3 months (mean, 42.1 months; range, 3-198.9 months). Cumulative overall survival by life-table analysis was 67%, 42%, and 26% at 1, 3, and 5 years, respectively. A total of 201 (70%) patients died during follow-up. Liver failure was the most common cause of death.

CONCLUSION

Repeated sclerotherapy eradicates esophageal varices in most alcoholic cirrhotic patients with a reduction in rebleeding. Despite control of variceal bleeding, survival at 5 years was only 26% because of death due to liver failure in most patients.

The Evolving Role of Endoscopic Treatment for Bleeding Esophageal Varices

The treatment of acute and recurrent variceal bleeding is best accomplished by a skilled, knowledgeable, and well-equipped team using a multidisciplinary integrated approach. Optimal management should provide the full spectrum of treatment options including pharmacologic therapy, endoscopic treatment, interventional radiologic procedures, surgical shunts, and liver transplantation. Endoscopic therapy with either band ligation or injection sclerotherapy is an integral component of the management of acute variceal bleeding and of the long-term treatment of patients after a variceal bleed. Variceal eradication with endoscopic ligation requires fewer endoscopic treatment sessions and causes substantially less esophageal complications than does injection sclerotherapy. Although the incidence of early gastrointestinal rebleeding is reduced by endoscopic ligation in most studies, there is no overall survival benefit relative to injection sclerotherapy. Simultaneous combined ligation and sclerotherapy confers no advantage over ligation alone. A sequential staged approach with initial endoscopic ligation followed by sclerotherapy when varices are small may prove to be the optimal method of reducing variceal recurrence. Overall, current data demonstrate clear advantages for using ligation in preference to sclerotherapy. Ligation should therefore be considered the endoscopic treatment of choice in the treatment of esophageal varices.

The characteristics and the prognosis for patients presenting with actively bleeding esophageal varices at endoscopy

BACKGROUND

It remains unresolved whether the prognosis is worse for patients who present with actively bleeding varices at endoscopy compared with those in whom variceal bleeding has stopped.

METHODS

Patients with acute esophageal variceal bleeding were enrolled in this study and were divided into two groups: an active bleeding group and an inactive bleeding group. All patients had band ligation shortly after endoscopic examination and underwent elective ligation procedures until the varices were obliterated. Patients were followed for 1 year or until death. Short- and long-term prognoses were compared.

RESULTS

The active bleeding group included 54 patients and the inactive bleeding included 251 patients. Initial hemostasis was achieved in 93% in the active group and 99% in the inactive group ( p = not significant). The rate of recurrent variceal bleeding within 30 days was 24% in the active bleeding group vs. 12% in the inactive bleeding group ( p = 0.01); the mortality rates were 18% and 8%, respectively ( p = 0.03 in a single statistical test; however, Bonferroni correction for the multiple testing of data removed this significance). The rate of recurrent variceal bleeding within 1 year was 37% in the active bleeding group and 27% in the inactive bleeding group ( p = 0.06); the mortality rates were 22% and 21%, respectively ( p = not significant).

CONCLUSIONS

Whether variceal bleeding is active or inactive at endoscopy, variceal ligation is equally effective for control of bleeding. The rates of recurrent bleeding and mortality at 1 month were significantly higher among patients with active bleeding. However, the mortality rate was similar for both groups at 1 year.

A prospective randomized controlled clinical trial comparing the effects of somatostatin and vasopressin for control of acute variceal bleeding in the patients with liver cirrhosis

BACKGROUND

Acute variceal bleeding is a serious complication of liver cirrhosis, which has an attendant mortality of approximately 60% over two years, and a variety of treatments, such as balloon tamponade, endoscopic varix ligation, sclerotherapy, histoacryl injection and vasoactive drugs, have been used. The aims of the present trial were to compare the effectiveness and complications of somatostatin and vasopressin in the treatment of acute variceal bleeding.

METHODS

Forty-three cirrhotic patients, with endoscopically proven acute variceal bleeding, were included in this trial. Both drugs were given as continuous intravenous infusions for 48 hours. Twenty patients received the somatostatin (250 mcg per hr after a bolus of 50 mcg) and twenty-three the vasopressin (0.4 units per min).

RESULTS

There were no significant differences between the two groups in relation to age, sex, etiology of cirrhosis, Child-Pugh classification, characteristics of bleeding episode, laboratory findings before randomization and units of transfused blood during therapy. Rebleeding, within 6 hours after beginning of therapy, was regarded as failure to control initial bleeding, and was observed in 3 (13.0%) of the patients who received vasopressin and in 1 (5.0%) treated with somatostatin (p > 0.05). Five patients in both the somatostatin (25.0%) and vasopressin (21.7%) groups rebled during the first 5 days following the initial therapy (p > 0.05). Meaningful complications related to the use of vasopressin were observed in 5 patients (chest pain or abdominal pain requiring nitroglycerin), but no complications were associated with the use of somatostatin (p < 0.05). The mortalities during hospitalization were similar in both the treatment groups. Two of the vasopressin and 1 of the somatostatin group died due to the uncontrolled rebleeding, and 1 of the vasopressin group died due to hepatic failure (2 weeks later after therapy).

CONCLUSION

This study showed no differences in the effectiveness of somatostatin and vasopressin, but the somatostatin group had a lower risk of the complications.

