A new "sandwich" method of combined endoscopic variceal ligation and sclerotherapy versus ligation alone in the treatment of esophageal variceal bleeding: a randomized trial

Efficacy and Safety of Treatments for Patients With Portal Hypertension and Cirrhosis: A Systematic Review and Bayesian Network Meta-Analysis

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.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Comparison of Therapies for Secondary Prophylaxis of Esophageal Variceal Bleeding in Cirrhosis: A Network Meta-analysis of Randomized Controlled Trials

PURPOSE

The decision regarding the optimal secondary prophylactic treatment for esophageal variceal bleeding (EVB) in hepatic cirrhosis is controversial. A network meta-analysis was conducted to assess the benefits of various treatments for the secondary prophylaxis of EVB in patients with cirrhosis.

METHODS

A thorough examination of databases, including EMBASE, PubMed, and Cochrane Database of Controlled Trials, was conducted to identify relevant randomized controlled trials up to December 2019. Key primary outcomes included mortality and rebleeding. Within the identified databases, a network meta-analysis was performed. Results were expressed by using a 95% credible interval (CrI) and odds ratios (ORs). The quality of results was assessed by using the Grading of Recommendations, Assessment, Development and Evaluation approach.

FINDINGS

Forty-eight trials with 4415 participants with cirrhosis and portal hypertension who had a history of recent variceal bleeding were included. Carvedilol ranked first (surface under the cumulative ranking curve [SUCRA], 87.4%) in overall survival, and some advantage was suggested; however, the findings were not statistically significant, compared with endoscopic variceal ligation + nonselective beta-blockers (NSBB) (OR, 0.59; CrI, 0.28, 1.3), NSBB + isosorbide mononitrate (OR, 0.67; CrI, 0.33, 1.4), and transjugular intrahepatic portosystemic shunt (TIPS) (OR, 0.52; CrI, 0.24, 1.1). NSBB + isosorbide mononitrate (SUCRA, 63.9%) ranked higher than NSBB + endoscopic variceal ligation (SUCRA, 49.6%) in reducing mortality. TIPS (SUCRA, 98.8%) ranked higher than other treatments in reducing rebleeding but did not confer any survival benefit.

IMPLICATIONS

TIPS ranks first in preventing rebleeding of secondary prophylaxis of EVB and carvedilol shows outstanding efficacy in improving survival. International Prospective Register of Systematic Reviews: identifier CRD42019131814.

Comparison of the effectiveness of 11 mainstay treatments for secondary prophylaxis of variceal bleeding in patients with cirrhosis: A network meta-analysis

The purpose of the present study was to compare the effectiveness of the transjugular intrahepatic portosystemic shunt (TIPS), endoscopic options, medications and mainstay combination therapies for patients with cirrhosis who have had at least one episode of variceal haemorrhage. The PubMed, Embase, Cochrane Library and Web of Science databases, as well as the reference lists of relevant articles, were searched to identify eligible studies. P-scores, that were based solely on the point estimates and standard errors of the network estimates, were performed to rank all treatments, on a scale from 0 (worst) to 1 (best). The odds ratio (OR) was determined to assess effects on mortality, treatment failure and bleeding from gastroesophageal ulcers. A total of 43 randomized controlled trials comprising 3,787 adult patients were included. In total, 26 (61%) trials adopted concealed randomization, while most studies did not specify blinding. The drug combination of nadolol and isosorbide mononitrate (ISMN) ranked first for lowering risks of overall mortality (P-score=0.8162), mortality due to liver failure (P-score=0.7536) and bleeding from gastroesophageal ulcers (P-score=0.7536). This combination was determined to be superior to endoscopic sclerotherapy (ES) alone (OR=0.63, 95% CI: 0.42-0.94) and TIPS alone in reducing overall mortality (OR=0.62, 95% CI: 0.40-0.96). ES was more likely to increase treatment failure compared with TIPS, endoscopic variceal ligation (EVL), ES plus EVL, EVL plus nadolol/propranolol plus ISMN and nadolol/propranolol plus ISMN. In conclusion, the present network meta-analysis suggested that for a decreased mortality due to variceal rebleeding in patients with cirrhosis, nadolol plus ISMN may be a preferable choice, while ES is associated with a higher risk of unfavourable treatment outcomes. Further well-controlled studies are required to further elucidate the appropriate treatment options.

