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Malik S, Tenorio BG, Moond V, Dahiya DS, Vora R, Dbouk N. Systematic review of machine learning models in predicting the risk of bleed/grade of esophageal varices in patients with liver cirrhosis: A comprehensive methodological analysis. J Gastroenterol Hepatol 2024. [PMID: 38886175 DOI: 10.1111/jgh.16645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/08/2024] [Accepted: 05/25/2024] [Indexed: 06/20/2024]
Abstract
Esophageal varices (EV) in liver cirrhosis carry high mortality risks. Traditional endoscopy, which is costly and subjective, prompts a shift towards machine learning (ML). This review critically evaluates ML applications in predicting bleeding risks and grading EV in patients with liver cirrhosis. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we conducted a systematic review of studies using ML to predict the risk of variceal bleeding and/or grade EV in liver disease patients. Data extraction and bias assessment followed the CHARMS (CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modeling Studies) checklist and PROBAST (Prediction model Risk Of Bias Assessment Tool) tool, respectively. Due to the heterogeneity of the study, a meta-analysis was not feasible; instead, descriptive statistics summarized the findings. Twelve studies were included, highlighting the use of various ML models such as extreme gradient boosting, artificial neural networks, and convolutional neural networks. These studies demonstrated high predictive accuracy, with some models achieving area under the curve values above 99%. However, significant heterogeneity was noted in input variables, methodologies, and outcome measures. Moreover, a substantial portion of the studies exhibited unclear or high risk of bias, mainly due to insufficient participant numbers, unclear handling of missing data, and a lack of detailed reporting on endoscopic procedures. ML models show significant promise in predicting the risk of variceal bleeding and grading EV in patients with cirrhosis, potentially reducing the need for invasive procedures. Nonetheless, the current literature reveals considerable heterogeneity and methodological limitations, including high or unclear risks of bias. Future research should focus on larger, prospective trials and the standardization of ML assessment criteria to confirm these models' practical utility in clinical settings.
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Affiliation(s)
- Sheza Malik
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, USA
| | | | - Vishali Moond
- Department of Internal Medicine, St. Peter's University Medicine School, Jersey City, New Jersey, USA
| | - Dushyant Singh Dahiya
- Department of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Ravi Vora
- Department of Gastroenterology and Hepatology, Emory School of Medicine, Atlanta, Georgia, USA
| | - Nader Dbouk
- Department of Gastroenterology and Hepatology, Emory School of Medicine, Atlanta, Georgia, USA
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Cao C, Jin J, Cai R, Chu Y, Wu K, Wang Z, Xiao T, Zhang H, Huang H, Liu H, Zhang Q, Mei X, Kong D. Correlation between diameter of esophageal varices and early rebleeding following endoscopic variceal ligation: a multicenter retrospective study based on artificial intelligence-based endoscopic virtual rule. Front Med (Lausanne) 2024; 11:1406108. [PMID: 38933116 PMCID: PMC11199532 DOI: 10.3389/fmed.2024.1406108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 05/29/2024] [Indexed: 06/28/2024] Open
Abstract
Background and objective Bleeding following endoscopic variceal ligation (EVL) may occur as a result of numerous factors, including a diameter of esophageal varices (EV) that is too large to be completely ligated. The present study aimed to develop an artificial intelligence-based endoscopic virtual ruler (EVR) to measure the diameter of EV with a view to finding more suitable cases for EVL. Methods The present study was a multicenter retrospective study that included a total of 1,062 EVLs in 727 patients with liver cirrhosis with EV, who underwent EVL from April 2016 to March 2023. Patients were divided into early rebleeding (n = 80) and non-rebleeding groups (n = 982) according to whether postoperative bleeding occurred at 6 weeks. The characteristics of patient baseline data, the status of rebleeding at 6 weeks after surgery and the survival status at 6 weeks after rebleeding were analyzed. Results The early rebleeding rate following 1,062 EVL procedures was 7.5%, and the mortality rate at 6 weeks after bleeding was 16.5%. Results of the one-way binary logistic regression analysis demonstrated that the risk factors for early rebleeding following EVL included: high TB (P = 0.009), low Alb (P = 0.001), high PT (P = 0.004), PVT (P = 0.026), HCC (P = 0.018), high Child-Pugh score (P < 0.001), Child-Pugh grade C(P < 0.001), high MELD score(P = 0.004), Japanese variceal grade F3 (P < 0.001), diameter of EV (P < 0.001), and number of ligature rings (P = 0.029). Results of the multifactorial binary logistic regression analysis demonstrated that Child-Pugh grade C (P = 0.007), Japanese variceal grade F3 (P = 0.009), and diameter of EV (P < 0.001) may exhibit potential in predicting early rebleeding following EVL. ROC analysis demonstrated that the area under curve (AUC) for EV diameter was 0.848, and the AUC for Japanese variceal grade was 0.635, which was statistically significant (P < 0.001). Thus, results of the present study demonstrated that EV diameter was more optimal in predicting early rebleeding following EVL than Japanese variceal grade criteria. The cut-off value of EV diameter was calculated to be 1.35 cm (sensitivity, 70.0%; specificity, 89.2%). Conclusion If the diameter of EV is ≥1.4 cm, there may be a high risk of early rebleeding following EVL surgery; thus, we recommend caution with EVL.
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Affiliation(s)
- Chuankun Cao
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Anhui Provincial Key Laboratory of Digestive Diseases, Hefei, China
- Department of Gastroenterology, Phoenix Hospital of Huainan Oriental Hospital Group, Huainan, China
| | - Jing Jin
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Anhui Provincial Key Laboratory of Digestive Diseases, Hefei, China
| | - Rui Cai
- Department of Gastroenterology, Phoenix Hospital of Huainan Oriental Hospital Group, Huainan, China
| | - Yuan Chu
- Department of Gastroenterology, General Hospital of Huainan Oriental Hospital Group, Huainan, China
| | - Kai Wu
- Department of Gastroenterology, General Hospital of Huainan Oriental Hospital Group, Huainan, China
| | - Zuo Wang
- Department of Gastroenterology, General Hospital of Huainan Oriental Hospital Group, Huainan, China
| | - Ting Xiao
- Department of Gastroenterology, Phoenix Hospital of Huainan Oriental Hospital Group, Huainan, China
| | - Heng Zhang
- Department of Gastroenterology, Phoenix Hospital of Huainan Oriental Hospital Group, Huainan, China
| | - Hongfei Huang
- Department of Gastroenterology, Phoenix Hospital of Huainan Oriental Hospital Group, Huainan, China
| | - Heng Liu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Anhui Provincial Key Laboratory of Digestive Diseases, Hefei, China
| | - Qianqian Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Anhui Provincial Key Laboratory of Digestive Diseases, Hefei, China
| | - Xuecan Mei
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Anhui Provincial Key Laboratory of Digestive Diseases, Hefei, China
| | - Derun Kong
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Anhui Provincial Key Laboratory of Digestive Diseases, Hefei, China
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Borhani A, Luu H, Mohseni A, Xu Z, Shaghaghi M, Tolosa C, Attari MMA, Madani SP, Shahbazian H, Khoshpouri P, Afyouni S, Zandieh G, Kamel IR, Kim AK. Screening for exclusion of high-risk bleeding features of esophageal varices in cirrhosis through CT and MRI. Clin Imaging 2024; 110:110168. [PMID: 38703476 DOI: 10.1016/j.clinimag.2024.110168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 04/14/2024] [Accepted: 04/18/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND & AIM Esophageal varices (EV) screening guidelines have evolved with improved risk stratification to avoid unnecessary esophagogastroduodenoscopy (EGD) in individuals with low bleeding risks. However, uncertainties persist in the recommendations for certain patient groups, particularly those with hepatocellular carcinoma (HCC) and/or receiving non-selective beta-blockers (NSBB) without prior endoscopy. This study assessed the efficacy of imaging in ruling out EVs and their high-risk features associated with bleeding in patients with cirrhosis and with HCC. We also evaluated the impact of NSBB on the detection of these characteristics. METHODS A total of 119 patients undergoing EGD with CT and/or MRI within 90 days of the procedure were included. 87 patients had HCC. A new imaging grading system was developed utilizing the size of EVs and the extent of their protrusion into the esophagus lumen. The negative predictive value (NPV) of EVimaging(-) versus EVimaging (+) (grades 1-3) in ruling out the presence of EV and/or high-risk features by EGD was calculated. The predictive performance of imaging was determined by logistic regression. RESULTS The NPV of imaging for detecting EV and high-risk features was 81 % and 92 %, respectively. Among HCC patients, the NPV for EV and high-risk features was 80 % and 64 %, respectively. Being on NSBB didn't statistically impact the imaging detection of EV. Imaging was a better predictor of high-risk EGD findings than Child-Turcotte-Pugh scores. CONCLUSIONS Our results suggest that imaging can effectively rule out the presence of EV and high-risk features during EGD, even in patients with HCC and/or receiving NSBB.
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Affiliation(s)
- Ali Borhani
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Harry Luu
- Department of Medicine, Gastroenterology and Hepatology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Alireza Mohseni
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ziyi Xu
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Mohammadreza Shaghaghi
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Celestina Tolosa
- Department of Medicine, Gastroenterology and Hepatology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Seyedeh Panid Madani
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Haneyeh Shahbazian
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Pegah Khoshpouri
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Shadi Afyouni
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ghazal Zandieh
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ihab R Kamel
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - Amy K Kim
- Department of Medicine, Gastroenterology and Hepatology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Abramowitz BR, Meier RR, Chen M, Graham-Hill S. Ultrarapid Development of Ruptured Esophageal Varices in a Patient With a History of Heller Myotomy. Cureus 2024; 16:e58954. [PMID: 38800322 PMCID: PMC11126783 DOI: 10.7759/cureus.58954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2024] [Indexed: 05/29/2024] Open
Abstract
Esophageal varices commonly affect cirrhotic patients as a result of elevated portal system resistance. Blood pools within esophageal portosystemic collateral vessels, which can eventually rupture, leading to life-threatening hemorrhage. To prevent this, cirrhotic patients without a history of varices undergo endoscopic surveillance for varices every 2-3 years. We present an unusual case of variceal hemorrhage in a patient who was seen to have no varices on endoscopic evaluation only a month earlier.
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Affiliation(s)
- Binyamin R Abramowitz
- Internal Medicine, State University of New York Downstate Health Sciences University, Brooklyn, USA
| | | | - Michelle Chen
- Internal Medicine, State University of New York Downstate Health Sciences University, Brooklyn, USA
| | - Suzette Graham-Hill
- Cardiology, State University of New York Downstate Health Sciences University, Brooklyn, USA
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Murillo Pineda MI, Siu Xiao T, Sanabria Herrera EJ, Ayala Aguilar A, Arriaga Escamilla D, Aleman Reyes AM, Rojas Marron AD, Fabila Lievano RR, de Jesús Correa Gomez JJ, Martinez Ramirez M. The Prediction and Treatment of Bleeding Esophageal Varices in the Artificial Intelligence Era: A Review. Cureus 2024; 16:e55786. [PMID: 38586705 PMCID: PMC10999134 DOI: 10.7759/cureus.55786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 04/09/2024] Open
Abstract
Esophageal varices (EVs), a significant complication of cirrhosis, present a considerable challenge in clinical practice due to their high risk of bleeding and associated morbidity and mortality. This manuscript explores the transformative role of artificial intelligence (AI) in the management of EV, particularly in enhancing diagnostic accuracy and predicting bleeding risks. It underscores the potential of AI in offering noninvasive, efficient alternatives to traditional diagnostic methods such as esophagogastroduodenoscopy (EGD). The complexity of EV management is highlighted, necessitating a multidisciplinary approach that includes pharmacological therapy, endoscopic interventions, and, in some cases, surgical options tailored to individual patient profiles. Additionally, the paper emphasizes the importance of integrating AI into medical education and practice, preparing healthcare professionals for the evolving landscape of medical technology. It projects a future where AI significantly influences the management of gastrointestinal bleeding, improving clinical decision-making, patient outcomes, and overall healthcare efficiency. The study advocates for a patient-centered approach in healthcare, balancing the incorporation of innovative technologies with ethical principles and the diverse needs of patients to optimize treatment efficacy and enhance healthcare accessibility.
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Affiliation(s)
| | - Tania Siu Xiao
- Radiology, Thomas Jefferson University Hospital, Philadelphia, USA
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Aggeletopoulou I, Tsounis EP, Kalafateli M, Michailidou M, Tsami M, Zisimopoulos K, Mandellou M, Diamantopoulou G, Kouskoura M, Michalaki M, Markopoulou CK, Thomopoulos K, Triantos C. Low Urinary Free Cortisol as a Risk Factor for Patients with Variceal Bleeding. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2112. [PMID: 38138215 PMCID: PMC10744924 DOI: 10.3390/medicina59122112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023]
Abstract
Background and Objectives: Specificity and reliability issues of the current cortisol assessment methods lead to limitations on the accurate assessment of relative adrenal insufficiency. Although free cortisol provides a more accurate evaluation of adrenal cortisol production, the expense and time-consuming nature of these assays make them impractical for routine use. Research has, thus, focused on alternative methods, such as indirectly measuring free cortisol using Coolens' equation or directly assessing salivary cortisol concentration, which is considered a more favorable approach despite associated challenges like sampling issues and infection risks. The aim of this study was to explore correlations between 24 h urinary free cortisol (UFC), free plasma cortisol, serum total cortisol, and salivary cortisol as potential reliable indices of free cortisol in the setting of variceal bleeding. Additionally, we assessed the predictive value of UFC for 6-week mortality and 5-day treatment failure in patients with liver cirrhosis and variceal bleeding. Materials and Methods: A total of 40 outpatients with liver cirrhosis and variceal bleeding were enrolled. Free cortisol levels in serum, saliva, and urine were assessed using the electrochemiluminescence immunoassay method. For the measurement of plasma-free cortisol, a single quadrupole mass spectrometer was employed. The quantification of free cortisol was fulfilled by analyzing the signal response in the negative ESI-MS mode. Results: UFC was significantly correlated to free plasma cortisol. Negative correlations were demonstrated between UFC, the Child-Pugh (CP) score, and C reactive protein (CRP) levels. In the multivariate analysis, CP stage C was associated with 6-week mortality risk and portal vein thrombosis with 5-day treatment failure using Cox regression and binary logistic regression analyses, respectively. Patients who experienced rebleeding, infection, or death (or any combination of these events) presented with lower levels of UFC. Conclusions: This study suggests that low levels of UFC may impose a risk factor for patients with liver cirrhosis and variceal bleeding. The use of UFC as an index of adrenal cortisol production in variceal bleeding warrants further investigation.