Banding ligation versus nadolol and isosorbide mononitrate for the prevention of esophageal variceal rebleeding

BACKGROUND & AIMS

beta-blockers and banding ligation are effective in the prevention of variceal rebleeding. However, the relative efficacy and safety remains unresolved.

METHODS

One hundred twenty-one patients with a history of esophageal variceal bleeding were enrolled. Patients were randomized to undergo regular endoscopic variceal ligation (EVL group, 60 patients) until variceal obliteration, or drug therapy by using nadolol plus isosorbide mononitrate (N+I group, 61 patients) during the study period to prevent rebleeding.

RESULTS

After a median follow-up period of 25 months, recurrent upper gastrointestinal bleeding developed in 23 patients in the EVL group and 35 patients in the N+I group (P = 0.10). Recurrent bleeding from esophageal varices occurred in 12 patients (20%) in the EVL group and 26 patients (42%) in the N+I group (relative risk = 0.45; 95% confidence interval, 0.24-0.85). The actuarial probability of rebleeding from esophageal varices was lower in the EVL group (P = 0.01). The multivariate Cox analysis indicated that the treatment was the only factor predictive of rebleeding. Treatment failure occurred in 8 patients (13%) in the EVL group and 17 patients (28%) in the N+I group (P = 0.01). Fifteen patients in the EVL group and 8 patients of the N+I group died (P = 0.06). Complications occurred in 17% of the EVL group and in 19% of the N+I group (P = 0.6).

CONCLUSIONS

Our trial showed that ligation was more effective than nadolol plus isosorbide-5-mononitrate in the prevention of variceal rebleeding, with similar complications in both treatment modalities. However, there is no significant difference in the survival rate between the 2 groups.

Transjugular intra-hepatic portosystemic shunt for refractory variceal bleeding

BACKGROUND

The most dramatic complication of portal hypertension in cirrhotic patients is oesophageal variceal bleeding. Moreover, patients with bleeding unresponsive to medical and endoscopic treatment have a poor prognosis.

OBJECTIVE

The aim of this study was to evaluate the efficacy of early transjugular intra-hepatic portosystemic shunt (TIPS) in patients with refractory variceal bleeding.

PATIENTS AND METHODS

TIPS was performed for 28 patients (17 were stage Child C), successfully in 26. Variceal bleeding was controlled in all but one successfully stented patient.

RESULTS

There was no mortality associated with the procedure. The two patients with a failure of TIPS insertion died of persistent bleeding in the first 48 h after failed TIPS. The 40-day mortality rate was 25%. Five patients died (one from persistent bleeding from gastric varices and four from multi-organ failure). Using multivariate analysis, the only independent factor associated with early mortality was the total bilirubin value. Fifteen surviving patients were listed for liver transplantation: four deaths occurred, eight patients were transplanted in the 6 months after TIPS and three are still waiting. Among the six patients who survived but were ineligible for transplantation, two died and four are still alive. Two episodes of early rebleeding and eight of late rebleeding occurred. Actuarial survival was 75% at one year and 52% at two years.

CONCLUSIONS

Early TIPS is an effective rescue therapy for controlling refractory variceal bleeding.

Endoscopic recurrence of esophageal varices is associated with the specific EUS abnormalities: severe periesophageal collateral veins and large perforating veins

BACKGROUND

Endoscopic ultrasonography (EUS) with a 20 MHz ultrasound (US) catheter probe can clearly demonstrate esophageal collateral veins. The presence of large periesophageal collateral veins has been correlated with large esophageal varices in patients with portal hypertension. The correlation between the size of esophageal collateral veins and endoscopic recurrence of esophageal varices in patients with portal hypertension who had undergone endoscopic injection sclerotherapy was investigated. Furthermore, whether EUS findings could predict the variceal recurrence was retrospectively studied.

METHODS

Thirty-eight patients who had undergone endoscopic injection sclerotherapy were examined every 3 to 4 months with endoscopy and US catheter probe for a period of 2 years. Recurrence of esophageal varices was determined by endoscopic findings of either new varix formation or appearance of red color sign. Esophageal collateral veins were identified by US catheter probe as peri-esophageal collateral veins (adjacent to the esophageal wall) and para-esophageal collateral veins (separated from the esophageal wall) along with perforating veins; and they were graded as severe and mild type by US catheter probe.

RESULT

Ten of the 38 patients (26.3%) had endoscopic recurrence at a mean of 10.9 months after endoscopic injection sclerotherapy. In patients with endoscopic recurrences, EUS findings included a significantly (p < 0.001) higher incidence of severe type peri-esophageal collateral veins, a significantly larger number of perforating veins (p < 0.001) and a significantly larger diameter of perforating veins (p < 0.001) compared with patients without recurrence (8 of 10, 80% vs. 2 of 28, 7.1%; 1.30 vs. 0.21; 2.00 vs. 0.32 mm, respectively). The presence of veins at the esophagogastric junction did not correlate with recurrence.

CONCLUSION

Severe type peri-esophageal collateral veins and large perforating veins of the esophagus detected by EUS in patients treated by endoscopic injection sclerotherapy signify recurrence of esophageal varices and predict endoscopic recurrence of varices in subsequent months.