Antiviral therapy reduces rebleeding rate in patients with hepatitis B-related cirrhosis with acute variceal bleeding after endotherapy

Background

The preventive effects of antiviral therapy to reduce rebleeding rate in patients with hepatitis B-related cirrhosis undergoing endoscopic treatment have not yet been reported.

Methods

In this retrospective cohort study, 1139 patients with chronic hepatitis B with first acute variceal bleeding after endoscopic therapy from September 2008 to December 2017 were included. Among them, 923 who received and 216 who did not receive antiviral therapy were followed up for rebleeding. Cumulative rebleeding rate was calculated using the Kaplan-Meier method. Univariate and multivariate logistic regression analyses were performed to estimate the effects of antiviral therapy on rebleeding risk. The propensity score matched method and inverse probability of treatment weighting analysis were used to calculate the rebleeding rate between the antiviral and non-antiviral groups.

Results

The rebleeding rates were 40.5, 60.7, 72.6, and 89.2% in antiviral group at 1, 2, 3, and 5 years, respectively. The corresponding rebleeding rates in the non-antiviral group were 54.2, 72.4, 84.4, and 93.3%, respectively. The multivariate logistic regression analysis revealed that antiviral therapy was an independent protective factor associated with rebleeding.

Conclusion

Antiviral treatment significantly reduced rebleeding rate in patients with HBV-related cirrhosis who received endoscopic treatment after the first variceal bleeding.

Electronic supplementary material

The online version of this article (10.1186/s12876-019-1020-2) contains supplementary material, which is available to authorized users.

Prognostic factors associated with mortality in patients with gastric fundal variceal bleeding

AIM

To determine the prognostic factors associated with mortality in patients with gastric fundal variceal (GFV) bleeding.

METHODS

In total, 42 patients were endoscopically diagnosed with GFV bleeding from January 2000 to March 2014. We retrospectively reviewed the patients' medical records and assessed their history, etiology of liver cirrhosis, disease conditions, treatment options for GFV bleeding, medications administered before and after onset of GFV bleeding, blood test results (hemoglobin, albumin, and bilirubin concentrations), and imaging results (including computed tomography and abdominal ultrasonography). We also assessed the prognostic factors associated with short-term mortality (up to 90 d) and long-term mortality in all patients.

RESULTS

Multivariate analysis showed that prophylactic administration of antibiotics was an independent prognostic factor associated with decreases in short-term mortality (OR = 0.08, 95%CI: 0.01-0.52) and long-term mortality (OR = 0.27, 95%CI: 0.08-0.91) in patients with GFV bleeding. In contrast, concurrent hepatocellular carcinoma (HCC) and regular use of proton pump inhibitors (PPI) were independent prognostic factors associated with increases in short-term mortality (HCC: OR = 15.4, 95%CI: 2.08-114.75; PPI: OR = 12.76, 95%CI: 2.13-76.52) and long-term mortality (HCC: OR = 7.89, 95%CI: 1.98-31.58; PPI: OR = 10.91, 95%CI: 2.86-41.65) in patients with GFV bleeding. The long-term overall survival rate was significantly lower in patients who regularly used PPI than in those who did not use PPI (P = 0.0074).

CONCLUSION

Administration of antibiotics is associated with decreased short- and long-term mortality, while concurrent HCC and regular PPI administration are associated with increased short- and long-term mortality.

Long-term efficacy of endoscopic ligation plus cyanoacrylate injection with or without sclerotherapy for variceal bleeding

OBJECTIVE

This study aimed to evaluate the long-term outcomes and efficacy of continued ligation plus cyanoacrylate injection compared with those of combined ligation and sclerotherapy plus cyanoacrylate injection for secondary prophylaxis of variceal bleeding in cirrhotic patients with concomitant esophageal and gastric varices.

