Management of variceal bleeding

Gastrointestinal endoscopy in the cirrhotic patient

As advances in liver disease continue, including the increasing use of liver transplantation, the endoscopist needs to be familiar with the standards of care and potential complications in the management of the cirrhotic population. This includes both elective endoscopic procedures, such as screening colonoscopies and variceal banding, as well as the acutely bleeding cirrhotic patient. Peri-procedural management and standards of care for acute gastrointestinal hemorrhaging of cirrhotic patients will be emphasized. This article will focus on the plethora of data available to highlight the benefits of endoscopic intervention in the care of patients with liver disease and outline the areas of future emphasis.

An economic evaluation of vasoactive agents used in the United Kingdom for acute bleeding oesophageal varices in patients with liver cirrhosis

OBJECTIVE

To conduct an economic evaluation of terlipressin, octreotide and placebo in the treatment of bleeding oesophageal varices (BOV) where endotherapy could be used concomitantly.

METHODS

A discrete event simulation model was created with transition states: bleeding, no bleeding, no bleeding post transjugular intrahepatic portosystemic shunt, post-salvage surgery, and death. Efficacy data on survival, re-bleeding and control of bleeding were obtained from high quality studies reported in Cochrane meta-analyses. Baseline outcomes related to the course of disease and health-state utilities were derived from published sources. Vasoactive treatment costs and all related BOV costs were obtained from published UK sources.

RESULTS

The average aggregated treatment cost per person for all medical interventions at 1 year was lower for terlipressin-treated patients (2623 pounds sterling) compared with those treated using octreotide (2758 pounds sterling) or placebo (2890 pounds sterling). The incremental analysis comparing terlipressin with octreotide and placebo using a cost per quality adjusted life year (QALY) and cost per life year gained (LYG) approach indicated that terlipressin was the dominant BOV treatment option (i.e. it cost less and it was more effective). Based on a maximum willingness to pay of 20,000 pounds sterling/QALY terlipressin was more effective and cost-saving compared to octreotide and placebo for simulations ranging from 42 days to 2 years. In point estimation analyses octreotide was dominant compared to placebo; however, probabilistic sensitivity analysis indicated that octreotide was unlikely to be cost-effective compared to placebo.

CONCLUSIONS

The findings indicated that vasoactive treatment in BOV was cost-saving compared to no vasoactive treatment. Furthermore, terlipressin was the more cost-effective vasoactive treatment for BOV in cirrhotic patients.

Emergency management of bleeding esophageal varices: drugs, bands or sleep?

Variceal bleeding is a severe complication of cirrhosis leading to significant morbidity and mortality. Treatment of acute variceal bleeding has improved dramatically since the era of the mechanical balloon tamponade. These advances include endoscopic band ligation or sclerotherapy, and vasoactive pharmacological options such as somatostatin, octreotide, vasopressin and terlipressin. Evidence from a multitude of clinical trials and meta-analyses comparing endoscopic and pharmacological treatments suggests near equivalence in efficacy for initial hemostasis, mortality and rate of rebleeding. This raises the question of whether on-call gastroenterologists should be performing emergency endoscopic treatment in the middle of the night or start pharmacological treatment and delay endoscopy until optimal patient and working conditions the next morning. The present review analyzes the available comparative data between endoscopic and pharmacological treatment options. Although the literature cannot yet definitively answer the question posed, the authors suggest that delaying endoscopic treatment until the next morning may be the most reasonable practical approach.

Severe alcohol-induced liver disease and the alcohol dependence syndrome

AIMS

To examine the hypothesis that patients who present in the UK to detoxification services differ from patients who present with severe alcohol-induced liver disease (ALD) with respect to severity of dependence on alcohol and other features of their drinking history.

METHODS

Levels of alcohol dependence were assessed in 34 patients with severe ALD, all of whom were cirrhotic, and 34 subjects from a residential alcohol detox centre in Southampton using the Severity of Alcohol Dependence Questionnaire (SADQ). During interview, various aspects of participants' alcohol consumption were recorded, including total monthly consumption, whom they usually drank with and where, and, if applicable, what caused them to start drinking heavily. Social circumstances were also noted, including participants' employment and marital status.

RESULTS

Among ALD patients, 58% scored none/mild on the SADQ, 32% moderate and 9% severe. In contrast, 76% of the detox group were graded severe and 34% moderate (P < 0.001). ALD patients were also significantly older, had lower scores on the Alcohol Use Disorders Identification Test, tended to drink less alcohol, were more likely to be in a stable relationship, were less likely to be unemployed and gave different reasons for starting to drink heavily. The ALD group were most likely to have started drinking heavily for social reasons, whereas subjects in the detox group were most likely to have started drinking heavily as a result of relationship or money problems.

CONCLUSION

Patients attending a liver unit and patients admitted to a detoxification unit were separate but overlapping populations of alcohol misusers. Perhaps these two populations of alcohol misusers are likely to require different approaches for effective detection, intervention and treatment.