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Affiliation(s)
- Ioanna Aggeletopoulou
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
| | - Efthymios P. Tsounis
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
| | - Maria Kalafateli
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
| | - Maria Michailidou
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
| | - Maria Tsami
- Laboratory of Pharmaceutical Analysis, Department of Pharmaceutical Technology, School of Pharmacy, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (M.T.); (M.K.); (C.K.M.)
| | - Konstantinos Zisimopoulos
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
| | - Martha Mandellou
- Department of Biochemistry, University Hospital of Patras, 26504 Patras, Greece;
| | - Georgia Diamantopoulou
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
| | - Maria Kouskoura
- Laboratory of Pharmaceutical Analysis, Department of Pharmaceutical Technology, School of Pharmacy, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (M.T.); (M.K.); (C.K.M.)
| | - Marina Michalaki
- Division of Endocrinology, Diabetes and Metabolic Diseases, Department of Internal Medicine, University of Patras, 26504 Patras, Greece;
| | - Catherine K. Markopoulou
- Laboratory of Pharmaceutical Analysis, Department of Pharmaceutical Technology, School of Pharmacy, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (M.T.); (M.K.); (C.K.M.)
| | - Konstantinos Thomopoulos
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
| | - Christos Triantos
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
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Wei M, Chen Y, Wang M, Li J, Zeng Y, Sun X, Zhang A, Liu X, Zhou T, Gao Y. Partial splenic embolization combined with endoscopic therapies and vasoconstrictive drugs reduces rebleeding in cirrhosis patients with acute variceal bleeding and hypersplenism: a multicenter randomized controlled trial. J Gastroenterol 2023; 58:1144-1153. [PMID: 37486372 DOI: 10.1007/s00535-023-02027-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/14/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND This study aimed to compare the efficacy of partial splenic embolization (PSE) combined with endoscopic therapy and endoscopic therapy alone in cirrhosis patients with acute variceal bleeding (AVB) and hypersplenism. METHODS Cirrhosis patients with AVB who visited three hospitals from June 2016 to June 2022 were prospectively enrolled and randomly allocated to either the endoscopic therapy combined with PSE group (EP group) or the endoscopic intervention group (E group) in a 1:1 ratio. The primary endpoint of the study was re-bleeding of varices during follow-up, and the secondary endpoints were the recurrence of varices, death, and adverse events. RESULTS One hundred and fourteen patients were prospectively included, of whom 110 completed the trial. The risk of variceal re-bleeding (19.3% vs. 40.4% (23/57), p = 0.013) and variceal recurrence (28.1% vs. 63.2%, p < 0.001) five years after treatment was significantly lower in the EP group than in the E group, and the EP treatment was the only significant independent risk factor affecting variceal re-bleeding and variceal recurrence in patients. The mortality rate was comparable between the EP and E groups. Peripheral blood counts and liver function all improved significantly in the EP group compared to the E group during the follow-up (p < 0.05). CONCLUSIONS The rates of variceal re-bleeding and recurrence were significantly lower in cirrhosis patients with AVB and hypersplenism after combined endoscopic and PSE treatment compared to those who were provided endoscopic treatment only. The peripheral blood counts and liver function were also improved significantly in EP group (NCT02778425).
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Affiliation(s)
- Min Wei
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Yong Chen
- Department of Gastroenterology, Shandong Provincial Hospital, Jinan, Shandong, China
| | - Minghui Wang
- Department of Gastroenterology, The 960th Hospital of the Chinese People's Liberation Army, Jinan, Shandong, China
| | - Jinhou Li
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Department of Gastroenterology, Taian City Central Hospital, Taian, Shandong, China
| | - Yunqing Zeng
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Xin Sun
- Department of Gastroenterology, Central Hospital Affiliated of Shandong First Medical University, Jinan, Shandong, China
| | - Anzhong Zhang
- Department of Gastroenterology, Shandong Provincial Hospital, Jinan, Shandong, China
| | - Xiaofeng Liu
- Department of Gastroenterology, The 960th Hospital of the Chinese People's Liberation Army, Jinan, Shandong, China
| | - Tao Zhou
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Jinan, Shandong, China.
- Key Laboratory of Cardiovascular Proteomics of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China.
| | - Yanjing Gao
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong, China.
- The Institute of Portal Hypertension, Shandong University, Jinan, Shandong, China.
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Pallio S, Melita G, Shahini E, Vitello A, Sinagra E, Lattanzi B, Facciorusso A, Ramai D, Maida M. Diagnosis and Management of Esophagogastric Varices. Diagnostics (Basel) 2023; 13:diagnostics13061031. [PMID: 36980343 PMCID: PMC10047815 DOI: 10.3390/diagnostics13061031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/03/2023] [Accepted: 03/04/2023] [Indexed: 03/30/2023] Open
Abstract
Acute variceal bleeding (AVB) is a potentially fatal complication of clinically significant portal hypertension and is one of the most common causes of acute upper gastrointestinal bleeding. Thus, esophagogastric varices represent a major economic and population health issue. Patients with advanced chronic liver disease typically undergo an upper endoscopy to screen for esophagogastric varices. However, upper endoscopy is not recommended for patients with liver stiffness < 20 KPa and platelet count > 150 × 109/L as there is a low probability of high-risk varices. Patients with high-risk varices should receive primary prophylaxis with either nonselective beta-blockers or endoscopic band ligation. In cases of AVB, patients should receive upper endoscopy within 12 h after resuscitation and hemodynamic stability, whereas endoscopy should be performed as soon as possible if patients are unstable. In cases of suspected variceal bleeding, starting vasoactive therapy as soon as possible in combination with endoscopic treatment is recommended. On the other hand, in cases of uncontrolled bleeding, balloon tamponade or self-expandable metal stents can be used as a bridge to more definitive therapy such as transjugular intrahepatic portosystemic shunt. This article aims to offer a comprehensive review of recommendations from international guidelines as well as recent updates on the management of esophagogastric varices.
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Affiliation(s)
- Socrate Pallio
- Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy
| | - Giuseppinella Melita
- Human Pathology of Adult and Child Department, University of Messina, 98100 Messina, Italy
| | - Endrit Shahini
- Gastroenterology Unit, National Institute of Gastroenterology "S. de Bellis" Research Hospital, Castellana Grotte, 70013 Bari, Italy
| | - Alessandro Vitello
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, 93100 Caltanissetta, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Instituto San Raffaele Giglio, 90015 Cefalù, Italy
| | - Barbara Lattanzi
- Gastroenterology and Emergency Endoscopy Unit, Sandro Pertini Hospital, 00100 Rome, Italy
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, 00161 Foggia, Italy
| | - Daryl Ramai
- Gastroenterology & Hepatology, University of Utah Health, Salt Lake City, UT 84132, USA
| | - Marcello Maida
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, 93100 Caltanissetta, Italy
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Zhang Q, Niu S, Yang L, Zhu B, Shi K, Zhang X, Zhang Y, Bi Y, Mu Y, Wang X. A novel prognostic model for predicting the risk of first variceal hemorrhage in patients with HBV-related cirrhosis. Front Cell Infect Microbiol 2023; 13:1062172. [PMID: 36733609 PMCID: PMC9886685 DOI: 10.3389/fcimb.2023.1062172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 01/03/2023] [Indexed: 01/18/2023] Open
Abstract
Background Variceal hemorrhage (VH) is a life-threatening complication of cirrhosis. An accurate VH risk evaluation is critical to determine appropriate prevention strategies. We aimed to develop an individualized prediction model to predict the risk of first VH in hepatitis B virus (HBV)-related cirrhotic patients. Methods A nomogram was developed based on a retrospective analysis of 527 consecutive HBV-related cirrhotic patients with gastroesophageal varices (GEVs). The nomogram evaluation was performed using the area under the receiver operating characteristic curve (AUC), concordance index (C-index), calibration plot, and decision curve analysis (DCA). The results were verified using an external cohort (n = 187). Results We developed a nomogram based on clinical and endoscopic features, including the size of varices, red wale marks, ascites, spleen thickness, γ-glutamyltransferase, and hematocrit. The C-index of the nomogram in the derivation and validation cohort was 0.806 and 0.820, respectively, and the calibration plot fitted well. Compared with those of the North Italian Endoscopic Club (NIEC) and revised NIEC indexes, the AUC (derivation cohort: 0.822 vs. 0.653 vs. 0.713; validation cohort: 0.846 vs. 0.685 vs. 0.747) and DCA curves of this nomogram were better. Further, based on the risk scores, patients were classified into low-, medium-, and high-risk groups, and significant differences were noted in VH incidence among the three risk groups (P <0.001 for each cohort). Conclusions An effective individualized nomogram to predict the risk of first VH in HBV-related GEV patients was established, which can assist clinicians in developing more appropriate prevention strategies.
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Affiliation(s)
- Qun Zhang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Shuaishuai Niu
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Li Yang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Bingbing Zhu
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Ke Shi
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Xiaohua Zhang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yi Zhang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yufei Bi
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yongping Mu
- Institute of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China,*Correspondence: Xianbo Wang, ; Yongping Mu,
| | - Xianbo Wang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China,*Correspondence: Xianbo Wang, ; Yongping Mu,
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10
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Wang J, Wang Z, Chen M, Xiao Y, Chen S, Wu L, Yao L, Jiang X, Li J, Xu M, Lin M, Zhu Y, Luo R, Zhang C, Li X, Yu H. An interpretable artificial intelligence system for detecting risk factors of gastroesophageal variceal bleeding. NPJ Digit Med 2022; 5:183. [PMID: 36536039 PMCID: PMC9763258 DOI: 10.1038/s41746-022-00729-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
Bleeding risk factors for gastroesophageal varices (GEV) detected by endoscopy in cirrhotic patients determine the prophylactical treatment patients will undergo in the following 2 years. We propose a methodology for measuring the risk factors. We create an artificial intelligence system (ENDOANGEL-GEV) containing six models to segment GEV and to classify the grades (grades 1-3) and red color signs (RC, RC0-RC3) of varices. It also summarizes changes in the above results with region in real time. ENDOANGEL-GEV is trained using 6034 images from 1156 cirrhotic patients across three hospitals (dataset 1) and validated on multicenter datasets with 11009 images from 141 videos (dataset 2) and in a prospective study recruiting 161 cirrhotic patients from Renmin Hospital of Wuhan University (dataset 3). In dataset 1, ENDOANGEL-GEV achieves intersection over union values of 0.8087 for segmenting esophageal varices and 0.8141 for gastric varices. In dataset 2, the system maintains fairly accuracy across images from three hospitals. In dataset 3, ENDOANGEL-GEV surpasses attended endoscopists in detecting RC of GEV and classifying grades (p < 0.001). When ranking the risk of patients combined with the Child‒Pugh score, ENDOANGEL-GEV outperforms endoscopists for esophageal varices (p < 0.001) and shows comparable performance for gastric varices (p = 0.152). Compared with endoscopists, ENDOANGEL-GEV may help 12.31% (16/130) more patients receive the right intervention. We establish an interpretable system for the endoscopic diagnosis and risk stratification of GEV. It will assist in detecting the first bleeding risk factors accurately and expanding the scope of quantitative measurement of diseases.
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Affiliation(s)
- Jing Wang
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zhengqiang Wang
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Mingkai Chen
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yong Xiao
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Shi Chen
- Department of Gastroenterology, Wuhan Puren Hospital, Wuhan, China
| | - Lianlian Wu
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Liwen Yao
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiaoda Jiang
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jiao Li
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Ming Xu
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Mengjuan Lin
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yijie Zhu
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Renquan Luo
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Chenxia Zhang
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xun Li
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Honggang Yu
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
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11
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Sohal A, Chaudhry H, Dhaliwal A, Singla P, Gupta G, Sharma R, Dukovic D, Prajapati D. Gender differences in esophageal variceal bleeding in the United States. Ann Med 2022; 54:2115-2122. [PMID: 35930410 PMCID: PMC9359179 DOI: 10.1080/07853890.2022.2104920] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND AIMS Esophageal variceal bleeding is a common reason for hospitalization in patients with cirrhosis. The main objective of this study was to analyze the effects of gender differences on outcomes in hospitalizations related to Esophageal variceal bleeding in the United States. METHODS A retrospective observational cohort study was performed using the National Inpatient Sample (NIS) database for all hospitalizations with a discharge diagnosis of esophageal varices with hemorrhage from 2016 to 2019. The primary outcome was in-hospital mortality, while secondary outcomes included rate of early endoscopy (defined as less than 1 day), AKI, blood transfusion, sepsis, ICU admission and TIPS (Transjugular Intrahepatic Portosystemic Shunt). We also compared the length of stay and total hospitalization charges. RESULTS We identified a total of 166,760 patients with variceal bleeding of which 32.7% were females. In-hospital mortality was higher in males, 9.91%, compared to females, 8.31% (adjusted odds ratio (aOR): 0.88, p-value=.008, when adjusted for confounding factors). The odds of undergoing an EGD, length of stay, or total hospitalization charges did not differ between the two groups. Compared to men, women had lower odds of receiving TIPS (aOR = 0.83, p-value=.002). CONCLUSION Women hospitalised with esophageal variceal bleeding are at a lower risk of death compared to males. Further research is needed to elucidate the factors associated with this lower risk.