METHODS

Medical records of the patients who were admitted for variceal bleeding due to liver cirrhosis were retrospectively reviewed and their related data was collected. The patients were divided into two groups, including the continued ligation plus cyanoacrylate injection group [the sclerotherapy (-) group] and the combined ligation and sclerotherapy plus cyanoacrylate injection group [the sclerotherapy (+) group]. The Kaplan-Meier survival analysis was conducted and log-rank test was used to compare the differences between the two groups.

RESULTS

Altogether 125 patients were enrolled between 1 April 2004 and 31 December 2012. After a median follow-up of 23.4 months, no significant difference was observed between the two groups in regard to variceal rebleeding (29.7% vs 47.5%, P = 0.097) and mortality (12.5% vs 14.8%, P = 0.879). Among patients with ascites the cumulative rebleeding rate was significantly lower in the sclerotherapy (-) group (26.3% vs 59.4%, P = 0.020). A relapse of bleeding after the initial endoscopic therapy was an independent prognostic factor of rebleeding (P = 0.004). Portal thrombosis was an independent prognostic factor for mortality (P = 0.044).

CONCLUSION

No superiority of combined ligation and sclerotherapy compared with continued ligation and cyanoacrylate injection for secondary prophylaxis of variceal bleeding is observed.

Randomized controlled trial comparing endoscopic ligation with or without sclerotherapy for secondary prophylaxis of variceal bleeding

OBJECTIVES

A recently published network meta-analysis showed that ligation combined with sclerotherapy might be the most efficacious intervention for secondary prophylaxis of variceal bleeding. Most studies excluded patients with concomitant gastric varices; thus, the outcomes in such patients have not yet been reported. The present study aimed to investigate the efficacy of two endoscopic procedures for secondary prophylaxis in cirrhotic patients presenting with both esophageal and gastric varices.

MATERIALS AND METHODS

A randomized controlled study was carried out in a tertiary care referral center. Patients were randomized into two groups: sclerotherapy- and sclerotherapy+ group. Continued endoscopic ligation was used to treat esophageal varices in the sclerotherapy- group, whereas combined ligation and sclerotherapy with lauromacrogol was performed in the sclerotherapy+ group. A cyanoacrylate injection was used for gastric varices in both groups. All participants were followed up for 6 months.

RESULTS

Overall, 96 patients were included between 25 March 2012 and 25 June 2013. Three patients were lost during follow-up (one in the sclerotherapy- group and two in the sclerotherapy+ group). The cumulative recurrence rate of bleeding was significantly higher in the sclerotherapy+ group (14.6 vs. 35.4%, P=0.013). The cumulative mortality rate (2.1 vs. 6.3%, P=0.286) and the incidence rate of adverse events were similar between the two groups.

CONCLUSION

Continued ligation+cyanoacrylate injection was superior to combined ligation and sclerotherapy+cyanoacrylate injection during the first 6 months in terms of rebleeding in cirrhotic patients presenting with both esophageal and gastric varices. Long-term results entail further investigation (http://www.clinicaltrials.gov, NCT01592578).

Effect of intravariceal sclerotherapy combined with esophageal mucosal sclerotherapy using small-volume sclerosant for cirrhotic patients with high variceal pressure

AIM: To explore the effect of intravariceal-mucosal sclerotherapy using small dose of sclerosant on the recurrence of esophageal varices.

METHODS: We randomly assigned 38 cirrhotic patients with previous variceal bleeding and high variceal pressure (> 15.2 mmHg) to receive endoscopic variceal ligation (EVL) and combined intravariceal and esophageal mucosal sclerotherapy (combined group) using small-volume sclerosant. The end-points of the study were rebleeding and recurrence of esophageal varices.

RESULTS: During a median follow-up period of 16 mo, varices recurred in 1 patient in the combined group as compared with 7 patients in the EVL group (P = 0.045). Rebleeding occurred in 3 patients in the EVL group as compared with 1 patient in the combined group (P = 0.687). No patient died in the two groups. No significant differences were observed between the two groups with respect to serious adverse events.

CONCLUSION: Intravariceal-mucosal sclerotherapy using small dose of sclerosant is more effective than EVL in decreasing the incidence of variceal recurrence for cirrhotic patients.