Prophylactic banding ligation of high-risk esophageal varices in patients with cirrhosis: a prospective, randomized trial

BACKGROUND/AIMS

Injection sclerotherapy has been used to prevent the first episode of variceal hemorrhage, but the results are controversial. The value of banding ligation in the prophylaxis of the first episode of variceal bleeding has not yet been completely evaluated. This study was conducted to determine whether prophylactic banding ligation is beneficial for cirrhotic patients with high-risk esophageal varices.

METHODS

A total of 127 cirrhotic patients with endoscopically-assessed high-risk esophageal varices but no history of bleeding were randomized to undergo banding ligation (64 patients) or to serve as controls (63 patients). Ligation was performed at 3-week intervals until variceal obliteration was obtained.

RESULTS

During a median follow-up of 29 months, 14 patients (21.8%) in the ligation group and 22 patients (34.9%) in the control group experienced upper gastrointestinal bleeding (p = 0.15). Variceal bleeding occurred in eight patients (12.5%) in the ligation group and 14 patients (22.2%) in the control group (p = 0.22). Blood transfusion requirements were fewer in the EVL group than in the control group (0.6+/-0.4 units vs. 1.2+/-0.8 units, p<0.001). Furthermore, variceal bleeding was significantly reduced in Child-Pugh class B patients treated with ligation compared with the control group (p<0.05). Sixteen patients (25%) in the ligation group and 23 patients (36.5%) in the control group died. Comparison of Kaplan-Meier estimates of time to death for the two groups did not show significant differences (p = 0.19). More patients died of uncontrollable variceal bleeding in the control group (7 patients, 11%) than in the ligation group (3 patients, 4.7%) (p = 0.15).

CONCLUSIONS

Although prophylactic ligation did not significantly reduce the first episode of bleeding from esophageal varices in cirrhotic patients with high-risk esophageal varices, a subgroup of patients (Child-Pugh class B) had a reduced frequency of the first episode of esophageal variceal bleeding after prophylactic banding ligation. Furthermore, there was a trend of reducing mortality from variceal bleeding in patients receiving prophylactic ligation. Prophylactic ligation is a promising treatment, but requires further investigation.

Percutaneous transhepatic catheterization of the portal vein: A combined CT- and fluoroscopy-guided technique

Combined CT- and fluoroscopy-guided transhepatic portal vein catheterization was performed in 44 patients selected for pancreatic islet cell transplantation. The method allowed catheterization with a single puncture attempt in 39 patients. In four patients two attempts and in one patient four attempts were necessary. One minor hematoma of the liver capsule occurred that required no further treatment. Compared with other methods the average number of puncture attempts was reduced.

Utility of endoscopic evaluations in liver transplant candidates

OBJECTIVE

The aim of this study was to determine whether endoscopic evaluation of patients referred for liver transplant evaluation contributes significantly to patient selection or management.

METHODS

Esophagogastroduodenoscopy (EGD) was performed in transplant candidates who had not undergone this examination within a previous 6-month period. Colonoscopy (CSP) was performed if the patient was >50 yr of age or had anemia, a history of colonic pathology such as adenomatous polyps, or a history suggesting gastrointestinal tract abnormalities.

RESULTS

A total of 118 patients were studied. EGD was performed in 74 (63%) patients. Forty-seven patients had esophageal varices identified; in 26, this represented a new diagnosis. Other findings on EGD included portal gastropathy (21 patients), gastric varices (seven patients), peptic ulceration (10 patients), Barrett's esophagus (three patients), and one case each of esophageal and gastric carcinoma. CSP was performed in 56 patients. Findings included adenomatous polyps (24 patients) and one case of colon carcinoma. Overall, gastrointestinal pathology was discovered in 67 (57%) of the patients undergoing endoscopic evaluation as part of our study. Alterations in patient selection or management resulted from 44% of the procedures performed; 42% of the patients were affected by these management changes and 2.5% of patients were removed from further transplant evaluation because of the diagnosis of malignancy.

CONCLUSION

Endoscopic evaluation of liver transplant candidates often identifies important gastrointestinal pathology and frequently impacts patient selection and management before OLT.

Influence of extravariceal collateral channel pattern on recurrence of esophageal varices after sclerotherapy

We investigated the influence of extravariceal collateral channel pattern on the recurrence of esophageal varices after sclerotherapy. One hundred and fifteen patients with cirrhosis and esophageal varices were studied. They were divided into four groups according to extravariceal collateral pattern on portal venography. Group 1 patients had neither paraesophageal veins nor gastrorenal veins (n = 49); group 2 patients had paraesophageal veins only (n = 30); group 3 patients had gastrorenal veins only (n = 25); and group 4 patients had paraesophageal veins plus gastrorenal veins (n = 11). Sclerotherapy was repeated to eradicate esophageal varices and follow-up endoscopic examination were performed. The overall recurrence-free rate at 36 months was 68%. The log-rank test showed the recurrence-free rate to be significantly higher in group 3 (76%) and group 4 patients (89%) than in group 1 patients (51%; P < 0.05 and P < 0.05, respectively). Although the recurrence-free rate was higher in group 4 than in group 2 patients (59%), this did not reach the level of significance (P = 0.10). No significant differences were found between other pairs of groups. These results suggest that gastrorenal veins play an important role in the protection against recurrent esophageal varices after sclerotherapy, while the protective role of paraesophageal veins appears to be small.