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Affiliation(s)
- Aalam Sohal
- Department of Internal Medicine, University of California, Fresno, CA, USA
| | - Hunza Chaudhry
- Department of Internal Medicine, University of California, Fresno, CA, USA
| | - Armaan Dhaliwal
- Department of Internal Medicine, University of Arizona, South Campus-Tucson, AZ, USA
| | - Piyush Singla
- Dayanand Medical College and Hospital, Punjab, India
| | - Gagan Gupta
- Dayanand Medical College and Hospital, Punjab, India
| | | | - Dino Dukovic
- Ross University School of Medicine, Bridgetown, Barbados
| | - Devang Prajapati
- Department of Gastroenterology and Hepatology, University of California, Fresno, CA, USA
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12
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El Sheref SEDM, Afify S, Berengy MS. Clinical characteristics and predictors of esophagogastric variceal bleeding among patients with HCV-induced liver cirrhosis: An observational comparative study. PLoS One 2022; 17:e0275373. [PMID: 36227871 PMCID: PMC9560135 DOI: 10.1371/journal.pone.0275373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 09/15/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES To investigate the clinical characteristics, risk factors, and predictors of esophagogastric variceal bleeding in patients with hepatitis C virus (HCV)-induced liver cirrhosis. METHODS This comparative observational study was carried out on 100 patients suffering from post hepatitis cirrhosis and portal hypertension who were admitted to the Internal Medicine Department, Al-Azhar University Hospital, Damietta Egypt. Patients were classified into two groups: 50 of them presented with esophagogastric varices with acute variceal bleeding, and 50 patients presented without bleeding. Data were collected, coded, revised, and entered into the Stata software version 16. RESULTS The mean age of patients with bleeding was slightly higher than those without bleeding (55.58 ± 5.89 vs. 52.54 ± 9.01 years), p = 0.049. Mild ascites, positive H.Pylori, and Child-Pugh score B and C were an independent predictors of esophagogastric variceal bleeding (OR = 0.036, 95% CI: 0.0004-0.36; p = 0.005), (OR = 7.36, 95% CI: 1.44-37.59; p = 0.016), (OR = 19.0, 95% CI: 2.02-186.3; p = 0.010), and (OR = 40.51, 95% CI: 2.18-751.31; p = 0.013). The sensitivity of this model was 93.88%, specificity was 53.85%, PPV was 88.46%, NPV was 70.0%, correctly classified patients were 85.48%, and AUC was 90.27%. In the second model, pepsinogen level higher than 43.5 μg/l, AST (>54.5), Bilirubin (>1.45), and Hemoglobin (>11.5) were a significant independent predictors of esophagogastric variceal bleeding (OR = 1.18, 95% CI: 1.09-1.27; p<0.001), (OR = 1.14, 95% CI: 1.03-1.27; p = 0.007), (OR = 5.55, 95% CI: 1.21-25.43; p = 0.027), and (OR = 0.05, 95% CI: 0.008-0.32; p = 0.002), respectively. The sensitivity of this model was 92%, specificity was 98%, PPV was 97.87%, NPV was 92.45%, correctly classified patients were 95%, and AUC was 98.68%. CONCLUSION The independent predictors of esophagogastric variceal bleeding were ascites, positive H. pylori, Child-Pugh score B and C, pepsinogen level higher than 43.5 μg/l, AST (>54.5), bilirubin (>1.45), and hemoglobin (>11.5). Laboratory investigations are more reliable in predicting variceal bleeding and excluding non-variceal bleeding; however, clinical symptoms should not be neglected, especially H. pylori infection, ascites, and Child-Pugh score.
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Affiliation(s)
| | - Shimaa Afify
- Gastroenterology Department, National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | - Mahmoud S. Berengy
- Internal Medicine Department, Faculty of Medicine, Al-Azhar University Hospital, New Damietta, Egypt
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13
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Kim TE, Kang JS, An W, Sohn JH. Systemic exposure to propranolol in patients with chronic liver disease and its correlation with portal blood flow. Front Med (Lausanne) 2022; 9:973606. [PMID: 36213672 PMCID: PMC9533297 DOI: 10.3389/fmed.2022.973606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Propranolol is a beta-blocker used for the prevention of variceal bleeding in cirrhotic patients. We investigated the pharmacokinetics of propranolol in patients with chronic liver disease compared to that in healthy individuals. The relative amount of portal blood flow was measured to investigate the correlation of portal blood flow and the systemic exposure of propranolol. Thirty healthy subjects, 18 patients with chronic active hepatitis (CAH), and 54 patients with cirrhosis were included in this prospective study. Blood samples for pharmacokinetic analysis were taken up to 8 h post-dose. The portal blood flow was estimated by H/L ratio using thallium-201 (201TI) per rectal scintigraphy. A total of 78 subjects completed the study. The area under the concentration-time curve (AUC) to the last measurable time (AUClast, ng⋅h/mL) were 150.2 ± 154.1, 112.2 ± 84.7, and 204.0 ± 137.3 in healthy subjects, CAH patients, and cirrhosis patients, respectively. AUCrmlast showed positive correlation with the H/L ratio in patients with chronic liver disease (r = 0.5817, p < 0.0001). In conclusion, the patients with cirrhosis showed higher systemic exposure to propranolol than healthy subjects or patients with CAH. The increase in systemic exposure to propranolol was correlated with the decrease in portal blood flow.
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Affiliation(s)
- Tae-Eun Kim
- Department of Clinical Pharmacology, Konkuk University Medical Center, Seoul, South Korea
| | - Ju-Seop Kang
- Department of Pharmacology and Clinical Pharmacology, College of Medicine, Hanyang University, Seoul, South Korea
- *Correspondence: Ju-Seop Kang,
| | - Wen An
- Department of Pharmacology and Clinical Pharmacology, College of Medicine, Hanyang University, Seoul, South Korea
| | - Joo Hyun Sohn
- Department of Internal Medicine (Gastroenterology), Hanyang University College of Medicine, Seoul, South Korea
- Hanyang University Guri Hospital, Guri-si, South Korea
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14
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Efficient Initial Eradication of Large Esophageal Varices by Balloon-compression Endoscopic Injection Sclerotherapy. SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2022; 32:571-576. [PMID: 36044334 DOI: 10.1097/sle.0000000000001092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 06/08/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The management of large esophageal varices (EVs) remains challenging because of the difficulty of endoscopic variceal ligation and fatal post-endoscopic variceal ligation bleeding ulcers. The current study evaluated the efficacy and safety of balloon-compression endoscopic injection sclerotherapy (bc-EIS) in the treatment of large EVs. MATERIALS AND METHODS This retrospective study included 105 patients with cirrhosis exhibiting large EVs (64 in the bc-EIS group and 41 in the EIS group). Primary outcomes included the initial rate of variceal eradication and intraoperative bleeding signs. Secondary outcomes included incidences of rebleeding, mortality, complications, and optimal time of balloon-compression (bc). RESULTS The initial rate of variceal eradication in the bc-EIS group was significantly higher than that in the EIS group (46.9 vs. 24.4%; P=0.021). The incidence of intraoperative bleeding, which was represented as oozing and spurting, in the bc-EIS group was markedly lower than that in the EIS group (43.8 vs. 61.0% and 9.4 vs. 39.0%, respectively; P=0.043). Patients in the bc-EIS group showed a significantly lower incidence of rebleeding (0.0 vs. 17.1%; P=0.001). However, no significant difference in mortality rate was observed between different groups. Chest pain or discomfort tended to be more common in the EIS group than in the bc-EIS group (58.5 vs. 17.2%; P=0.001). The cut-off value of 11.5-minutes appeared to have a maximum combined sensitivity and specificity of 80.0% and 58.8%, respectively. The area under the curve was 0.708 (95% confidence interval =0.576-0.839; P=0.004). CONCLUSION bc-EIS could achieve a higher variceal eradication rate and milder intraoperative bleeding signs in large EVs. Furthermore, 11.5-minutes appeared to be the optimal compression time in bc-EIS.
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15
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Practical Strategies Related to the Application of Balloon Tamponade Therapy in Acute Variceal Bleeding. Crit Care Explor 2022; 4:e0748. [PMID: 35982839 PMCID: PMC9380694 DOI: 10.1097/cce.0000000000000748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
IMPORTANCE: Acute gastrointestinal variceal hemorrhage is a major cause of morbidity and mortality in cirrhotic liver disease. Approximately one-third of cirrhotic patients will have variceal hemorrhage, and each bleeding episode is associated with up to 20% mortality. Balloon tamponade devices are used to achieve temporary hemostasis of bleeding esophagogastric varices and as a bridge to definitive therapy. Rapid and proper placement is crucial in a life-threatening bleed both to improve patient’s chances of survival and minimize procedural complications. Passage of the tube can be complicated by coiling in the oropharynx or mid-esophagus particularly if an endotracheal tube is in place or the patient has large variceal burden. Endoscopic placement can be a useful adjunct but may not be readily accessible depending on resources and availability of specialists. Here, we describe a technique of balloon tamponade placement using a stiffening guidewire to overcome this challenge. OBJECTIVES: The objectives were to: 1) describe the guidewire method for balloon tamponade tube placement and 2) highlight proof of concept through clinical application. DESIGN: We conducted a retrospective case series of patients treated with balloon tamponade using the guidewire method. SETTING AND PARTICIPANTS: This study was done at a single-center quaternary-care facility. Patients admitted to the surgical ICU and treated with a balloon tamponade device for acute variceal hemorrhage were included. MAIN OUTCOMES AND MEASURES: Patient characteristics were assessed including age, sex, model for end stage liver disease score, etiology of cirrhosis, and definitive treatment received. RESULTS: Nine patients were included in the final analysis. Mean age was 50 ± 19, and mean model for end stage liver disease was 39 ± 8. Alcohol cirrhosis was the most common cause of cirrhosis in this sample (n = 5). Six patients were able to be bridged to definitive treatment. CONCLUSIONS AND RELEVANCE: Guidewire-assisted balloon tamponade placement is practical, is effective, and can be performed by acute care providers.
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Biswas S, Vaishnav M, Pathak P, Gunjan D, Mahapatra SJ, Kedia S, Rout G, Thakur B, Nayak B, Kumar R. Effect of thrombocytopenia and platelet transfusion on outcomes of acute variceal bleeding in patients with chronic liver disease. World J Hepatol 2022; 14:1421-1437. [PMID: 36158909 PMCID: PMC9376768 DOI: 10.4254/wjh.v14.i7.1421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/13/2022] [Accepted: 07/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Platelet transfusion in acute variceal bleeding (AVB) is recommended by few guidelines and is common in routine clinical practice, even though the effect of thrombocytopenia and platelet transfusion on the outcomes of AVB is unclear.
AIM To determine how platelet counts, platelets transfusions, and fresh frozen plasma transfusions affect the outcomes of AVB in cirrhosis patients in terms of bleeding control, rebleeding, and mortality.
METHODS Prospectively maintained database was used to analyze the outcomes of cirrhosis patients who presented with AVB. The outcomes were assessed as the risk of rebleeding at days 5 and 42, and risk of death at day 42, considering the platelet counts and platelet transfusion. Propensity score matching (PSM) was used to compare the outcomes in those who received platelet transfusion. Statistical comparisons were done using Kaplan-Meier curves with log-rank tests and Cox-proportional hazard model for rebleeding and for 42-d mortality.
RESULTS The study included 913 patients, with 83.5% men, median age 45 years, and Model for End-stage Liver Disease score 14.7. Platelet count < 20 × 109/L, 20-50 × 109/L, and > 50 × 109/L were found in 23 (2.5%), 168 (18.4%), and 722 (79.1%) patients, respectively. Rebleeding rates were similar between the three platelet groups on days 5 and 42 (13%, 6.5%, and 4.7%, respectively, on days 5, P = 0.150; and 21.7%, 17.3%, and 14.4%, respectively, on days 42, P = 0.433). At day 42, the mortality rates for the three platelet groups were also similar (13.0%, 23.2%, and 17.2%, respectively, P = 0.153). On PSM analysis patients receiving platelets transfusions (n = 89) had significantly higher rebleeding rates on day 5 (14.6% vs 4.5%; P = 0.039) and day 42 (32.6% vs 15.7%; P = 0.014), compared to those who didn't. The mortality rates were also higher among patients receiving platelets (25.8% vs 23.6%; P = 0.862), although the difference was not significant. On multivariate analysis, platelet transfusion and not platelet count, was independently associated with 42-d rebleeding. Hepatic encephalopathy was independently associated with 42-d mortality.
CONCLUSION Thrombocytopenia had no effect on rebleeding rates or mortality in cirrhosis patients with AVB; however, platelet transfusion increased rebleeding on days 5 and 42, with a higher but non-significant effect on mortality.
