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Tsai SC, Lin CH, Chu CCJ, Lo HY, Ng CJ, Hsu CC, Chen SY. Machine Learning Models for Predicting Mortality in Patients with Cirrhosis and Acute Upper Gastrointestinal Bleeding at an Emergency Department: A Retrospective Cohort Study. Diagnostics (Basel) 2024; 14:1919. [PMID: 39272704 PMCID: PMC11394157 DOI: 10.3390/diagnostics14171919] [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: 07/31/2024] [Revised: 08/28/2024] [Accepted: 08/29/2024] [Indexed: 09/15/2024] Open
Abstract
BACKGROUND Cirrhosis is a major global cause of mortality, and upper gastrointestinal (GI) bleeding significantly increases the mortality risk in these patients. Although scoring systems such as the Child-Pugh score and the Model for End-stage Liver Disease evaluate the severity of cirrhosis, none of these systems specifically target the risk of mortality in patients with upper GI bleeding. In this study, we constructed machine learning (ML) models for predicting mortality in patients with cirrhosis and upper GI bleeding, particularly in emergency settings, to achieve early intervention and improve outcomes. METHODS In this retrospective study, we analyzed the electronic health records of adult patients with cirrhosis who presented at an emergency department (ED) with GI bleeding between 2001 and 2019. Data were divided into training and testing sets at a ratio of 90:10. The ability of three ML models-a linear regression model, an XGBoost (XGB) model, and a three-layer neural network model-to predict mortality in the patients was evaluated. RESULTS A total of 16,025 patients with cirrhosis and 32,826 ED visits for upper GI bleeding were included in the study. The in-hospital and ED mortality rates were 11.2% and 2.2%, respectively. The XGB model exhibited the highest performance in predicting both in-hospital and ED mortality (area under the receiver operating characteristic curve: 0.866 and 0.861, respectively). International normalized ratio, renal function, red blood cell distribution width, age, and white blood cell count were the strongest predictors in all the ML models. The median ED length of stay for the ED mortality group was 17.54 h (7.16-40.01 h). CONCLUSIONS ML models can be used to predict mortality in patients with cirrhosis and upper GI bleeding. Of the three models, the XGB model exhibits the highest performance. Further research is required to determine the actual efficacy of our ML models in clinical settings.
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Affiliation(s)
- Shih-Chien Tsai
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taoyuan 333, Taiwan
| | - Ching-Heng Lin
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan 333, Taiwan
- Bachelor Program in Artificial Intelligence, Chang Gung University, Taoyuan 333, Taiwan
| | - Cheng-C J Chu
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan 333, Taiwan
| | - Hsiang-Yun Lo
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taoyuan 333, Taiwan
| | - Chip-Jin Ng
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taoyuan 333, Taiwan
| | - Chun-Chuan Hsu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taoyuan 333, Taiwan
| | - Shou-Yen Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taoyuan 333, Taiwan
- Graduate Institute of Management, College of Management, Chang Gung University, Taoyuan 333, Taiwan
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Yin Y, Ji F, Romeiro FG, Sun M, Zhu Q, Ma D, Yuan S, He Y, Liu X, Philips CA, Méndez-Sánchez N, Basaranoglu M, Pinyopornpanish K, Li Y, Wu Y, Chen Y, Yang L, Shao L, Mancuso A, Tacke F, Lin S, Li B, Liu L, Qi X. Impact of peptic ulcer bleeding on the in-hospital outcomes of cirrhotic patients with acute gastrointestinal bleeding: an international multicenter study. Expert Rev Gastroenterol Hepatol 2024; 18:473-483. [PMID: 39101279 DOI: 10.1080/17474124.2024.2387823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 07/25/2024] [Accepted: 07/30/2024] [Indexed: 08/06/2024]
Abstract
OBJECTIVES Peptic ulcer is the most common source of non-variceal bleeding. However, it remains controversial whether the outcomes of cirrhotic patients with peptic ulcer bleeding differ from those with variceal bleeding. METHODS Cirrhotic patients with acute gastrointestinal bleeding (AGIB) who underwent endoscopy and had an identifiable source of bleeding were retrospectively screened from an international multicenter cohort. Logistic regression analyses were performed to explore the impact of peptic ulcer bleeding on in-hospital death and 5-day failure to control bleeding. Propensity score matching (PSM) analysis was performed by matching age, gender, Child-Pugh score, and model for end-stage liver disease score between the peptic ulcer bleeding and variceal bleeding groups. RESULTS Overall, 1535 patients were included, of whom 73 (4.7%) had peptic ulcer bleeding. Multivariate logistic regression analyses showed that peptic ulcer bleeding was not independently associated with in-hospital death (OR = 2.169, p = 0.126) or 5-day failure to control bleeding (OR = 1.230, p = 0.680). PSM analyses demonstrated that both in-hospital mortality (9.7% vs. 6.3%, p = 0.376) and rate of 5-day failure to control bleeding (6.9% vs. 5.4%, p = 0.787) were not significantly different between the two groups. CONCLUSIONS The impact of peptic ulcer bleeding on the in-hospital outcomes of cirrhotic patients is similar to that of variceal bleeding.