Early administration of somatostatin and efficacy of sclerotherapy in acute oesophageal variceal bleeds: the European Acute Bleeding Oesophageal Variceal Episodes (ABOVE) randomised trial

BACKGROUND

Sclerotherapy is widely used for acute variceal bleeding, although in emergencies bleeding makes it difficult to obtain the clear view required for safe and effective treatment. We investigated whether early administration of somatostatin would improve the efficacy of sclerotherapy.

METHODS

In this double-blind, prospective trial, patients who had cirrhosis with upper-gastrointestinal bleeding were randomly assigned natural somatostatin (6 mg per 24 h) or placebo for 120 h. In addition, intravenous bolus doses of somatostatin (250 micrograms) or placebo were injected after the start of the infusion, before emergency endoscopy or sclerotherapy, and when active bleeding was observed. The primary endpoint was treatment failure, defined as the occurrence during the infusion period of at least one of: excess transfusion of blood products, haematemesis, haemodynamic instability, need for rescue therapy, or death.

FINDINGS

205 patients were enrolled: 101 received somatostatin and 104 received placebo. Treatment failed in 35 somatostatin and 57 placebo recipients (p = 0.004); death or use of rescue therapy occurred in nine and 19 patients, respectively (p = 0.05). The mean quantity of blood products transfused over 120 h (adjusted for baseline haemoglobin) was 2.64 (SD 0.35) units in the somatostatin group versus 3.62 (0.35) units in the placebo group (p = 0.05). At endoscopy, active bleeding from oesophageal varices was less frequent (27 vs 42 patients, p = 0.012) and the sclerotherapy procedure was easier (2.8 vs 4.7 cm, p = 0.0027) in the somatostatin than in the placebo group.

INTERPRETATION

Early administration of natural somatostatin continued for 120 h, combined with additional bolus injections, is more effective than placebo in the overall control of acute variceal haemorrhage in patients with cirrhosis undergoing sclerotherapy.

Gallstones in cirrhotics revisited by a laparoscopic view

Surgical literature around 1980 has emphasized the technical challenge and the risks of cholecystectomy in cirrhotic patients reporting discouraging results. The aim of this study is the retrospective analysis of laparoscopic cholecystectomy in cirrhotics. The collected laparoscopic experience of 3 surgical groups for the last 5 years is reported. Cirrhotics were classified according to Child-Pugh criteria. Postoperative complications were classified using Clavien's rules. Forty patients were recruited; 31 received successful laparoscopic cholecystectomy. Liver cirrhosis was preoperatively diagnosed in all Child-Pugh B (n = 11) and in 11/20 Child-Pugh A patients. Compared with 989 noncirrhotics undergoing laparoscopic cholecystectomy, cirrhotics were similar in terms of age (59.9+/-10.3 vs. 58.1+/-10.9) and sex (male: 51.6% vs. 50.1%). Acute cholecystitis has a similar frequence in cirrhotics and noncirrhotics (3.2% vs. 4.1%, respectively). Bile duct stones and acute pancreatitis were significantly more frequent in cirrhotic patients (6.4% vs. 3.7%, p < 0.001; and 6.4% vs. 0.3%, p < 0.001, respectively). Endoscopic papillotomy and stone extraction combined with laparoscopic cholecystectomy was performed in 2 patients. Intraoperatively, technical problems occurred in 5 (16.1%) patients: liver bed bleeding (n = 4) was significatively more frequent in cirrhotics vs. noncirrhotics (p < 0.001). Mean operative time was 90 min, range 50-180, and it was not significantly longer than in noncirrhotics (85 min, range 30-200). Conversion rate was also similar (3%). Seven patients presented 8 postoperative complications (Class II): right side lung effusion (n = 2), ascites (n = 2), temporary worsening of Child-Pugh status (n = 2), hyperosmotic coma (n = 1), and umbilical hernia (n = 1). Mean hospital stay in noncomplicated cases was the same for noncirrhotics (3+/-1). The authors suggest a more liberal use of laparoscopic cholecystectomy for symptomatic gallstones in selected Child-Pugh A and B patients.

Sclerotherapy versus banding in the treatment of variceal bleeding

Endoscopic sclerotherapy has been the mainstay in the management of esophageal variceal bleeding to control acute bleeding and decrease recurrent bleeding. Endoscopic variceal ligation is a new technique that is equally effective in the control of acute bleeding but achieves obliteration of varices in fewer treatment sessions with presumably less cost, results in a lower rebleeding rate, has fewer complications, and is associated with reduced mortality. Combination therapy with both endoscopic variceal ligation and endoscopic sclerotherapy appears to have no clear advantage over variceal ligation alone. On the basis of the results of a number of trials comparing sclerotherapy with band ligation, endoscopic variceal ligation has evolved to be the preferred first line modality for the endoscopic treatment of variceal bleeding.

Endoscopic sclerotherapy versus variceal ligation in the long-term management of patients with cirrhosis after variceal bleeding. A prospective randomized study

BACKGROUND/AIMS

Long-term endoscopic injection sclerotherapy of oesophageal varices prevents rebleeding in patients with cirrhosis surviving an acute variceal bleeding episode. However, this treatment is associated with a substantial complication rate. Endoscopic band ligation is a newly developed technique in an attempt to provide a safer alternative. The aim of this study was to compare the efficacy and safety of injection sclerotherapy versus variceal ligation in the management of patients with cirrhosis after variceal haemorrhage.