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Affiliation(s)
- Sagnik Biswas
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| | - Manas Vaishnav
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| | - Piyush Pathak
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| | - Soumya Jagannath Mahapatra
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| | - Gyanranjan Rout
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| | - Bhaskar Thakur
- Division of Biostatistics, UT Southwestern Medical Center, Dallas, Texas 75390, United States
| | - Baibaswata Nayak
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 800014, Bihar, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
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17
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Bayani A, Hosseini A, Asadi F, Hatami B, Kavousi K, Aria M, Zali MR. Identifying predictors of varices grading in patients with cirrhosis using ensemble learning. Clin Chem Lab Med 2022; 60:1938-1945. [DOI: 10.1515/cclm-2022-0508] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 06/28/2022] [Indexed: 12/15/2022]
Abstract
Abstract
Objectives
The present study was conducted to improve the performance of predictive methods by introducing the most important factors which have the highest effects on the prediction of esophageal varices (EV) grades among patients with cirrhosis.
Methods
In the present study, the ensemble learning methods, including Catboost and XGB classifier, were used to choose the most potent predictors of EV grades solely based on routine laboratory and clinical data, a dataset of 490 patients with cirrhosis gathered. To increase the validity of the results, a five-fold cross-validation method was applied. The model was conducted using python language, Anaconda open-source platform. TRIPOD checklist for prediction model development was completed.
Results
The Catboost model predicted all the targets correctly with 100% precision. However, the XGB classifier had the best performance for predicting grades 0 and 1, and totally the accuracy was 91.02%. The most significant variables, according to the best performing model, which was CatBoost, were child score, white blood cell (WBC), vitalism K (K), and international normalized ratio (INR).
Conclusions
Using machine learning models, especially ensemble learning models, can remarkably increase the prediction performance. The models allow practitioners to predict EV risk at any clinical visit and decrease unneeded esophagogastroduodenoscopy (EGD) and consequently reduce morbidity, mortality, and cost of the long-term follow-ups for patients with cirrhosis.
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Affiliation(s)
- Azadeh Bayani
- Department of Health Information Technology and Management, School of Allied Medical Sciences , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Azamossadat Hosseini
- Department of Health Information Technology and Management, School of Allied Medical Sciences , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Farkhondeh Asadi
- Department of Health Information Technology and Management, School of Allied Medical Sciences , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Behzad Hatami
- Gastroenterology and Liver Diseases Research Center , Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Kaveh Kavousi
- Laboratory of Complex Biological Systems and Bioinformatics (CBB), Department of Bioinformatics , Institute of Biochemistry and Biophysics (IBB), University of Tehran , Tehran , Iran
| | - Mehrdad Aria
- Department of Computer Engineering, Faculty of Electrical and Computer Engineering , Shiraz University , Shiraz , Iran
| | - Mohammad Reza Zali
- Gastroenterology and Liver Diseases Research Center , Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences , Tehran , Iran
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18
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Liu H, Zhang Q, Gao F, Yu H, Jiang Y, Wang X. Platelet Count/Spleen Thickness Ratio and the Risk of Variceal Bleeding in Cirrhosis With Esophagogastric Varices. Front Med (Lausanne) 2022; 9:870351. [PMID: 35911391 PMCID: PMC9329511 DOI: 10.3389/fmed.2022.870351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/10/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionThe platelet count/spleen thickness ratio (PC/ST ratio) is associated with the grade of esophagogastric varices (EGV) in cirrhotic patients, but little is known about its relationship with esophagogastric variceal bleeding (EGVB). The aim of this study was to investigate the association between the PC/ST ratio and the risk of EGVB within 1 year in cirrhotic patients.MethodsA total of 1,354 patients with cirrhosis who had EGV were enrolled in this cohort study. A logistic regression model was used to determine the association between the PC/ST ratio and the risk of EGVB within 1 year in patients with cirrhosis by adjusting the PC/ST ratio with all the important clinical variables and confounders.ResultsThe quartile values of the PC/ST ratio were 1.01, 1.36, and 1.98, respectively. The PC/ST ratio was an independent risk factor for variceal bleeding in cirrhotic patients with moderate or severe EGV. After adjusting for multiple variables, the relationship was still unchanged. The odds ratios of the first EGVB in these patients were 5.07-fold at non-adjustment and 3.28-fold after multivariate adjustment. The odds ratios of rebleeding in these patients from the lowest to the highest quartile were 2.34-fold at non-adjustment and 2.01-fold after multivariable adjustment. The PC/ST ratio ≤ 1.36 elevated the 1-year risk of first-time variceal bleeding or rebleeding in cirrhotic patients with moderate or severe EGV (All P < 0.05).ConclusionThe PC/ST ratio ≤ 1.36 is an independent risk factor for the onset of first bleeding or rebleeding in cirrhotic patients with moderate or severe EGV.
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Affiliation(s)
- Huimin Liu
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
- Department of Traditional Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Qun Zhang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Fangyuan Gao
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Hao Yu
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yuyong Jiang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
- *Correspondence: Yuyong Jiang,
| | - Xianbo Wang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
- Xianbo Wang,
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19
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Abstract
Acute variceal bleeding is a complication of portal hypertension, usually due to cirrhosis, with high morbidity and mortality. There are 3 scenarios for endoscopic treatment of esophageal varices: prevention of first variceal bleed, treatment of active variceal bleed, and prevention of rebleeding. Patients with cirrhosis should be screened for esophageal varices. Recommended endoscopic therapy for acute variceal bleeding is endoscopic variceal banding. Although banding is the first-choice treatment, sclerotherapy may have a role. Treatment with Sengstaken-Blakemore tube or self-expanding covered metallic esophageal stent can be used for acute variceal bleeding refractory to standard pharmacologic and endoscopic therapy.
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Affiliation(s)
- Marc J Zuckerman
- Division of Gastroenterology and Hepatology, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, TX 79905, USA.
| | - Sherif Elhanafi
- Division of Gastroenterology and Hepatology, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, TX 79905, USA
| | - Antonio Mendoza Ladd
- Division of Gastroenterology and Hepatology, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, TX 79905, USA
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20
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El Shazli LB, Ragab DA, Abdelhady KA, Abdelaziz AW. Role of plasma von Willebrand factor antigen in prediction of esophageal varices in pediatric and adolescent patients with portal hypertension. EGYPTIAN LIVER JOURNAL 2021. [DOI: 10.1186/s43066-021-00159-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Ruptured esophageal varices (EVs) are a leading cause of death in Portal hypertension (PHT), it has been a big concern of research to screen EVs through non-invasive approaches. This study aimed to evaluate the role of plasma von Willebrand factor antigen (VWF-Ag) assay for early detection of EVs in patients with portal hypertension. This was a cross-sectional study, done on 47 portal hypertensive children and adolescents who were collected from the Pediatrics Hepatology Clinic, Children Hospital, Ain Shams University. All patients were subjected to comprehensive history taking, thorough clinical examination, routine investigations, abdominal ultrasound, upper GI endoscopy, and measurement of plasma VWF-Ag level. The patients were divided based on their endoscopic findings into two groups; a varices group which included 37 patients, and a non-varices group which included 10 patients.
Results
VWF-Ag rise significantly in patients with EVs, revealing a direct positive association with the degree of EVs.
Conclusion
The plasma VWF-Ag can be applied as a non-invasive evidence of the presence and grading of EVs.
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21
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Yu SY, Wang WH, Xu L. Clip-Assisted Endoscopic Cyanoacrylate Injection: A Novel Technique for Acute Gastroesophageal Variceal Bleeding. J Laparoendosc Adv Surg Tech A 2021. [PMID: 34748420 DOI: 10.1089/lap.2021.0377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background and Aim: Endoscopic injection sclerotherapy is effective for the treatment of gastric variceal bleeding, but may cause fatal ectopic embolism. Spontaneous portosystemic shunts are one of the risk factors for ectopic embolism. This present study aims to evaluate the efficacy and safety of clip-assisted endoscopic cyanoacrylate injection for the treatment of acute gastroesophageal variceal bleeding. Methods: The medical records of patients with gastroesophageal varices (GOVs) who underwent clip-assisted cyanoacrylate injection at the Ningbo First Hospital from March 2017 to August 2020 were reviewed. The outcomes were immediate hemostasis rate, early rebleeding rate, late rebleeding rate, and procedure-related complications. The gastrorenal and splenorenal shunts were evaluated by the computed tomography angiography. Results: A total of 9 patients with GOVs (GOV1 and GOV2) were analyzed, and 4 of the patients had spontaneous portosystemic shunts. The average number of clips used in each patient was 2.11 ± 1.96, and an average of 5.11 ± 1.76 mL of cyanoacrylate was injected into each patient. All patients completed immediate hemostasis. Two patients experienced rebleeding, including 1 case of early rebleeding and 1 case of late rebleeding (both due to cyanoacrylate extrusion) during a median follow-up of 367 days (interquartile range 270-855 days). Five patients underwent follow-up endoscopy; eradicated gastric varices (GVs) were revealed in 1 patient, and shrunken GVs were found in 4 patients. No serious complications, including ectopic embolism, were observed. Conclusion: The present study showed the efficacy and safety of clip-assisted endoscopic cyanoacrylate injection in acute GOV bleeding, but these results require verification by randomized controlled studies with larger sample numbers.
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Affiliation(s)
- Si-Yi Yu
- Department of Gastroenterology, Ningbo First Hospital, Ningbo, China
| | - Wei-Hong Wang
- Department of Gastroenterology, Ningbo First Hospital, Ningbo, China
| | - Lei Xu
- Department of Gastroenterology, Ningbo First Hospital, Ningbo, China
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22
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Bouzbib C, Cluzel P, Sultanik P, Bernard-Chabert B, Massard J, Benosman H, Mallet M, Tripon S, Conti F, Thabut D, Rudler M. Prognosis of patients undergoing salvage TIPS is still poor in the preemptive TIPS era. Clin Res Hepatol Gastroenterol 2021; 45:101593. [PMID: 33667917 DOI: 10.1016/j.clinre.2020.101593] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/19/2020] [Accepted: 12/02/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Salvage transjugular intrahepatic portosystemic shunts (TIPS) are associated with poor prognosis, especially in patients with Child-Pugh C cirrhosis. Since preemptive TIPS improved prophylaxis of variceal bleeding in those patients, recourse to salvage TIPS may now affect patients with a better prognosis. AIM To assess the impact of the preemptive TIPS policy on outcomes after salvage TIPS placement. METHODS We conducted a retrospective monocentric study on cirrhotic patients undergoing salvage TIPS with polytetrafluoroethylene-covered stents from 2002 to 2017 (period 1 until February 2011; period 2 after the preemptive TIPS policy in March 2011). The primary endpoint was one-year transplant-free survival. RESULTS We included 106 patients (period 1/2 = 53/53 patients, male gender 82%, age 54 ± 9 years, alcoholic cirrhosis 70%, Child-Pugh score B/C 94%). One-year transplant-free survival was 46.0% during period 1 compared to 40.2% during period 2 (p = 0.65). Amongst 61 patients with history of variceal bleeding, 32 (52.5%) had an inadequate secondary prophylaxis, including 19 (59.4%) with a previous indication of preemptive TIPS. One-year transplant-free survival was 33.2% if inadequate secondary prophylaxis vs 65.2% if adequate (p = 0.008). Independent factors associated with survival were a lower Child-Pugh or MELD score, infection, failure to control bleeding, and hepatic encephalopathy after TIPS. CONCLUSION Prognosis after salvage TIPS remained poor in our series. Optimizing secondary prophylaxis, including preemptive TIPS placement, should be the main concern to improve prognosis.
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Affiliation(s)
- Charlotte Bouzbib
- Hepatology Intensive Care Unit, Hepatology Department, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Philippe Cluzel
- Sorbonne Universities, UPMC University Paris 06, AP-HP, Pitié-Salpêtrière Hospital, F-75013 Paris, France; Interventional Radiology Unit, Radiology Department, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Philippe Sultanik
- Hepatology Intensive Care Unit, Hepatology Department, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Brigitte Bernard-Chabert
- Hepatology Intensive Care Unit, Hepatology Department, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Julien Massard
- Hepatology Intensive Care Unit, Hepatology Department, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Hedi Benosman
- Hepatology Intensive Care Unit, Hepatology Department, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Maxime Mallet
- Hepatology Intensive Care Unit, Hepatology Department, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Simona Tripon
- Hepatology Intensive Care Unit, Hepatology Department, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Filomena Conti
- Liver Transplantation Unit, Hepatology Department, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital 75013, Paris, France
| | - Dominique Thabut
- Hepatology Intensive Care Unit, Hepatology Department, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75013 Paris, France; Sorbonne Universities, UPMC University Paris 06, AP-HP, Pitié-Salpêtrière Hospital, F-75013 Paris, France
| | - Marika Rudler
- Hepatology Intensive Care Unit, Hepatology Department, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75013 Paris, France.