Delayed endoscopy increases re-bleeding and mortality in patients with hematemesis and active esophageal variceal bleeding: a cohort study

BACKGROUND & AIMS

Active bleeding is a poor prognostic indicator in patients with acute esophageal variceal bleeding. This study aimed at determining indicators of 6-week re-bleeding and mortality in patients with "active" esophageal variceal bleeding, particularly emphasizing the presenting symptoms and timing of endoscopy to define the treatment strategy.

METHODS

From July 2005 to December 2009, cirrhotic patients with endoscopy-proven active esophageal variceal bleeding were evaluated. Cox proportional hazards regression analysis was used to determine the indicators of 6-week re-bleeding and mortality. Outcome comparisons were performed by Kaplan-Meier method and log rank test.

RESULTS

In 101 patients, the overall 6-week and 3-month re-bleeding rates were 25.7% (n=26) and 29.7% (n=30), respectively. The overall 6-week and 3-month mortality was 31.7% (n=32) and 38.6% (n=39), respectively. Door-to-endoscopy time (hr), MELD score, and portal vein thrombosis were indicators of 6-week re-bleeding, while hematemesis upon arrival, MELD score, and hepatocellular carcinoma were indicators of 6-week mortality. Overall mortality was poorer in hematemesis than in non-hematemesis patients (39.7% vs. 10.7%, p=0.007). In hematemesis patients, 6-week re-bleeding rate (18.9% vs. 38.9%, p=0.028) and mortality (27% vs. 52.8%, p=0.031) were lower in those with early (≤ 12 h) than delayed (>12h) endoscopy. In non-hematemesis patients, early and delayed endoscopy had no difference on 6-week re-bleeding rate (17.6% vs. 18.2%, p=0.944) and mortality (11.8% vs. 9.1%, p=0.861).

CONCLUSIONS

It is likely that early endoscopy (≤ 12 h) is associated with a better outcome in hematemesis patients, but a randomized trial with larger case numbers is required before making a firm conclusion.

Endoscopic management of portal hypertension

Cirrhosis is the leading cause of portal hypertension worldwide, with the development of bleeding gastroesophageal varices being one of the most life-threatening consequences. Endoscopy plays an indispensible role in the diagnosis, staging, and prophylactic or active management of varices. With the expected future refinements in endoscopic technology, capsule endoscopy may one day replace traditional gastroscopy as a diagnostic modality, whereas endoscopic ultrasound may more precisely guide interventional therapy for gastric varices.

Does sclerotherapy of remnant little oesophageal varices after endoscopic ligation have impact on the reduction of recurrent varices? Prospective study

INTRODUCTION

Endoscopic band ligation (EBL) is superior to endoscopic injection sclerotherapy (EIS) of oesophageal varices, however, EBL is associated with a higher rate of variceal recurrences.

OBJECTIVE

To examine whether the reduction of recurrent varices can be achieved by additional sclerotherapy of remnant little varices after ligation.

METHODS

Forty-eight patients with liver cirrhosis who had previously bled from oesophageal varices were examined. Endoscopic therapy was performed in order to prevent recurrent variceal bleeding. I group: in 23 patients ligation of oesophageal varices with multi band ligation device was applied (EBL group). II group: in 25 patients sclerotherapy using polydocanol or absolute alcohol was applied after reducing the size of varices using ligation (EBL and EIS group).

RESULTS

There was no statistically significant difference between the examined groups of patients in relation to the number of sessions for variceal eradication, recurrence of variceal bleeding, deterioration of portal gastropathy and mortality in the observed period from 18.8 +/- 18.6 months (EBL group) and 22.2 +/- 26.2 months (EBL and EIS group). Variceal recurrence was verified in 21.7% of patients of the EBL group and 16% of the EBL and EIS group, but the difference was not statistically important. Several complications, such as dysphagia and chest pain, were statistically more frequent in the EBL and EIS group of patients.

CONCLUSION

The combined method of ligation and extra sclerosing of remnant small oesophageal varices after ligation does not have advantage in relation to the ligation alone.