METHODS

Seventy-seven patients with cirrhosis who proved to have oesophageal variceal bleeding were studied. After initial control of haemorrhage by sclerotherapy, 40 of the patients were randomly assigned to sclerotherapy and 37 to ligation. Both procedures were performed under midazolam sedation at intervals of 7-14 days until all varices in the distal oesophagus were eradicated or were too small to receive further treatment.

RESULTS

The eradication of varices required a lower mean number of sessions with ligation (3.7 +/- 1.9) than with sclerotherapy (5.8 +/- 2.7, p = 0.002). The mean duration of follow-up was similar in both groups (15.6 months +/- 7.3 and 15 +/- 7.4, respectively). The proportion of patients remaining free from recurrent bleeding against time was significantly higher in the ligation group as compared to the sclerotherapy group (chi 2 = 3.86, p = 0.05). Only 13 patients (35%) developed complications in the ligation group as compared to 24 (60%, p = 0.05) in the sclerotherapy group. The mortality rate was similar in both groups (20% and 21%, respectively).

CONCLUSIONS

Variceal ligation is better than sclerotherapy in the long-term management of patients with cirrhosis after variceal haemorrhage which was initially controlled with sclerotherapy.

Portosystemic shunting for paediatric portal hypertension

The records of 22 patients who received portosystemic shunting for portal hypertension from 1985 to 1995 inclusive at the Royal Alexandra Hospital for Children (RAHC) were retrospectively reviewed. There were 11 girls and 11 boys. The average age at operation was 8 years, 3 months (range, 2 years, 3 months to 16 years, 7 months). The aetiology was idiopathic portal cavernomatous transformation (n = 9), billiary atresia (n = 4), cystic fibrosis (n = 3), documented neonatal portal vein thrombosis (n = 3), congenital hepatic fibrosis (n = 2), and portal vein obstruction after liver transplant (n = 1). The major presenting problem was upper gastrointestinal haemorrhage. Two patients had recurrent melaena from Roux-en-Y jejunal loop and caecal varices, respectively. Before receiving shunts, 12 patients had endoscopic sclerotherapy, 1 had gastric transection, and 2 had gastric varices oversewn. Portal pressure at preoperative splenoportogram averaged 28 mm Hg (range, 20 to 41). Urgent shunts were performed on 13 patients. Two disadvantaged patients had prophylactic shunts for severe hypersplenism. The types of shunts used were reversed splenorenal (n = 13), splenoadrenal (n = 6), inferior mesenteric renal (n = 1), portocaval (n = 1), inferior mesenteric caval (n = 1), and superior and inferior mesenteric caval (n = 1). In all, 22 patients had 23 shunts. The patency rate was 96% on 6 months to 10 years follow-up (average, 5.8 years). No spleen was lost. There were 2 late deaths. Two cystic fibrosis patients and one child with extrahepatic portal hypertension experienced post-shunt encephalopathy. Three patients rebled in the early postoperative period despite a patent shunt. Two patients subsequently received liver transplantation without any additional difficulties. Thus, portosystemic shunting using a method appropriate for the patient is a reliable option for treating children with portal hypertension in whom variceal sclerotherapy is inappropriate or has failed.

Effect of previous sclerotherapy on the outcome of gastro-oesophageal devascularization and oesophageal transection in bleeding oesophageal varices

This retrospective analysis studied the effect of sclerotherapy on subsequent oesophageal transection in the management of patients with bleeding oesophageal varices and compared the result with that in those who did not receive sclerotherapy as the primary treatment. Fifty patients were treated by gastro-oesophageal devascularization and oesophageal transection for bleeding oesophageal varices over a 4-year period. Twenty-six patients did not receive sclerotherapy (group 1) and 24 received between one and four sessions of sclerotherapy (group 2) before surgery. Oedema and thickness of the lower end of the oesophagus and some adhesions were noted during surgery in patients who had had previous sclerotherapy; however, stapled oesophageal transection and anastomosis could be performed in all these patients. There was no oesophageal leak in any patient, although there was a higher rate of chest complications (nine versus six patients) in group 2. Six patients (12 per cent) died (three in each group) during the postoperative period; three had Child grade C disease. It is concluded that the decision to operate to control bleeding varices should be made early. One or two sessions of sclerotherapy before surgery does not increase intraoperative difficulty or the postoperative leak rate following oesophageal transection. The outcome of surgery is directly related to the state of liver reserve (Child grade).