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23
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Acute variceal bleeding and out-of-hours endoscopy: Evaluation of an emergency care setting according to Baveno VI guidelines adherence. Dig Liver Dis 2021; 53:1320-1326. [PMID: 34348881 DOI: 10.1016/j.dld.2021.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The extent to which patients with acute variceal bleeding (AVB) receive recommended care is largely unknown. AIM to evaluate the adherence of the 4 major Baveno VI recommendations [vasoactive agents, prophylactic antibiotic, esophagogastroduodenoscopy (EGD) within 12 hours, endoscopic variceal ligation (EVL)] as a marker of quality of an emergency model. METHODS Retrospective evaluation of AVB admissions to a tertiary centre in which endoscopy was available 24hours-a-day, with a regional out-of-hours service at night (the furthest hospital is 200Km away). Patients were divided in directly admitted or transferred from other centres. RESULTS 210 AVB patients were included; 101 (48.1%) were directly admitted. The majority of patients were submitted to vasoactive agents (85.7%) and prophylactic antibiotics (79%) before EGD. In 178 patients (84.8%) endoscopy was performed within 12h and EVL was the procedure of choice in 116 (74.8%) (only oesophageal varices). No significant differences were observed between directly admitted and transferred patients in adherence rates. Overall rebleeding rate was 8.6%, in-hospital mortality 11.4% and 6-week mortality 20%. CONCLUSION Adherence to quality metrics was high which might have played a vital role for reported outcomes. These results suggest that this model of care, provides accessibility and equity in access to urgent endoscopy.
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24
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Park MK, Lee YB. [Diagnosis and Management of Esophageal and Gastric Variceal Bleeding: Focused on 2019 KASL Clinical Practice Guidelines for Liver Cirrhosis]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 78:152-160. [PMID: 34565784 DOI: 10.4166/kjg.2021.113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 12/14/2022]
Abstract
Varices are a frequent complication of liver cirrhosis and a major cause of mortality in patients with liver cirrhosis. Patients with decompensated cirrhosis complications have a poor prognosis and require careful management. Portal hypertension is the most common complication of liver cirrhosis, which is the key determinant for varices development. Increased intrahepatic vascular resistance to portal flow leads to the development of portal hypertension. Collateral vessels develop at the communication site between the systemic and portal circulation with the progression of portal hypertension. Varices are the representative collaterals, develop gradually with the progression of portal hypertension and may eventually rupture. Variceal bleeding is a major consequence of portal hypertension and causes the death of cirrhotic patients. The present paper reviews the latest knowledge regarding the diagnosis and management of esophageal and gastric variceal bleeding.
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Affiliation(s)
- Min Kyung Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yun Bin Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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25
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Ma JL, He LL, Li P, Jiang L, Wei HS. Prognosis of endotherapy versus splenectomy and devascularization for variceal bleeding in patients with hepatitis B-related cirrhosis. Surg Endosc 2021; 35:2620-2628. [PMID: 32504262 DOI: 10.1007/s00464-020-07682-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 05/27/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE This study aimed to compare the long-term outcome of endotherapy versus a combination of splenectomy and devascularization for variceal bleeding in patients with hepatitis B-related cirrhosis (HBRC). MATERIALS AND METHODS A total of 1074 patients with HBRC and acute variceal bleeding (AVB) treated with endotherapy and 248 patients with HBRC treated with a combination of splenectomy and devascularization surgery were included in the analysis. After one-to-one propensity score matching, 151 paired patients were selected. The primary end-point was death. The secondary outcomes were 3-year survival, 5-year survival, and rebleeding. Complications were recorded. RESULTS The median follow-up time was 1165 days in the endoscopic group and 1709 days in the surgical group. Before matching, the 1-year, 3-year, and 5-year survival rates were significantly lower in the endoscopic group than in the surgical group (91.1 vs 96.3%, P = 0.017; 79.6 vs 91.6%, P = 0.001; 65.2 vs 81.3%, P = 0.001). After matching, no significant differences were found between groups (94.5 vs 95.2%, P = 0.767; 87.0 vs 88.9%, P = 0.635; 77.9 vs 77.9%, P = 0.905). The rebleeding rate was lower in the surgical group than in the endoscopic group; the rebleeding-free survival rate was similar in the two groups. No patient died of complications. No statistically significant difference was observed in complications between groups. CONCLUSIONS Both endotherapy and a combination of splenectomy and devascularization are good choices for patients with AVB. The rebleeding rate was lower after the surgical procedure, but the long-term prognosis was similar.
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Affiliation(s)
- Jia-Li Ma
- Department of Gastroenterology, Beijing Ditan Hospital, Capital Medical University, No.8, Jingshun East Str.Chaoyang, Beijing, 100015, China
| | - Ling-Ling He
- Department of Gastroenterology, Beijing Ditan Hospital, Capital Medical University, No.8, Jingshun East Str.Chaoyang, Beijing, 100015, China
| | - Ping Li
- Department of Gastroenterology, Beijing Ditan Hospital, Capital Medical University, No.8, Jingshun East Str.Chaoyang, Beijing, 100015, China
| | - Li Jiang
- Department of General Surgery, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Hong-Shan Wei
- Department of Gastroenterology, Beijing Ditan Hospital, Capital Medical University, No.8, Jingshun East Str.Chaoyang, Beijing, 100015, China.
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26
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Abstract
PURPOSE OF REVIEW This article reviews the most recent studies regarding the management of acute esophageal variceal haemorrhage. RECENT FINDINGS New randomized control trials and meta-analyses confirmed the role of early transjugular intrahepatic portosystemic shunt (TIPS) in the management of acute variceal haemorrhage in Child-Pugh C (10-13) and B patients with active bleeding. A recent randomized controlled trial focused on the duration of vasoactive therapy showed no difference between 2 and 5 days of octreotide. A randomized trial showed decreased use of blood products for the correction of coagulopathy using a thromboelastography-guided approach (vs. conventional parameters) as well as decreased bleeding rates when compared with standard of care. A meta-analysis found that for rescue of variceal bleeding, self-expanding metallic stents were more efficacious and safer than balloon tamponade. In addition, studies showed that Child-Pugh C patients and those with hepatic vein pressure gradient more than 20 were at the highest risk of treatment failure, while model for end-stage liver disease was highly predictive of in-hospital mortality. SUMMARY In patients with severe coagulopathy and uncontrolled bleeding, TEG-based transfusion strategies are recommended. Antibiotics should be used for all cirrhotic patients presenting with upper gastrointestinal bleeding, but should be tailored in accordance to local resistance patterns. Early TIPS for high-risk patients has been shown to have a significant survival benefit. Certain aspects of the management of variceal bleeding remain poorly studied such as the role of early TIPS in Child-B patients as well as strategies for rescue therapy in patients who are not TIPS candidates, and require further investigation.
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Affiliation(s)
- Jerome Edelson
- Department of Gastroenterology and Hepatology, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Jessica E Basso
- Department of Gastroenterology and Hepatology, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA
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Bertoldi ADS, Guetter CR, Coltro GA, Vosgerau LM, Brighenti LMV, Fauat NI, Kubrusly FB, Marques CAM, Kubrusly LF. CARVEDILOL AS PRIMARY PROPHYLAXIS FOR GASTRIC VARICEAL BLEEDING IN PORTAL HYPERTENSION MODEL IN RATS. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2020; 33:e1525. [PMID: 33331427 PMCID: PMC7743326 DOI: 10.1590/0102-672020200003e1525] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 09/10/2020] [Indexed: 01/04/2023]
Abstract
Background: Portal hypertension (PH) can be measured indirectly through a hepatic vein
pressure gradient greater than 5 mmHg. Cirrhosis is the leading cause for PH
and can present as complications ascites, hepatic dysfunction, renal
dysfunction, and esophagogastric varices, characterizing gastropathy. Aim: To evaluate the use of carvedilol as primary prophylaxis in the development
of collateral circulation in rats submitted to the partial portal vein
ligament (PPVL) model. Method: This is a combined qualitative and quantitative experimental study in which
32 Wistar rats were divided into four groups (8 animals in each): group I -
cirrhosis + carvedilol (PPVL + C); group II - cirrhosis + vehicle (PPVL);
group III - control + carvedilol (SO-sham-operated + C); group IV - control
+ vehicle (SO-sham-operated). After seven days of the surgical procedure
(PPVL or sham), carvedilol (10 mg/kg) or vehicle (1 mL normal saline) were
administered to the respective groups daily for seven days. Results: The histological analysis showed no hepatic alteration in any group and a
decrease in edema and vasodilatation in the PPVL + C group. The laboratory
evaluation of liver function did not show a statistically significant change
between the groups. Conclusion: Carvedilol was shown to have a positive effect on gastric varices without
significant adverse effects.
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Affiliation(s)
- Andressa de Souza Bertoldi
- Mackenzie Evangelical Faculty of Paraná - FEMPAR, Curitiba, PR, Brazil.,Institute Denton Cooley Brazil - IDC, Curitiba, PR, Brazil
| | - Camila Roginski Guetter
- Institute Denton Cooley Brazil - IDC, Curitiba, PR, Brazil.,Federal University of Paraná - UFPR, Curitiba, PR, Brazil
| | - Gabriel Antonio Coltro
- Mackenzie Evangelical Faculty of Paraná - FEMPAR, Curitiba, PR, Brazil.,Institute Denton Cooley Brazil - IDC, Curitiba, PR, Brazil
| | - Larissa Maria Vosgerau
- Mackenzie Evangelical Faculty of Paraná - FEMPAR, Curitiba, PR, Brazil.,Institute Denton Cooley Brazil - IDC, Curitiba, PR, Brazil
| | - Laura Maria Viscardi Brighenti
- Mackenzie Evangelical Faculty of Paraná - FEMPAR, Curitiba, PR, Brazil.,Institute Denton Cooley Brazil - IDC, Curitiba, PR, Brazil
| | - Natália Izycki Fauat
- Institute Denton Cooley Brazil - IDC, Curitiba, PR, Brazil.,Pontifical Catholic University of Paraná - PUCPR, Curitiba, PR, Brazil
| | | | | | - Luiz Fernando Kubrusly
- Mackenzie Evangelical Faculty of Paraná - FEMPAR, Curitiba, PR, Brazil.,Institute Denton Cooley Brazil - IDC, Curitiba, PR, Brazil
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28
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Li QQ, Li HY, Bai ZH, Philips CA, Guo XZ, Qi XS. Esophageal collateral veins in predicting esophageal variceal recurrence and rebleeding after endoscopic treatment: a systematic review and meta-analysis. Gastroenterol Rep (Oxf) 2020; 8:355-361. [PMID: 33163190 PMCID: PMC7603868 DOI: 10.1093/gastro/goaa004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/20/2019] [Accepted: 08/13/2019] [Indexed: 12/15/2022] Open
Abstract
Background Endoscopic treatment is recommended for the management of esophageal varices. However, variceal recurrence or rebleeding is common after endoscopic variceal eradication. Our study aimed to systematically evaluate the prevalence of esophageal collateral veins (ECVs) and the association of ECVs with recurrence of esophageal varices or rebleeding from esophageal varices after endoscopic treatment. Methods We searched the relevant literature through the PubMed, EMBASE, and Cochrane Library databases. Prevalence of paraesophageal veins (para-EVs), periesophageal veins (peri-EVs), and perforating veins (PVs) were pooled. Risk ratio (RR) and odds ratio (OR) with 95% confidence intervals (CIs) were calculated for cohort studies and case-control studies, respectively. A random-effects model was employed. Heterogeneity among studies was calculated. Results Among the 532 retrieved papers, 28 were included. The pooled prevalence of para-EVs, peri-EVs, and PVs in patients with esophageal varices was 73%, 88%, and 54%, respectively. The pooled prevalence of para-EVs and PVs in patients with recurrence of esophageal varices was 87% and 62%, respectively. The risk for recurrence of esophageal varices was significantly increased in patients with PVs (OR = 9.79, 95% CI: 1.95-49.22, P = 0.006 for eight case-control studies), but not in those with para-EVs (OR = 4.26, 95% CI: 0.38-38.35, P = 0.24 for four case-control studies; RR = 1.81, 95% CI: 0.83-3.97, P = 0.14 for three cohort studies). Patients with para-EVs had a significantly higher incidence of rebleeding from esophageal varices (RR = 13.00, 95% CI: 2.43-69.56, P = 0.003 for two cohort studies). Statistically significant heterogeneity was notable across the meta-analyses. Conclusions ECVs are common in patients with esophageal varices. Identification of ECVs could be helpful for predicting the recurrence of esophageal varices or rebleeding from esophageal varices after endoscopic treatment.
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Affiliation(s)
- Qian-Qian Li
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, Liaoning, P. R. China
| | - Hong-Yu Li
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, Liaoning, P. R. China
| | - Zhao-Hui Bai
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, Liaoning, P. R. China
| | - Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, India
| | - Xiao-Zhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, Liaoning, P. R. China
| | - Xing-Shun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, Liaoning, P. R. China
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29
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Gunarathne LS, Rajapaksha H, Shackel N, Angus PW, Herath CB. Cirrhotic portal hypertension: From pathophysiology to novel therapeutics. World J Gastroenterol 2020; 26:6111-6140. [PMID: 33177789 PMCID: PMC7596642 DOI: 10.3748/wjg.v26.i40.6111] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/28/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023] Open
Abstract
Portal hypertension and bleeding from gastroesophageal varices is the major cause of morbidity and mortality in patients with cirrhosis. Portal hypertension is initiated by increased intrahepatic vascular resistance and a hyperdynamic circulatory state. The latter is characterized by a high cardiac output, increased total blood volume and splanchnic vasodilatation, resulting in increased mesenteric blood flow. Pharmacological manipulation of cirrhotic portal hypertension targets both the splanchnic and hepatic vascular beds. Drugs such as angiotensin converting enzyme inhibitors and angiotensin II type receptor 1 blockers, which target the components of the classical renin angiotensin system (RAS), are expected to reduce intrahepatic vascular tone by reducing extracellular matrix deposition and vasoactivity of contractile cells and thereby improve portal hypertension. However, these drugs have been shown to produce significant off-target effects such as systemic hypotension and renal failure. Therefore, the current pharmacological mainstay in clinical practice to prevent variceal bleeding and improving patient survival by reducing portal pressure is non-selective -blockers (NSBBs). These NSBBs work by reducing cardiac output and splanchnic vasodilatation but most patients do not achieve an optimal therapeutic response and a significant proportion of patients are unable to tolerate these drugs. Although statins, used alone or in combination with NSBBs, have been shown to improve portal pressure and overall mortality in cirrhotic patients, further randomized clinical trials are warranted involving larger patient populations with clear clinical end points. On the other hand, recent findings from studies that have investigated the potential use of the blockers of the components of the alternate RAS provided compelling evidence that could lead to the development of drugs targeting the splanchnic vascular bed to inhibit splanchnic vasodilatation in portal hypertension. This review outlines the mechanisms related to the pathogenesis of portal hypertension and attempts to provide an update on currently available therapeutic approaches in the management of portal hypertension with special emphasis on how the alternate RAS could be manipulated in our search for development of safe, specific and effective novel therapies to treat portal hypertension in cirrhosis.