The role of endoscopy in secondary prophylaxis of esophageal varices

The rate of rebleeding from esophageal varices remains appreciably high after cessation of acute esophageal variceal hemorrhage. Many measures have been developed to prevent the occurrence of rebleeding. Endoscopic therapy plays a central role in the prevention of variceal bleeding. In the 1980s sclerotherapy played a pivotal role in the prevention of variceal rebleeding, but now yields to endoscopic variceal ligation. Compared with sclerotherapy, a lower incidence of complications and rebleeding is associated with banding ligation. On the other hand, beta-blockers are also noted to be able to reduce portal pressure, leading to the reduction of variceal rebleeding. The reduction of variceal rebleeding with beta-blockers plus nitrates is as effective as banding ligation. The combination of beta-blockers and endoscopic variceal ligation has proven to be more efficacious than banding ligation alone in the reduction of variceal rebleeding and is the treatment of choice for patients with failure in either medical or endoscopic therapy. Patients with repeated rebleeding despite endoscopic therapies may require transjugular intrahepatic portosystemic stent shunt or shunt operation as a rescue therapy.

Evolution of portal-systemic collateral vasopressin response in endotoxemic portal hypertensive rats

Cirrhotic patients with portal hypertension and variceal hemorrhage are vulnerable to endotoxemia. However, the direct influence of endotoxemia on portal-systemic collateral vasculature remains unexplored. In this study, portal hypertension was induced in Sprague-Dawley rats by partial portal vein ligation. On the 7th day after portal vein ligation, at 0.5, 1.5, and 5 h post endotoxin (LPS; Escherichia coli serotype O111:B4, 3 mg/kg, i.p., E0.5, E1.5 and E5, respectively) or saline (control, C0.5, C1.5, and C5, respectively) injection, hemodynamic measurements and concentration-response relationships to arginine vasopressin (AVP; 10(-10)-10(-7) mol/L) in collateral vascular bed were obtained. In another six parallel groups, reverse-transcriptase-polymerase chain reaction of iNOS, eNOS, and endothelin 1 (ET-1) mRNA expressions for splenorenal shunt, the most prominent intra-abdominal collateral vessel, was performed. The results showed that E0.5 had lower perfusion pressure changes to AVP and higher splenorenal shunt eNOS expression than C0.5 group (P < 0.05). Compared with C1.5, tachycardia, higher perfusion pressure changes and enhanced splenorenal shunt iNOS and ET-1 expression were observed in E1.5 group (P < 0.05). In E5, systemic and portal hypotension with markedly enhanced collateral AVP responsiveness and splenorenal shunt iNOS and ET-1 expressions were noted (P < 0.05). In conclusion, vasoactive substances counterregulation participates, at least in part, the time-dependent changes of collateral AVP responsiveness in endotoxemic portal hypertensive rats.

Microwave coagulation versus sclerotherapy after band ligation to prevent recurrence of high risk of bleeding esophageal varices in Child-Pugh's A and B patients

BACKGROUND

The combination of endoscopic band ligation (EBL) with either endoscopic injection sclerotherapy (EIS) or thermal therapy has been shown to reduce recurrence of esophageal varices compared to EBL alone. The aim of this prospective trial was twofold: 1) to evaluate the safety and efficacy of EBL used in association with microwave coagulation (MC), a thermal endoscopic therapy method, for treating esophageal varices and preventing recurrence; and 2) to compare these results to the joint application of EBL and EIS.

METHODS

Seventy cirrhotic patients with bleeding esophageal varices were treated with EBL until only thin vessels remained. Thirty-six randomly selected patients received EIS (group A) and 34 received MC (group B) until complete eradication had been achieved. Endoscopic follow-up was performed to detect recurrence. The effectiveness of the treatment was measured using variceal recurrence, rebleeding, intervention complications, and recurrence factors.

RESULTS

During follow-up evaluations averaging 34.9 +/- 11.4 months, no significant differences were found between groups A and B in variceal recurrence (27.7 vs. 17.6%, P = 0.31) or rebleeding (8.3 vs. 0%, P = 0.23). Complications were rare, with no difference detected between groups. The presence of gastric varices influenced recurrence with an odds ratio of 3.9 (95% CI 1.14-13.1, P = 0.029).