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Affiliation(s)
- Yuhang Yin
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Teaching Hospital of China Medical University), Shenyang, China
| | - Fanpu Ji
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | | | - Mingyu Sun
- Institute of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qiang Zhu
- Department of Gastroenterology, Shandong Provincial Hospital, Jinan, China
| | - Dapeng Ma
- Department of Critical Care Medicine, The Sixth People's Hospital of Dalian, Dalian, China
| | - Shanshan Yuan
- Department of Gastroenterology, Xi'an Central Hospital, Xi'an, China
| | - Yingli He
- Department of Infectious Diseases, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiaofeng Liu
- Department of Gastroenterology, The 960th Hospital of Chinese PLA, Jinan, China
| | - Cyriac Abby Philips
- Department of Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | | | - Metin Basaranoglu
- Gastroenterology and Hepatology, Bezmialem Vakif University, Istanbul, Turkey
| | - Kanokwan Pinyopornpanish
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Yiling Li
- Department of Gastroenterology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Yunhai Wu
- Department of Critical Care Medicine, The Sixth People's Hospital of Shenyang, Shenyang, China
| | - Yu Chen
- Difficult and Complicated Liver Diseases and Artificial Liver Center, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Ling Yang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lichun Shao
- Department of Gastroenterology, Air Force Hospital of Northern Theater Command, Shenyang, China
| | - Andrea Mancuso
- Medicina Interna 1, Azienda di Rilievo Nazionale ad Alta Specializzazione Civico-Di Cristina-Benfratelli, Palermo, Italy
| | - Frank Tacke
- Department of Hepatology & Gastroenterology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Su Lin
- Liver Research Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Bimin Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Lei Liu
- Department of Infectious Diseases, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
- State Key Laboratory of Cancer Biology and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Teaching Hospital of China Medical University), Shenyang, China
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Zhuang Y, Xia S, Chen J, Ke J, Lin S, Lin Q, Tang X, Huang H, Zheng N, Wang Y, Chen F. Construction of a prediction model for rebleeding in patients with acute upper gastrointestinal bleeding. Eur J Med Res 2023; 28:351. [PMID: 37715244 PMCID: PMC10502990 DOI: 10.1186/s40001-023-01349-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 09/08/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND The incidence of rebleeding in patients with upper gastrointestinal bleeding (UGIB) remains despite advances in intervention approaches. Therefore, early prediction of the risk of rebleeding could help to greatly reduce the mortality rate in these patients. We aim to develop and validate a new prediction model to predict the probability of rebleeding in patients with AUGIB. METHODS A total of 1170 AUGIB patients who completed the procedure of emergency gastroscopy within 48 h of admission were included. Logistic regression analyses were performed to construct a new prediction model. A receiver operating characteristic curve, a line graph, and a calibration and decision curve were used to assess the predictive performance of our new prediction model and compare its performance with that of the AIMS65 scoring system to determine the predictive value of our prediction model. RESULTS A new prediction model was constructed based on Lactic acid (LAC), neutrophil percentage (NEUTP), platelet (PLT), albumin (ALB), and D-DIMER. The AUC values and their 95% confidence interval (CI) for the new prediction model and the AIMS65 score were 0.746 and 0.619, respectively, and 0.697-0.795 and 0.567-0.670, respectively. In the training group, the C index values based on the prediction model and the AIMS65 scoring system were 0.720 and 0.610, respectively. In the validation group, the C index values based on the prediction model and the AIMS65 scoring system were 0.828 and 0.667, respectively. The decision and calibration curve analysis also showed that the prediction model was superior to the AIMS65 scoring system in terms of accuracy of prediction, consistency, and net clinical benefit. CONCLUSION The prediction model can predict the probability of rebleeding in AUGIB patients after endoscopic hemostasis therapy.