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Affiliation(s)
- Lakmie S Gunarathne
- Department of Medicine, Melbourne Medical School, The University of Melbourne, Heidelberg, VIC 3084, Australia
| | - Harinda Rajapaksha
- School of Molecular Science, College of Science, Health and Engineering, La Trobe University, Bundoora, VIC 3086, Australia
| | | | - Peter W Angus
- Department of Gastroenterology, Austin Health, Heidelberg, VIC 3084, Australia
| | - Chandana B Herath
- Department of Medicine, Melbourne Medical School, The University of Melbourne, Heidelberg, VIC 3084, Australia
- South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170, Australia
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30
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Sonwani NS, Ateriya N, Kumar A, Kohli A, Banerjee KK. Sudden death due to ruptured oesophageal varices - autopsy-based case report. Med Leg J 2020; 88:189-191. [PMID: 32502364 DOI: 10.1177/0025817220926929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Acute haemorrhage from ruptured oesophageal varices is a serious consequence of portal hypertension in cirrhotic patients. It represents a medical emergency with a high morbidity and mortality rate. Studies over the years have shown a direct link with chronic alcoholism in the development of such complications. Although the gastrointestinal system accounts for a few numbers of sudden deaths, bleeding through ruptured varices represent a life-threatening condition. The role of forensic pathologist is vital in dealing with sudden deaths. Here, we report a case of a 46-year-old man who died suddenly following the rupture of oesophageal varices.
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Affiliation(s)
- Nagendra Singh Sonwani
- Department of Forensic Medicine, University College of Medical Sciences & GTB Hospital, Delhi, India
| | - Navneet Ateriya
- Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Gorakhpur, India
| | - Arvind Kumar
- Department of Forensic Medicine, University College of Medical Sciences & GTB Hospital, Delhi, India
| | - Anil Kohli
- Department of Forensic Medicine, University College of Medical Sciences & GTB Hospital, Delhi, India
| | - Kalyan Kumar Banerjee
- Department of Forensic Medicine, University College of Medical Sciences & GTB Hospital, Delhi, India
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31
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Lesmana CRA, Kalista KF, Sandra S, Hasan I, Sulaiman AS, Kurniawan J, Jasirwan COM, Nababan SH, Lirendra M, Aprilicia G, Gani RA. Clinical significance of isolated gastric varices in liver cirrhotic patients: A single‐referral‐centre retrospective cohort study. JGH Open 2020; 4:511-518. [PMID: 32514463 PMCID: PMC7273693 DOI: 10.1002/jgh3.12292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 11/23/2019] [Accepted: 12/01/2019] [Indexed: 12/14/2022]
Abstract
Introduction Gastric varices (GVs) occur in 10–30% of liver cirrhotic patients, with a mortality rate of up to 45%. Rupture of isolated GVs (IGVs) is less prevalent but often results in more severe hemorrhage and a higher risk of mortality than rupture of esophageal varices (EVs). However, there is no clear consensus yet about the optimal management for incidentally discovered IGVs. Objective To determine the clinical significance of IGVs in liver cirrhotic patients. Methods This was a retrospective cohort endoscopy database study within a 2‐year period (2016–2017). All study subjects were liver cirrhotic patients with OVs or GVs. The exclusion criteria were noncirrhotic portal hypertension, presence of malignancy, absence of varices, and incomplete data. Statistical analysis was performed using IBM SPSS 23. Results A total of 153 patients were included in this study. IGVs were found in 13 (8.49%) patients, whereas OVs were found in 112 (73.20%) patients and gastro‐OVs were found in 28 (18.30%) patients. Child‐Pugh class C (CP C) score was the strongest independent risk factor for variceal bleeding in bivariate analysis (hazard ratio [HR]: 10.21, 95% confidence interval [CI]: 4.15–25.12, P = 0.001) and multivariate analysis (HR: 12.49, 95% CI: 4.95–31.54, P 0.001); however, the presence of IGVs was not an independent risk factor. CP C score was also the only significant risk factor associated with 1‐year mortality in liver cirrhotic patients on multivariate analysis (HR: 26.77, 95% CI: 6.01–119.34, P 0.001). Conclusion The presence of IGVs has no clinical significance in the occurrence of 1‐year rebleeding and in patient survival.
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Affiliation(s)
- Cosmas Rinaldi A Lesmana
- Hepatobiliary Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General HospitalUniversitas Indonesia Jakarta Indonesia
- Digestive Disease & GI Oncology CentreMedistra Hospital Jakarta Indonesia
| | - Kemal F Kalista
- Hepatobiliary Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General HospitalUniversitas Indonesia Jakarta Indonesia
| | - Sharon Sandra
- Hepatobiliary Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General HospitalUniversitas Indonesia Jakarta Indonesia
| | - Irsan Hasan
- Hepatobiliary Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General HospitalUniversitas Indonesia Jakarta Indonesia
| | - Andri Sanityoso Sulaiman
- Hepatobiliary Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General HospitalUniversitas Indonesia Jakarta Indonesia
| | - Juferdy Kurniawan
- Hepatobiliary Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General HospitalUniversitas Indonesia Jakarta Indonesia
| | - Chyntia O M Jasirwan
- Hepatobiliary Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General HospitalUniversitas Indonesia Jakarta Indonesia
| | - Saut H Nababan
- Hepatobiliary Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General HospitalUniversitas Indonesia Jakarta Indonesia
| | - Mutiara Lirendra
- Hepatobiliary Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General HospitalUniversitas Indonesia Jakarta Indonesia
| | - Gita Aprilicia
- Hepatobiliary Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General HospitalUniversitas Indonesia Jakarta Indonesia
| | - Rino A Gani
- Hepatobiliary Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General HospitalUniversitas Indonesia Jakarta Indonesia
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Clinical Features and Outcomes of Repeated Endoscopic Therapy for Esophagogastric Variceal Hemorrhage in Cirrhotic Patients: Ten-Year Real-World Analysis. Gastroenterol Res Pract 2020; 2020:5747563. [PMID: 32508912 PMCID: PMC7245665 DOI: 10.1155/2020/5747563] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 03/11/2020] [Accepted: 04/20/2020] [Indexed: 12/11/2022] Open
Abstract
Objective This study is aimed at evaluating the survival of cirrhotic patients with different etiologies after endoscopic therapy for acute variceal bleeding and the effect of repeated endotherapy on patients' prognosis. Methods We retrospectively evaluated the clinical features and outcomes between cirrhotic patients with chronic HBV or HCV infections and other etiologies. The 3-year and 5-year survival rates and rehemorrhage rate in one year between the viral and nonviral cirrhosis patients were compared by Kaplan-Meier curves and log-rank test. Cox analysis was used to identify the impact factors that affect the long-term survival of patients with cirrhosis and variceal bleeding after endotherapy. Results Out of 2665 patients with liver cirrhosis and variceal hemorrhage selected from our medical center between September 2008 and December 2017, a total of 1342 patients were included for analysis. The median follow-up duration was 32.9 months (range 0.16-111.4 months), the 3- and 5-year cumulative survival rates were 75.3% and 52.8%, respectively. The median survival time was significantly longer in viral cirrhosis patients (47.1 months [95% CI: 24.9-69.1]) compared with nonviral cirrhosis patients (37.0 months [95% CI: 25.0-56.0], p = 0.001). The 3-year and 5-year survival rates of the viral group were higher than the nonviral group. The rehemorrhage rate at one year was higher in nonviral patients than in viral patients (p < 0.001). Conclusion Repeated endotherapy combined with effective antiviral therapy is helpful for long-term survival of cirrhotic population with variceal hemorrhage and HBV or HCV infection.
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Thirty-Day Readmission After Esophageal Variceal Hemorrhage and its Impact on Outcomes in the United States. J Clin Gastroenterol 2020; 54:477-483. [PMID: 31373937 DOI: 10.1097/mcg.0000000000001249] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIMS The authors sought to determine the 30-day readmission rate of patients with esophageal variceal hemorrhage (EVH) and its impact on mortality, morbidity, and health care utilization. BACKGROUND EVH is a common complication of cirrhosis and leads to substantial morbidity and mortality. STUDY The 2014 National Readmission Database was used to examine adult patients with urgent/emergent admissions and a principal diagnosis of EVH. The primary outcome was 30-day readmission. Secondary outcomes were in-hospital and 30-day mortality rate, most common reasons for readmission, readmission mortality rate, morbidity, and resource utilization. Independent risk factors for readmission were identified using multivariate regression analysis. RESULTS A total of 2003 patients with EVH were included. The mean age was 57 years and 29% of patients were female individuals. The all-cause 30-day readmission rate was 16.6%. EVH was the cause of readmission in only 5% of readmissions. Independent predictors of readmission were age and insurance type. The in-hospital and 30-day mortality rate for index admissions were 7.3% and 8.2%, respectively. For readmitted patients, the mortality rate was 3.9%. Although morbidity was lower during readmissions (prolonged mechanical ventilation: 0.4% vs. 3.5%, P<0.01 and shock: 1.8% vs. 9.9%, P<0.01), the cumulative additional length of stay was substantial at 2054 days with additional total hospitalization charges of US$20 million. CONCLUSIONS The all-cause 30-day readmission rate after EVH is 16.6%, with most patients being readmitted for diagnoses unrelated to EVH. Readmission was associated with a substantial increase in in-hospital mortality and resource utilization. Risk factors for readmission were identified, which can potentially be used to decrease readmission rates.
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34
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Mansilla-Vivar R, Vargas JI, Parra-Blanco A. Endoscopic hemostasis with hemoclips for post-variceal ligation bleeding ulcer. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2020; 5:56-57. [PMID: 32051909 PMCID: PMC7003062 DOI: 10.1016/j.vgie.2019.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Rodrigo Mansilla-Vivar
- Endoscopy Unit, Digestive Diseases Department, La Fe Polytechnic University Hospital, Gastrointestinal Endoscopy Research Group, IIS Hospital La Fe, Valencia, Spain
- Digestive Endoscopy Unit, Hospital Puerto Montt, Puerto Montt, Chile
| | - José Ignacio Vargas
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Adolfo Parra-Blanco
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Nottingham Digestive Diseases Centre, The University of Nottingham, Nottingham, UK
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35
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KASL clinical practice guidelines for liver cirrhosis: Varices, hepatic encephalopathy, and related complications. Clin Mol Hepatol 2020; 26:83-127. [PMID: 31918536 PMCID: PMC7160350 DOI: 10.3350/cmh.2019.0010n] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 02/06/2023] Open
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36
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Solanki S, Haq KF, Chakinala RC, Khan Z, Aronow WS, Ali Khan M, Siddiqui MT, Haq KS, Frager S, Alimirah M, Nabors C, Samson DJ, Lebovics E, Wolf DC. Inpatient burden of esophageal varices in the United States: analysis of trends in demographics, cost of care, and outcomes. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:480. [PMID: 31700916 DOI: 10.21037/atm.2019.08.34] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Esophageal variceal bleeding remains a common reason for hospitalization in the United States. The main objective of this study was to analyze demographic variations and outcomes in hospitalizations related to esophageal varices (EV) in the US. Methods We performed a retrospective observational cohort study using National Inpatient Sample (NIS) database for all hospitalizations with discharge diagnoses of EV, with and without hemorrhage from 2001 to 2011. Results In 2001, there were 19,167 hospitalizations with discharge diagnoses of EV with and without bleeding compared to 45,578 in 2011 (P<0.001). There was a 138% increase in the number of total EV hospitalizations, a 221% increase in hospitalizations with EV without hemorrhage, and a 7% increase in hospitalizations for patients with EV and hemorrhage. Age group 50-64 was the most affected, accounting for 31.4% of EV hospitalizations in 2001 and 46.7% of EV hospitalizations in 2011 (P<0.001). The overall in-hospital mortality rate was 3.4% for patients with EV without hemorrhage and 8.7% for patients with EV with hemorrhage (P=0.0003). Conclusions The number of hospitalizations for patients with asymptomatic EV increased significantly between 2001 to 2011, with only a small concurrent increase in the number of hospitalizations for patients with esophageal variceal bleeding.