CONCLUSIONS

Application of MC to esophageal varices after band ligation is safe. The post-MC recurrence rate may be comparable to that observed following the combined treatment of EBL and EIS. The presence of gastric varices increases the risk of esophageal variceal recurrence.

Prevention of esophageal variceal rebleeding

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

[Endoscopic diagnosis and therapy for gastrointestinal bleeding]

Gastrointestinal bleeding is still one of the most frequent medical emergencies. Despite improvements in endoscopic diagnosis and therapy, mortality from bleeding is still high (15%). Since conclusive trials are lacking, the endoscopist often has to rely on personal experience in the selection of therapeutic options. Therefore this article gives an overview of new publications in this field and recommendations based on personal experience.

Improved prognosis of cirrhosis patients with esophageal varices and thrombocytopenia treated by endoscopic variceal ligation plus partial splenic embolization

The aim of this study was to assess the efficacy of the combination of endoscopic variceal ligation (EVL) and partial splenic embolization (PSE) compared with EVL alone in cirrhosis patients with thrombocytopenia. In a prospective study, 84 cirrhosis patients with esophageal varices and thrombocytopenia (platelet count < 50,000/mm(3)) underwent EVL plus PSE (N = 42) or EVL alone (N = 42). Primary end points assessed during the follow-up period included the recurrence of varices, progression to variceal bleeding, and death. Comparison between combined treatment and variceal ligation alone by multivariate analysis showed a hazard ratio of 0.44 for the recurrence of varices (P = 0.02), 0.19 for progression to variceal bleeding (P = 0.01), and 0.31 for death (P = 0.04). These results suggest that the combination of EVL plus PSE can prevent the recurrence of varices, progression to variceal bleeding, and death in cirrhosis patients with esophageal varices and thrombocytopenia.

Combination endoscopic band ligation and sclerotherapy compared with endoscopic band ligation alone for the secondary prophylaxis of esophageal variceal hemorrhage: a meta-analysis

Endoscopic band ligation (EBL) is the community-accepted standard therapy for the secondary prophylaxis of esophageal variceal hemorrhage. Recent data indicate that combination EBL and sclerotherapy may be a more effective therapy than EBL alone. Yet existing data are conflicting. We therefore performed a meta-analysis to compare the efficacy and safety of EBL and sclerotherapy versus EBL alone for the secondary prophylaxis of esophageal variceal hemorrhage. We performed a systematic review of two computerized databases (MEDLINE and EMBASE) along with manual-searching of published abstracts to identify relevant citations without language restrictions from 1990 to 2002. Eight studies met explicit inclusion criteria. We performed meta-analysis of these studies to pool the relative risk for the following outcomes: esophageal variceal rebleeding, death, number of endoscopic sessions to achieve variceal obliteration, and therapeutic complications. There were no significant differences between EBL and sclerotherapy versus EBL alone in the risk of esophageal variceal rebleeding (RR = 1.05; 95% CI = 0.67-1.64; P = 0.83), death (RR = 0.99; 95% CI = 0.68-1.44; P = 0.96), or number of endoscopic sessions to variceal obliteration (RR = 0.23; 95% CI = 0.055-0.51; P = 0.11). However, the incidence of esophageal stricture formation was significantly higher in the EBL group than in the sclerotherapy group. There is no evidence that the addition of sclerotherapy to endoscopic band ligation changes clinically relevant outcomes (variceal rebleeding, death, time to variceal obliteration) in the secondary prophylaxis of esophageal variceal hemorrhage. Moreover, combination EBL and sclerotherapy had more esophageal stricture formation than EBL alone.