Distinctive portal venographic pattern in patients with sclerotherapy resistant oesophageal varices

We performed prophylactic sclerotherapy in 350 patients with 'high risk' oesophageal varices (F2 or F3 with a moderate or severe red colour sign). Of these patients, eight exhibited sclerotherapy resistance (i.e. no significant reduction in the size of varices after five sessions of sclerotherapy). Thus, the prevalence of sclerotherapy resistant varices was 2%. Of 350 patients, 97 underwent haemodynamic investigation before sclerotherapy. This group consisted of seven patients with sclerotherapy resistant varices and 90 patients with non-resistant varices. Portal pressure, assessed by portal venous pressure gradient, was similar in these two groups (21.5 +/- 4.8 vs 19.8 +/- 5.0 mmHg, respectively; NS). However, the prevalence of the 'pipe-line' form of variceal feeding pattern (a large dilated left gastric vein running up the oesophagus) was higher in patients with resistant varices than in those with non-resistant varices (100 vs 3%, respectively; P < 0.01) and the diameter of the left gastric vein was larger in patients with resistant varices than in those with non-resistant varices (12.4 +/- 2.0 vs 7.8 +/- 2.3 mm, respectively; P < 0.01). Moreover, the extravariceal portosystemic shunt was poorly developed in patients with resistant varices compared with non-resistant varices (0 vs 52%, respectively; P < 0.05). We conclude that the pipe-line pattern, fed by a large left gastric vein and associated with poorly developed extravariceal portosystemic shunt, is a distinctive portal venographic feature of sclerotherapy resistant varices.

Indications for and timing of liver transplantation

The tremendous success of OLT as a highly effective treatment for patients with end-stage liver disease has resulted in a rapid increase in the number of candidates for the procedure. Refinements in organ preservation, improvements in surgical technique and immunosuppression, and better postoperative management have contributed to improved survival rates. The discrepancy between the paucity of organs and the increasing numbers of potential recipients will continue to worsen until there are extraordinary breakthroughs in providing alternatives to human whole-organ livers, such as xenografts or cultured hepatocyte infusions. For now, the vast majority of patients with life-threatening liver disease are not likely to receive a liver graft. Thus, the issues of patient selection and timing of OLT have become even more relevant. Prompt referral to a transplant center is not only in the patient's best interest, but also it has been shown to be cost-effective. Over the last 30 years, it has become clear that hepatic malignancy, initially a common reason for OLT, should be an indication for transplantation only in highly selected individuals. The role of adjuvant chemotherapy needs to be defined, and proven treatment alternatives need to be developed. New antiviral agents may enable a large group of patients with chronic hepatitis B to be successfully transplanted, placing even greater demands on the already limited supply of donor livers. Hepatitis B appears to be species specific, and it is conceivable that xenotransplantation from a nonsusceptible donor species may confer protection to HBV reinfection, eliminating the problems of an inadequate donor supply. Until novel approaches, including xenotransplantation, gene therapy, or replacement of hepatic function by cultured hepatocyte infusions, become a widespread reality, future allocation policies may highlight outcome as well as urgency as a fundamental variable to determine if transplantation is reasonable. Survival rates have been shown to fall with advancing levels of urgency, resulting in a conflict between equity and efficacy in organ allocation. As waiting lists for liver transplantation continue to grow, it is becoming increasingly apparent that patients must be referred to a transplant center earlier in the course of liver disease.

Upper gastrointestinal tract bleeding

Upper GI bleeding is a serious and common emergency. Most upper GI bleeding will stop spontaneously but determining which patients will continue to bleed or rebleed is very difficult in the ED. Resuscitation and stabilization are the primary goals of the emergency physician. Hemorrhage control with pharmacotherapy or balloon tamponade may be necessary until urgent or emergent consultation with a gastroenterologist or surgeon is obtained. Early detection and treatment of H. pylori and the development of safer NSAIDs should alter the future of upper GI bleeding dramatically.

The impact of endoscopic variceal ligation on the pressure of the portal venous system

BACKGROUND/AIMS

Endoscopic variceal ligation is a viable substitute for injection sclerotherapy. It is still not known how endoscopic variceal ligation may influence the portal venous system. To clarify this issue we investigated the impact of endoscopic variceal ligation on the pressure of the portal venous system.

METHODS

Twenty-nine patients with a history of esophageal variceal bleeding but without ascites were enrolled. All had cirrhosis; 63% of them were post-hepatitic. Ligation was performed at intervals of 2-3 weeks until all the varices were obliterated. Portal venograms were performed before institution of ligation and after variceal obliteration to assess venographic findings and pressure changes. The pressures of the main portal vein, splenic vein and superior mesenteric vein were recorded.

RESULTS

Twenty-five patients completed the study. A mean of 4.4 sessions (range: 2-7) of ligation over a period of 2 months was needed. Seventeen (68%) patients experienced elevated pressure and eight (32%) patients reduced pressure after ligation. Mean (median) pressure changes were as follows: portal venous pressure, 26.5 +/- 4.7 (25.0) mmHg vs. 28.2 +/- 7.2 (28.0) mmHg (p > 0.05); splenic venous pressure, 28.2 +/- 4.9 (26.0) mmHg vs. 29.0 +/- 6.8 (29.0) mmHg (p > 0.05); superior mesenteric venous pressure, 28.4 +/- 6.0 (27.0) mmHg vs. 29.5 +/- 7.0 (29.0) mmHg (p > 0.05). Five patients (20%) experienced rebleeding before variceal obliteration; all of them presented elevated portal pressures after variceal obliteration. Among the eight patients with decreased portal pressure, seven (87%) had other major collaterals apart from esophageal varices, compared to three out of the 17 (18%) patients with elevated portal pressure who had other major collaterals (p < 0.01).