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Affiliation(s)
- Shantanu Solanki
- Hospitalist Department, Guthrie Robert Packer Hospital, Sayre, PA, USA
| | - Khwaja Fahad Haq
- Division of Gastroenterology, Henry Ford Hospital, Detroit, MI, USA
| | - Raja Chandra Chakinala
- Department of Medicine, New York Medical College at Westchester Medical Center, Valhalla, NY, USA
| | - Zubair Khan
- Department of Gastroenterology, Hepatology & Nutrition, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Wilbert S Aronow
- Department of Cardiology, New York Medical College at Westchester Medical Center, Valhalla, NY, USA
| | - Muhammad Ali Khan
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mohamed Tausif Siddiqui
- Department of Medicine, New York Medical College at Westchester Medical Center, Valhalla, NY, USA
| | - Khwaja Saad Haq
- Department of Medicine, Kingsbrook Jewish Medical Center, Brooklyn, NY, USA
| | - Shalom Frager
- Division of Gastroenterology & Hepatobiliary Diseases, New York Medical College at Westchester Medical Center, Valhalla, NY, USA
| | - Maryam Alimirah
- Department of Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Christopher Nabors
- Department of Medicine, New York Medical College at Westchester Medical Center, Valhalla, NY, USA
| | - David J Samson
- Clinical Research Unit, Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Edward Lebovics
- Division of Gastroenterology & Hepatobiliary Diseases, New York Medical College at Westchester Medical Center, Valhalla, NY, USA
| | - David Cary Wolf
- Division of Gastroenterology & Hepatobiliary Diseases, New York Medical College at Westchester Medical Center, Valhalla, NY, USA
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37
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Al-Khazraji A, Curry MP. The current knowledge about the therapeutic use of endoscopic sclerotherapy and endoscopic tissue adhesives in variceal bleeding. Expert Rev Gastroenterol Hepatol 2019; 13:893-897. [PMID: 31389265 DOI: 10.1080/17474124.2019.1652092] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: The most recent guidelines vary in their approach to the management of variceal bleeding especially with the use of endoscopic sclerotherapy (ES) and endoscopic tissue adhesive (ETA). This review highlights their clinical use for variceal bleeding from different guidelines perspectives. Areas covered: A comprehensive literature review of three major guidelines including the American Association for the Study of Liver Diseases (AASLD) 2017, United Kingdom (UK) guidelines 2015 and Baveno VI Consensus workshop guidelines in 2015 on the use of ES and ETA in variceal bleeding. Expert opinion: While endoscopic band ligation (EBL) completely replaced endoscopic sclerotherapy (ES) for esophageal varices. There is a valuable use of endoscopic sclerotherapy (ES) and endoscopic tissue adhesive (ETA) especially for patients with gastroesophageal varices (GOV2) and isolated gastric varices (IGV2). The current standard of care heading toward portosystemic shunting with Trans-jugular-Intrahepatic Portosystemic Shunt (TIPS) and balloon retrograde transvenous obliteration (BRTO). However, recent advancement in endoscopic ultrasound (EUS) allowing direct injection of sclerosant and tissue adhesive into the varix bringing promising results in achieving hemostasis and lowering the risk of complications. Also, ES and ETA have great clinical value in achieving hemostasis for isolated (ectopic) varices and stomal varices.
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Affiliation(s)
- Ahmed Al-Khazraji
- Department of Gastroenterology & Hepatology, Transplant Liver Center, Harvard School of Medicine, Beth Israel Deaconess Medical Center , Boston , MA , USA
| | - Michael P Curry
- Department of Gastroenterology & Hepatology, Transplant Liver Center, Harvard School of Medicine, Beth Israel Deaconess Medical Center , Boston , MA , USA
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Schiavon LDL, Ejima FH, Menezes MRD, Bittencourt PL, Moreira AM, Farias AQ, Chagas AL, Assis AMD, Mattos ÂZD, Salomão BC, Terra C, Martins FPB, Carnevale FC, Rezende GFDM, Paulo GAD, Pereira GHS, Leal Filho JMDM, Meneses JD, Costa LSND, Carneiro MDV, Álvares-DA-Silva MR, Soares MVA, Pereira OI, Ximenes RO, Durante RFS, Ferreira VA, Lima VMD. RECOMMENDATIONS FOR INVASIVE PROCEDURES IN PATIENTS WITH DISEASES OF THE LIVER AND BILIARY TRACT: REPORT OF A JOINT MEETING OF THE BRAZILIAN SOCIETY OF HEPATOLOGY (SBH), BRAZILIAN SOCIETY OF DIGESTIVE ENDOSCOPY (SOBED) AND BRAZILIAN SOCIETY OF INTERVENTIONAL RADIOLOGY AND ENDOVASCULAR SURGERY (SOBRICE). ARQUIVOS DE GASTROENTEROLOGIA 2019; 56:213-231. [PMID: 31460590 DOI: 10.1590/s0004-2803.201900000-42] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 04/12/2019] [Indexed: 12/12/2022]
Abstract
Liver and biliary tract diseases are common causes of morbidity and mortality worldwide. Invasive procedures are usually performed in those patients with hepatobiliary diseases for both diagnostic and therapeutic purposes. Defining proper indications and restraints of commonly used techniques is crucial for proper patient selection, maximizing positive results and limiting complications. In 2018, the Brazilian Society of Hepato-logy (SBH) in cooperation with the Brazilian Society of Interventional Radiology and Endovascular surgery (SOBRICE) and the Brazilian Society of Digestive Endoscopy (SOBED) sponsored a joint single-topic meeting on invasive procedures in patients with hepatobiliary diseases. This paper summarizes the proceedings of the aforementioned meeting. It is intended to guide clinicians, gastroenterologists, hepatologists, radiologists, and endoscopists for the proper use of invasive procedures for management of patients with hepatobiliary diseases.
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Affiliation(s)
- Leonardo de Lucca Schiavon
- Universidade Federal de Santa Catarina, Faculdade de Medicina, Departamento de Clínica Médica, Florianópolis, SC, Brasil
| | | | - Marcos Roberto de Menezes
- Instituto do Câncer do Estado de São Paulo, Setor de Diagnóstico por Imagem, São Paulo, SP, Brasil.,Instituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, Serviço de Radiologia Intervencionista, São Paulo, SP, Brasil
| | | | | | - Aírton Mota Moreira
- Universidade de São Paulo, Faculdade de Medicina, Serviço de Radiologia Intervencionista do Instituto de Radiologia, São Paulo, SP, Brasil
| | - Alberto Queiroz Farias
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, São Paulo, SP, Brasil
| | - Aline Lopes Chagas
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, São Paulo, SP, Brasil
| | - André Moreira de Assis
- Universidade de São Paulo, Faculdade de Medicina, Serviço de Radiologia Intervencionista do Instituto de Radiologia, São Paulo, SP, Brasil.,Hospital Sírio-Libanês, São Paulo, SP, Brasil
| | - Ângelo Zambam de Mattos
- Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Medicina: Hepatologia, RS, Brasil
| | | | - Carlos Terra
- Universidade do Estado do Rio de Janeiro, Faculdade de Medicina, Departamento de Gastroenterologia, RJ, Brasil.,Hospital Federal de Lagoa, Departamento de Gastroenterologia, Rio de Janeiro, RJ, Brasil
| | | | - Francisco Cesar Carnevale
- Instituto de Radiologia da Faculdade de Medicina da Universidade de São Paulo, Serviço de Radiologia Intervencionista, São Paulo, SP, Brasil
| | | | | | | | - Joaquim Maurício da Motta Leal Filho
- Instituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, Serviço de Radiologia Intervencionista, São Paulo, SP, Brasil
| | - Juliana de Meneses
- Instituto Hospital de Base do Distrito Federal, Brasília, DF, Brasil.,Instituto Nacional do Câncer, Brasília, DF, Brasil
| | - Lucas Santana Nova da Costa
- Instituto Hospital de Base do Distrito Federal, Brasília, DF, Brasil.,Hospital Sírio-Libanês Unidade Brasília, Brasília, DF, Brasil
| | - Marcos de Vasconcelos Carneiro
- Hospital das Forças Armadas, Brasília, DF, Brasil.,Universidade Católica de Brasília, Curso de Medicina, Brasília, DF, Brasil
| | - Mário Reis Álvares-DA-Silva
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Departamento de Medicina Interna, Rio Grande do Sul, RS, Brasil
| | - Mayra Veloso Ayrimoraes Soares
- Hospital Sírio-Libanês Unidade Brasília, Brasília, DF, Brasil.,Universidade de Brasília, Serviço de Radiologia, Brasília, DF, Brasil
| | - Osvaldo Ignácio Pereira
- Instituto de Radiologia da Faculdade de Medicina da Universidade de São Paulo, Serviço de Radiologia Intervencionista, São Paulo, SP, Brasil
| | - Rafael Oliveira Ximenes
- Hospital das Clínicas da Universidade Federal de Goiás, Serviço de Gastroenterologia e Hepatologia, Goiás, GO, Brasil
| | | | - Valério Alves Ferreira
- Instituto Hospital de Base do Distrito Federal, Brasília, DF, Brasil.,Hospital Santa Marta, Brasília, DF, Brasil
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Malandris K, Paschos P, Katsoula A, Manolopoulos A, Andreadis P, Sarigianni M, Athanasiadou E, Akriviadis E, Tsapas A. Carvedilol for prevention of variceal bleeding: a systematic review and meta-analysis. Ann Gastroenterol 2019; 32:287-297. [PMID: 31040627 PMCID: PMC6479656 DOI: 10.20524/aog.2019.0368] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 02/04/2019] [Indexed: 12/15/2022] Open
Abstract
Background Beta-blockers are used for prophylaxis of variceal bleeding. Our aim was to assess the efficacy and safety of carvedilol for primary or secondary prevention of variceal bleeding in patients with cirrhosis. Methods We searched Medline, Embase, CENTRAL and gray literature sources for randomized controlled trials (RCTs) comparing carvedilol with placebo or any active intervention. We synthesized data using random effects models. We summarized the strength of evidence using GRADE criteria. Results We included 13 trials with 1598 patients. Carvedilol was as efficacious as endoscopic variceal ligation (EVL) (4 RCTs, risk ratio [RR] 0.74, 95% confidence interval [CI] 0.37-1.49) or propranolol (3 RCTs, RR 0.76, 95%CI 0.27-2.14) for primary prevention of variceal bleeding. Likewise, carvedilol was as efficacious as EVL (3 RCTs, RR 1.10, 95%CI 0.75-1.61), non-selective beta-blockers (NSBBs) plus isosorbide-5-mononitrate (2 RCTs, RR 1.02, 95%CI 0.70-1.51) or propranolol (2 RCTs, RR 0.39, 95%CI 0.15-1.03) for secondary prevention of variceal bleeding. Carvedilol was associated with lower all-cause mortality compared to EVL (3 RCTs, RR 0.51, 95%CI 0.33-0.79). There was no difference in any other efficacy outcome. Finally, there were no significant differences in the safety profiles compared with EVL and NSBBs. Our confidence in the effect estimates for all outcomes was very low. Conclusion Carvedilol is as efficacious and safe as standard-of-care interventions for the primary and secondary prevention of variceal bleeding.
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Affiliation(s)
- Konstantinos Malandris
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece (Konstantinos Malandris, Paschalis Paschos, Anastasia Katsoula, Apostolos Manolopoulos, Panagiotis Andreadis, Maria Sarigianni, Eleni Athanasiadou, Apostolos Tsapas)
| | - Paschalis Paschos
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece (Konstantinos Malandris, Paschalis Paschos, Anastasia Katsoula, Apostolos Manolopoulos, Panagiotis Andreadis, Maria Sarigianni, Eleni Athanasiadou, Apostolos Tsapas).,First Department of Internal Medicine, "Papageorgiou" Hospital, Thessaloniki, Greece (Paschalis Paschos)
| | - Anastasia Katsoula
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece (Konstantinos Malandris, Paschalis Paschos, Anastasia Katsoula, Apostolos Manolopoulos, Panagiotis Andreadis, Maria Sarigianni, Eleni Athanasiadou, Apostolos Tsapas)
| | - Apostolos Manolopoulos
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece (Konstantinos Malandris, Paschalis Paschos, Anastasia Katsoula, Apostolos Manolopoulos, Panagiotis Andreadis, Maria Sarigianni, Eleni Athanasiadou, Apostolos Tsapas)
| | - Panagiotis Andreadis
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece (Konstantinos Malandris, Paschalis Paschos, Anastasia Katsoula, Apostolos Manolopoulos, Panagiotis Andreadis, Maria Sarigianni, Eleni Athanasiadou, Apostolos Tsapas)
| | - Maria Sarigianni
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece (Konstantinos Malandris, Paschalis Paschos, Anastasia Katsoula, Apostolos Manolopoulos, Panagiotis Andreadis, Maria Sarigianni, Eleni Athanasiadou, Apostolos Tsapas)
| | - Eleni Athanasiadou
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece (Konstantinos Malandris, Paschalis Paschos, Anastasia Katsoula, Apostolos Manolopoulos, Panagiotis Andreadis, Maria Sarigianni, Eleni Athanasiadou, Apostolos Tsapas)
| | - Evangelos Akriviadis
- Fourth Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece (Evangelos Akriviadis)
| | - Apostolos Tsapas
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece (Konstantinos Malandris, Paschalis Paschos, Anastasia Katsoula, Apostolos Manolopoulos, Panagiotis Andreadis, Maria Sarigianni, Eleni Athanasiadou, Apostolos Tsapas).,First Department of Internal Medicine, "Papageorgiou" Hospital, Thessaloniki, Greece (Paschalis Paschos)
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Elsebaey MA, Tawfik MA, Elshweikh SA, Negm MS, Elnaggar MH, Alghazaly GM, Abd-Elsalam S. Impact of Helicobacter pylori Infection on Gastric Variceal Bleeding among Patients with Liver Cirrhosis. Gastroenterol Res Pract 2019; 2019:6529420. [PMID: 30881448 PMCID: PMC6387698 DOI: 10.1155/2019/6529420] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/03/2018] [Accepted: 01/01/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND AIMS Currently, it is well known that Helicobacter pylori- (H. pylori-) related peptic ulcer is one of the main causes of nonvariceal bleeding in cirrhotic patients. However, there is a lack of data to identify the exact effect of H. pylori infection on variceal bleeding. This study was conducted to identify the impact of H. pylori infection on gastric variceal bleeding in cirrhotic patients. PATIENTS AND METHODS 76 cirrhotic patients with gastric varices were included in this prospective study and divided into 2 groups: nonbleeding gastric varices (32 patients) and bleeding gastric varices (44 patients). The fasting serum gastrin level was measured. Mucosal biopsies from the gastric body and antrum were examined to determine the patterns of gastritis and the presence of H. pylori. RESULTS The frequency of H. pylori infection in the studied patients was 59.2%. There were significant differences between both groups regarding liver decompensation (P = 0.001), red color sign over gastric varices (P = 0.0011), prevalence of H. pylori infection (P = 0.0049), histological patterns of gastritis (P = 0.0069), and serum gastrin level (P = 0.0200). By multivariate analysis, Child C cirrhosis, red color sign over gastric varices, and H. pylori-induced follicular gastritis were independent risk factors for bleeding from gastric varices. CONCLUSION H. pylori-induced follicular gastritis is considered as an additional risk factor for bleeding from gastric varices.