Antibiotic prophylaxis after endoscopic therapy prevents rebleeding in acute variceal hemorrhage: a randomized trial

Bacterial infection may adversely affect the hemostasis of patients with gastroesophageal variceal bleeding (GEVB). Antibiotic prophylaxis can prevent bacterial infection in such patients, but its role in preventing rebleeding is unclear. Over a 25-month period, patients with acute GEVB but without evidence of bacterial infection were randomized to receive prophylactic antibiotics (ofloxacin 200 mg i.v. q12h for 2 days followed by oral ofloxacin 200 mg q12h for 5 days) or receive antibiotics only when infection became evident (on-demand group). Endoscopic therapy for the GEVB was performed immediately after infection work-up and randomization. Fifty-nine patients in the prophylactic group and 61 patients in the on-demand group were analyzed. Clinical and endoscopic characteristics of the gastroesophageal varices, time to endoscopic treatment, and period of follow-up were not different between the two groups. Antibiotic prophylaxis decreased infections (2/59 vs. 16/61; P <.002). The actuarial probability of rebleeding was higher in patients without prophylactic antibiotics (P =.0029). The difference of rebleeding was mostly due to early rebleeding within 7 days (4/12 vs. 21/27, P =.0221). The relative hazard of rebleeding within 7 days was 5.078 (95% CI: 1.854-13.908, P <.0001). The multivariate Cox regression indicated bacterial infection (relative hazard: 3.85, 95% CI: 1.85-13.90) and association with hepatocellular carcinoma (relative hazard: 2.46, 95% CI: 1.30-4.63) as independent factors predictive of rebleeding. Blood transfusion for rebleeding was also reduced in the prophylactic group (1.40 +/- 0.89 vs. 2.81 +/- 2.29 units, P <.05). There was no difference in survival between the two groups. In conclusion, antibiotic prophylaxis can prevent infection and rebleeding as well as decrease the amount of blood transfused for patients with acute GEVB following endoscopic treatment.

Endoscopic therapy for upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is one of the most common medical emergencies and remains a major cause of morbidity and mortality among patients. Although initially employed diagnostically, endoscopy has steadily replaced surgery as a first-line treatment in all but the haemodynamically unstable patient. A vast selection of techniques and devices are now available to the dedicated therapeutic endoscopist, including injection therapy, electrical or thermal coagulation and mechanical banding or clipping. The use of endoscopic ultrasound for targeting treatment is increasing and the development of new technologies, such as capsule endoscopy, is likely to play an important role in future protocols. However, despite numerous randomized controlled trials and meta-analyses comparing the efficacy of different endoscopic interventions, the implementation of obtained results into treatment regimes has so far failed to impact significantly on overall UGIB mortality, which remains stubbornly at 10-14%. Reducing this continues to be one of the main challenges facing the therapeutic endoscopist.

Endoscopic banding ligation can effectively resect hyperplastic polyps of the stomach

AIM: Bleeding and perforation are major and serious complications associated with endoscopic polypectomy. To develop a safe and effective method to resect hyperplastic polyps of the stomach, we employed rubber bands to strangulate hyperplastic polyps and to determine the possibility of inducing avascular necrosis in these lesions.

METHODS: Forty-seven patients with 72 hyperplastic polyps were treated with endoscopic banding ligation (EBL). At 14 days after endoscopic ligation, follow-up endoscopies were performed to assess the outcomes of the strangulated polyps.

RESULTS: After being strangulated by the rubber bands, all of the polyps immediately became congested (100%), and then developed cyanotic changes (100%) approximately 4 minutes later. On follow-up endoscopy 2 weeks later, all the polyps except one had dropped off. The only one residual polyp shrank with a rubber band in its base, and it also dropped off spontaneously during subsequent follow-up. No complications occurred during or following the ligation procedures.

CONCLUSION: Gastric polyps develop avascular necrosis following ligation by rubber bands. Employing suction equipment, EBL can easily capture sessile polyps. It is an easy, safe and effective method to eradicate hyperplastic polyps of the stomach.

Management of acute variceal bleeding

Portal hypertension as a consequence of liver cirrhosis is responsible for its most common complications: ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, hepatic encephalopathy and the most important one--variceal hemorrhage. Variceal bleeding results in considerable morbidity and mortality. This review covers all areas of importance in the therapy of acute variceal hemorrhage--endoscopic and pharmacological treatment, transjugular intrahepatic portosystemic shunt, surgery and balloon tamponade. Indications and limitations of these therapeutic modalities are widely discussed.

Update on treatment of variceal hemorrhage

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

Management of bleeding in the cirrhotic patient

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