CONCLUSIONS

Among patients receiving endoscopic variceal ligation, 68% experienced elevated portal pressure, while 32% had decreased portal pressure. Elevation of portal pressure after variceal ligation may be an important factor in variceal rebleeding. The presence of other major collaterals apart from esophageal varices may be responsible for the decrease in portal pressure after obliteration of esophagel varices.

A prospective study of upper gastrointestinal hemorrhage in patients with hepatocellular carcinoma

Our purpose was to determine, in a prospective study, the causes of gastrointestinal hemorrhage in patients with hepatocellular carcinoma, and the relationship of portal vein invasion with variceal hemorrhage in these patients. During an 11-month period, 55 patients presented with hepatocellular carcinoma presented with signs and/or symptoms of upper gastrointestinal hemorrhage. Forty-seven percent had bleeding from varices, whereas the majority, 53%, had a nonvariceal bleeding source. Among those with nonvariceal bleeding, duodenal ulceration was the commonest cause. Direct tumor invasion into the gastrointestinal tract was found in three patients. Tumor invasion of the portal venous system was detected by ultrasound examination in 76% of the variceal bleeders, compared to only 45% of the nonvariceal bleeders. Despite the very high frequency of cirrhosis among patients with hepatocellular carcinoma, the source of bleeding was variceal in less than half of the patients. Portal vein invasion is a risk factor for subsequent variceal bleed.

Sclerotherapy with or without octreotide for acute variceal bleeding

BACKGROUND

Sclerotherapy is considered the most effective way to stop bleeding from esophageal varices, but acute variceal bleeding is still associated with a high risk of rebleeding and death. We compared sclerotherapy alone with sclerotherapy and octreotide to control acute variceal bleeding and prevent early rebleeding in patients with cirrhosis.

METHODS

In a double-blind, prospective trial, 199 patients with cirrhosis and acute variceal bleeding who underwent emergency sclerotherapy were randomly assigned to receive a continuous infusion of octreotide (25 micrograms per hour) or placebo for five days. The primary outcome measure was survival without rebleeding five days after sclerotherapy.

RESULTS

After five days, the proportion of patients who had survived without rebleeding was higher in the octreotide group (85 of 98 patients, or 87 percent) than in the placebo group (72 of 101, or 71 percent; 95 percent confidence interval for the difference, 4 to 27 percent; P = 0.009). The mean number of units of blood transfused within the first 24 hours after sclerotherapy was lower in the octreotide group (1.2 units; range, 0 to 7) than in the placebo group (2.0 units; range, 0 to 10; P = 0.006). A logistic-regression analysis showed that the treatment assignment (P = 0.003) and the number of blood units transfused before any other treatment was undertaken (P = 0.002) were the only two variables independently associated with survival without rebleeding. After adjustment for base-line differences between the two groups, the odds ratio for treatment failure in the placebo group, as compared with the octreotide group, was 3.3 (95 percent confidence interval, 1.5 to 7.3). The mean (+/- SD) 15-day cumulative survival rate (estimated by the Kaplan-Meier method) was 88 +/- 12 percent in both groups. Side effects were minor, and their incidence was similar in the two groups.

CONCLUSIONS

In patients with cirrhosis, the combination of sclerotherapy and octreotide is more effective than sclerotherapy alone in controlling acute variceal bleeding, but there is no difference between the overall mortality rates associated with the two approaches to treatment.

A prospective, randomized trial of sclerotherapy versus ligation in the management of bleeding esophageal varices

We conducted a prospective, randomized trial comparing sclerotherapy and ligation in 120 patients with acute bleeding of esophageal varices. All the patients were cirrhotic, 59 received sclerotherapy, and 61 received ligation. Treatment was repeated regularly until the varices were obliterated. The mean follow-up period was 295 +/- 120 days and 310 +/- 105 days for the sclerotherapy and ligation groups, respectively. The control of active bleeding was 12/15 (80%) in the sclerotherapy group and 18/19 (94%) in the ligation group (P = .23). The numbers of treatment sessions required to achieve variceal obliteration were 6.5 +/- 1.2 in the sclerotherapy group and 3.8 +/- 0.4 in the ligation group (P < .001). Recurrent bleeding from the gastrointestinal tract was 51% in the sclerotherapy group compared with 33% in the ligation group (P < .05). Recurrent bleeding from esophageal varices was 36% in the sclerotherapy group and 11% in the ligation group (P < .01). However, bleeding from ectopic varices and congestive gastropathy was less common in the sclerotherapy group (7%) than in the ligation group (18%) (P = .05). Significant complications were encountered in 19% of the sclerotherapy group and in 3.3% of the ligation group (P < .01). Comparison of Kaplan-Meier estimates of time to death of both groups showed a significantly lower mortality in the ligation group (P = .011). Both sclerotherapy and ligation can effectively arrest active bleeding from esophageal varices. However, ligation is more effective than sclerotherapy in decreasing the risk of rebleeding from esophageal varices with fewer complications. Ligation can also achieve obliteration of esophageal varices more rapidly than sclerotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)

A critical appraisal of the small-diameter portacaval H-graft

BACKGROUND

The ideal portasystemic shunt should prevent variceal hemorrhage and preserve portal flow to reduce hepatic encephalopathy. The partial shunting proposed by Sarfeh effectively controls variceal bleeding while preserving prograde hepatic portal flow.