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Ray G. Long-term outcome of endoscopic variceal band ligation of esophageal varices in patients with chronic liver disease. Indian J Gastroenterol 2019; 38:69-76. [PMID: 30868452 DOI: 10.1007/s12664-019-00938-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 01/10/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND There are scanty data on the long-term outcome of endoscopic variceal band ligation (EVL) for esophageal varices. METHODS Adult patients suffering from a chronic liver disease (CLD) undergoing EVL of esophageal varices of grade 2 and above between January 2006 and December 2015 were followed up for the recurrence of varices, worsening of portal hypertensive gastropathy (PHG), rebleeding, and mortality. EVL was done as primary prophylaxis of bleeding in 72 and as secondary prophylaxis in 175 patients. All received propranolol after EVL if there was no contraindication. RESULTS Two hundred and forty-seven CLD patients (mean age 51.83 ± 11.28 years, 179 males) underwent 306 EVL sessions. The most common etiology was alcohol (53%). Sixty-eight percent of patients had grade 3 esophageal varices 76.5% had PHG. There was no immediate post-EVL bleeding or 30-day mortality. Variceal obliteration was achieved in 100% with 19% recurrence within a mean period of 53.74 ± 27.2 months. PHG worsened in 49.7%. Overall, rebleeding occurred in 13.8%, 4.3% from recurrent varices. There was no difference in variceal recurrence (16.7% vs. 20%) and incidence of rebleeding (9.7% vs. 13.7%) between patients undergoing EVL for primary and secondary prophylaxis. Cumulative rebleeding rates after 1, 5, and 9 years were 1.6%, 9.2%, and 11.4%, respectively. The overall mortality was 85%, mostly from progressive CLD, and only 8.6% was due to rebleeding. On subgroup analysis, the factors significantly associated with rebleeding was Child-Pugh class C and worsened PHG those with mortality were alcohol and Child-Pugh class C. CONCLUSION EVL is effective in the long-term for both primary and secondary prophylaxis of esophageal variceal bleeding.
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Affiliation(s)
- Gautam Ray
- Department of Medicine, B R Singh Hospital, Kolkata, 700 014, India.
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Predictive Value of a Noninvasive Serological Hepatic Fibrosis Scoring System in Cirrhosis Combined with Oesophageal Varices. Can J Gastroenterol Hepatol 2018; 2018:7671508. [PMID: 30186822 PMCID: PMC6112226 DOI: 10.1155/2018/7671508] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 07/25/2018] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE In recent years, the noninvasive serological scoring system has become a research hotspot in predicting hepatic fibrosis and has achieved good results. However, it has rarely been applied to the prediction of oesophageal varices. The aim of the study was to evaluate the predictive value of the four following scoring systems in cirrhosis combined with oesophageal varices: aspartate and platelet ratio index (APRI), aspartate aminotransferase-alanine aminotransferase ratio (AAR), FIB-4, and S index. METHODS A total of 153 patients with cirrhosis were categorized into groups with or without oesophageal varices. In addition, cirrhosis patients with oesophageal varices were further divided into mild, moderate, and severe grades. The rank sum test was used to compare the significant differences of APRI, AAR, FIB-4, and S index between the two groups of cirrhosis patients with or without oesophageal varices. A ROC curve was generated to compare the area under the curve of the three groups and to obtain the corresponding optimal prediction value. Moreover, multivariate logistic regression analysis was employed to assess the predictive factors for cirrhosis combined with oesophageal varices. RESULTS 44 patients had no oesophageal varices and 108 patients had oesophageal varices. Of the 108 patients with oesophageal varices, 43 were mild, 32 were moderate, and 33 were severe. The rank sum test indicated that the APRI, FIB-4, and S index were statistically significant between two groups (P < 0.05), while no significant difference was detected in terms of AAR between the two groups (P > 0.05). In addition, all four scoring systems were statistically significant between nonoesophageal varices group and severe oesophageal varices group (P < 0.05). In the ROC curve of oesophageal varices, the AUC values of APRI, FIB-4, and S index for predicting oesophageal varices were 0.681, 0642, and 0.673, respectively. However, in the ROC curve of severe oesophageal varices, the AUC values of APRI, AAR, FIB-4, and S index were 0.729, 0.648, 0.673, and 0.695, respectively. Multivariate logistic regression analysis indicated that APRI and FIB-4 were predictors of disease progression (P < 0.05). CONCLUSION AAR harboured a poor predictive value for oesophageal varices, APRI can be used as a reference index for the prediction of severe oesophageal varices, and the S index harboured potential value in predicting the degree of progression of cirrhosis.
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Aggeletopoulou I, Konstantakis C, Manolakopoulos S, Triantos C. Role of band ligation for secondary prophylaxis of variceal bleeding. World J Gastroenterol 2018; 24:2902-2914. [PMID: 30018485 PMCID: PMC6048424 DOI: 10.3748/wjg.v24.i26.2902] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/05/2018] [Accepted: 06/25/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To summarize and critically examine the role of band ligation in secondary prophylaxis of variceal bleeding in patients with cirrhosis.
METHODS A literature review was performed using the MEDLINE and PubMed databases. The search terms consisted of the words “endoscopic band ligation” OR “variceal band ligation” OR “ligation” AND “secondary prophylaxis” OR “secondary prevention” AND “variceal bleeding” OR “variceal hemorrhage” AND “liver cirrhosis”. The data collected from relevant meta-analyses and from the most recent randomized studies that were not included in these meta-analyses were used to evaluate the role of endoscopic band ligation in an effort to demonstrate the most recent advances in the treatment of esophageal varices.
RESULTS This study included 11 meta-analyses published from 2002 to 2017 and 10 randomized trials published from 2010 to 2017 that evaluated the efficacy of band ligation in the secondary prophylaxis of variceal bleeding. Overall, the results proved that band ligation was superior to endoscopic sclerotherapy. Moreover, the use of β-blockers in combination with band ligation increased the treatment effectiveness, supporting the current recommendations for secondary prophylaxis of variceal bleeding. The use of transjugular intrahepatic portosystemic shunt was superior to combination therapy regarding rebleeding prophylaxis, with no difference in the survival rates; however, the results concerning the hepatic encephalopathy incidence were conflicting. Recent advances in the management of secondary prophylaxis of variceal bleeding have targeted a decrease in portal pressure based on the pathophysiological mechanisms of portal hypertension.
CONCLUSION This review suggests that future research should be conducted to enhance current interventions and/or to develop innovative treatment options with improved clinical endpoints.
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Affiliation(s)
| | | | - Spilios Manolakopoulos
- 2nd Department of Internal Medicine, Hippokration General Hospital of Athens, Athens 11527, Greece
| | - Christos Triantos
- Department of Gastroenterology, University Hospital of Patras, Patras 26504, Greece
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Abstract
Acute variceal bleeding is one of the most fatal complications of cirrhosis and is responsible for about one-third of cirrhosis-related deaths. Therefore, every effort should be made to emergently resuscitate the patients, start pharmacotherapy as soon as possible and do endoscopic therapy in a timely manner. Despite the recent advances in treatment, mortality rate is still high. We provide a comprehensive review of evaluation and management of variceal bleeding.
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Affiliation(s)
- Obada Tayyem
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Mohammad Bilal
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX.
| | - Ronald Samuel
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Sheharyar K Merwat
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX
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Abstract
Bleeding from gastroesophageal varices is a serious complication in patients with liver cirrhosis and portal hypertension. Although there has been significance improvement in the prognosis of variceal bleeding with advancement in diagnostic and therapeutic modalities for its management, mortality rate still remains high. Therefore, appropriate prevention and rapid, effective management of bleeding from gastroesophageal varices is very important. Recently, various studies about management of gastoesophageal varices, including prevention of development and aggravation of varices, prevention of first variceal bleeding, management of acute variceal bleeding, and prevention of variceal rebleeding, have been published. The present article reviews published articles and practice guidelines to present the most optimal management of patients with gastroesophageal varices.
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Affiliation(s)
- Yeon Seok Seo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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Tang L, Liu H, Wu Y, Li M, Li W, Jiang M, Hou J, Jiang Y, Xia Z, Meng Q. Sevoflurane may be more beneficial than propofol in patients receiving endoscopic variceal ligation and endoscopic variceal sclerotherapy: A randomized, double-blind study. Exp Ther Med 2017; 14:3145-3152. [PMID: 28966686 DOI: 10.3892/etm.2017.4919] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Accepted: 05/31/2017] [Indexed: 12/25/2022] Open
Abstract
The aim of the present study was to evaluate the safety and efficacy of various general anesthesia regimens during endoscopic variceal ligation (EVL) and endoscopic variceal sclerotherapy (EVS). A total of 123 patients with American Society of Anesthesiologists physical status III and IV, aged 40-70 years, undergoing general anesthesia for EVL and EVS were randomly divided into two groups: Sevoflurane anesthesia (group S; n=60) and propofol anesthesia (group P; n=60). Vital signs, particularly heart rate (HR) and mean arterial pressure (MAP), were monitored. The designated time points were as follows: 5 min before induction (T0), and 1, 5, 10, 15, 20, 25 and 30 min after intubation (T1, T2, T3, T4, T5, T6 and T7, respectively). Time intervals were recorded, including recovery time and extubation time. Following surgery, the observer recorded the Ramsay sedation scale (RSS) score and the visual analogue scale (VAS) score. Adverse reactions were noted. Results demonstrated that there were significant differences in MAP between the two groups at T2, T3, T5, T6 and T7 (P<0.05). There was a significant difference in HR between the two groups at T2, T3 and T4 (P<0.05). Recovery time and extubation time in group P were significantly longer than those in group S (P<0.05; 18.38±2.25 min vs. 14.57±1.04 min and 21.70±2.70 min vs. 15.83±0.88 min, respectively). The rate of ephedrine injected was 58.3% (35/60 patients) in group P vs. 28.3% (17/60 patients) in group S (P<0.05). There was a significant difference in the RSS score between the two groups 5 min after extubation (P<0.05). VRS scores demonstrated that anesthetists and patients were significantly more satisfied with the procedure in group S than in group P (P<0.01). In conclusion, the superiority and special clinical value of inhalational anesthesia has been demonstrated during EVL and EVS attributed to stable hemodynamics and high quality of anesthesia recovery in the present study.
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Affiliation(s)
- Linghua Tang
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Huimin Liu
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Yang Wu
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Mei Li
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Wei Li
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Meng Jiang
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Jiabao Hou
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Ying Jiang
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Zhongyuan Xia
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Qingtao Meng
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
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Mallet M, Rudler M, Thabut D. Variceal bleeding in cirrhotic patients. Gastroenterol Rep (Oxf) 2017; 5:185-192. [PMID: 28852523 PMCID: PMC5554384 DOI: 10.1093/gastro/gox024] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 05/10/2017] [Indexed: 02/06/2023] Open
Abstract
Variceal bleeding is one of the major causes of death in cirrhotic patients. The management during the acute phase and the secondary prophylaxis is well defined. Recent recommendations (2015 Baveno VI expert consensus) are available and should be followed for an optimal management, which must be performed as an emergency in a liver or general intensive-care unit. It is based on the early administration of a vasoactive drug (before endoscopy), an antibiotic prophylaxis and a restrictive transfusion strategy (hemoglobin target of 7 g/dL). The endoscopic treatment is based on band ligations. Sclerotherapy should be abandoned. In the most severe patients (Child Pugh C or B with active bleeding during initial endoscopy), transjugular intrahepatic portosystemic shunt (TIPS) should be performed within 72 hours after admission to minimize the risk of rebleeding. Secondary prophylaxis is based on the association of non-selective beta-blockers (NSBBs) and repeated band ligations. TIPS should be considered when bleeding reoccurs in spite of a well-conducted secondary prophylaxis or when NSBBs are poorly tolerated. It should also be considered when bleeding is refractory. Liver transplantation should be discussed when bleeding is not controlled after TIPS insertion and in all cases when liver function is deteriorated.
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Affiliation(s)
- Maxime Mallet
- Unité de Soins Intensifs d'Hépatologie, Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marika Rudler
- Unité de Soins Intensifs d'Hépatologie, Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Dominique Thabut
- Unité de Soins Intensifs d'Hépatologie, Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Assistance Publique-Hôpitaux de Paris, Paris, France
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