PATIENTS AND METHODS

We analyzed results of the partial portacaval shunt prospectively in 43 patients undergoing small-diameter (8-mm or 10-mm) portacaval H-graft. Patients entered into the study had Child-Pugh class A and class B cirrhosis, and all had documented previous variceal hemorrhages. We used the Sarfeh technique without performing portal collateral ligation.

RESULTS

Operative mortality was 5%. Acute graft thrombosis occurred in 3 patients, 2 of whom were successfully lysed by urokinase infusion angiographically, while later graft occlusion occurred in 1 case. Only 1 patient rebled from varices in our late follow-up (14 to 65 months). Prograde portal flow was maintained in 90% of patients undergoing repeat angiography 27 +/- 13 months postoperatively. The incidence of all encephalopathy episodes was 16%, with only 1 patient having this complication chronically.

CONCLUSIONS

The small-diameter portacaval H-graft of Sarfeh is an effective operation for controlling variceal hemorrhage. It preserves hepatic portal perfusion over time in the majority of patients, reducing the risk of encephalopathy. The procedure may be particularly suited for alcoholic cirrhotic patients with less advanced liver disease.

Mesocaval shunt or repeated sclerotherapy: effects on rebleeding and encephalopathy--a randomized trial

BACKGROUND

Sclerotherapy is usually effective in controlling acutely bleeding esophageal varices. It may not be as effective as shunt surgery for prevention of rebleeding; therefore we undertook a prospective study comparing interposition mesocaval shunt (MCS) and repeated sclerotherapy.

METHODS

Forty-five patients (mean age, 52.6 +/- 9.8 years) with variceal bleeding were randomized after emergency endoscopic sclerotherapy either to repeat variceal obliteration followed by regular check endoscopy (n = 21) or to elective interposition mesocaval shunting by use of 14 mm polytetrafluoroethylene graft (n = 24). There was an equal distribution of Child's classes in the two groups.

RESULTS

In the sclerotherapy group 12 patients had recurrent hemorrhages causing five deaths compared with the shunt group, in which four patients had postoperative bleeding but without associated death. No difference was noted in the incidence of encephalopathy despite the development of total shunting 1 year after MCS. The median hospital stay was similar; 34.5 days (MCS) and 33 days (sclerotherapy). The number of intensive care unit days was also similar in the two groups. No difference was noted in survival in patients with Child's A and Child's B disease in the treatment groups. In patients with Child's C cirrhosis there was a statistically significant longer survival in patients undergoing MCS compared with patients undergoing sclerotherapy.

CONCLUSIONS

The results of the study show that the rate of rebleeding is significantly higher after sclerotherapy than after mesocaval shunting. In patients with Child's C cirrhosis MCS may be an alternative to sclerotherapy for the prevention of rebleeding from esophageal varices in patients not suitable for transplantation.

Predictors of mortality in patients admitted to hospital for acute upper gastrointestinal hemorrhage

BACKGROUND

We wanted to identify features of prognostic significance in patients admitted to hospital because of acute upper gastrointestinal (UGI) hemorrhage.

METHODS

A prospective, longitudinal study of 321 consecutive cases admitted during 1988-91 was carried out. The relative risk of mortality associated with each of the background, laboratory, and endoscopic features and the hospital course was calculated. Multiple stepwise logistic regression was used to define factors independently associated with mortality. Two models were evaluated, the first based on the data at presentation (history, physical findings, initial laboratory data) and the second based on the first, plus the endoscopic and follow-up data.

RESULTS

The overall mortality was 7.8%. At presentation the features associated with a significantly (p < 0.05) increased risk of mortality were (adjusted odds ratios in parentheses) age > or = 75 years (11.2), a history of cancer (12.1), blood in the gastric aspirate (9.6), and a systolic blood pressure < or = 90 mm Hg (6.4). The overall predictors of mortality were age > or = 75 years (12.7), blood in the gastric aspirate (18.9), serum creatinine level > or = 150 mumol/l (14.8), increased serum aminotransferase level (20.2), and persistent or recurrent bleeding (57.3).

CONCLUSIONS

In patients admitted to hospital because of UGI hemorrhage the prognosis depends on age, underlying diseases, hemodynamic status, and the persistence or recurrence of bleeding. The causes of bleeding were not relevant to the prognosis.

Hepatic disorders. Features and appropriate management

The spectrum of liver disease is extremely wide, with many of the underlying disorders having acute and chronic presentations. Most of the underlying pathogenetic mechanisms are accounted for by autoimmune disease, viral infection and toxic insult. The management strategy of any liver disease is a combination of treating the symptoms and complications that arise, as well as drug therapies relevant to the specific underlying diagnosis. Encephalopathy, ascites, spontaneous bacterial peritonitis, variceal bleeding and pruritus are the main complications at which drug therapy is directed, although in some cases it represents only 1 aspect of the overall management. Drug therapy per se is largely ineffective in acute liver failure with the possible exception of acetylcysteine, but many drugs are used in the management of the constituent components of this complex medical emergency. Treatments for specific liver conditions are expanding, especially in the areas of autoimmune and viral disease. The increasing availability and success of liver transplantation has tended to change the emphasis of management, and it is often not appropriate to exhaust the treatment options before referring the patient for transplantation. A comprehensive review of all liver disease is beyond the scope of this article, but hopefully the important principles of management and commonly occurring clinical decisions are discussed.