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Affiliation(s)
- Yangping Zhuang
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fuzhou, China
- Department of Emergency, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
- Fujian Key Laboratory of Emergency Medicine, Fujian Provincial Hospital, Fuzhou, China
| | - Shaohuai Xia
- Department of Neurosurgery, Affiliated Hospital of Guilin Medical University, Guilin, 541001, Guangxi, China
| | - Junwei Chen
- Department of Emergency, The Affiliated Hospital of Putian University, Putian, Fujian, China
| | - Jun Ke
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Emergency Medicine, Fujian Provincial Hospital, Fuzhou, China
| | - Shirong Lin
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Emergency Medicine, Fujian Provincial Hospital, Fuzhou, China
| | - Qingming Lin
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Emergency Medicine, Fujian Provincial Hospital, Fuzhou, China
| | - Xiahong Tang
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Emergency Medicine, Fujian Provincial Hospital, Fuzhou, China
| | - Hanlin Huang
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Emergency Medicine, Fujian Provincial Hospital, Fuzhou, China
| | - Nan Zheng
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Emergency Medicine, Fujian Provincial Hospital, Fuzhou, China
| | - Yi Wang
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Feng Chen
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fuzhou, China.
- Fujian Key Laboratory of Emergency Medicine, Fujian Provincial Hospital, Fuzhou, China.
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Lieto E, Auricchio A, Belfiore MP, Del Sorbo G, De Sena G, Napolitano V, Ruggiero A, Galizia G, Cardella F. Mallory-Weiss syndrome from giant gastric trichobezoar: A case report. World J Gastrointest Surg 2023; 15:972-977. [PMID: 37342849 PMCID: PMC10277944 DOI: 10.4240/wjgs.v15.i5.972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/02/2023] [Accepted: 04/07/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Mallory-Weiss syndrome (MWS), representing a linear mucosal laceration at the gastroesophageal junction, is a quite frequent cause of upper gastrointestinal bleeding, usually induced by habitual vomiting. The subsequent cardiac ulceration in this condition is likely due to the concomitance of increased intragastric pressure and inappropriate closure of the gastroesophageal sphincter, collectively inducing ischemic mucosal damage. Usually, MWS is associated with all vomiting conditions, but it has also been described as a complication of prolonged endoscopic procedures or ingested foreign bodies.
CASE SUMMARY We described herein a case of upper gastrointestinal bleeding in a 16-year-old girl with MWS and chronic psychiatric distress, the latter of which deteriorated following her parents’ divorce. The patient, who was residing on a small island during the coronavirus disease 2019 pandemic lockdown period, presented with a 2-mo history of habitual vomiting, hematemesis, and a slight depressive mood. Ultimately, a huge intragastric obstructive trichobezoar was detected and discovered to be due to a hidden habit of continuously eating her own hair; this habit had persisted for the past 5 years until a drastic reduction in food intake and corresponding weight loss occurred. The relative isolation in her living status without school attendance had worsened her compulsory habit. The hair agglomeration had reached such enormous dimensions and its firmness was so hard that its potential for endoscopic treatment was judged to be impossible. The patient underwent surgical intervention instead, which culminated in complete removal of the mass.
CONCLUSION According to our knowledge, this is the first-ever described case of MWS due to an excessively large trichobezoar.
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Affiliation(s)
- Eva Lieto
- Department of Translational Medical Sciences, University of Campania L. Vanvitelli, Napoli 80138, Campania, Italy
| | - Annamaria Auricchio
- Department of Translational Medical Sciences, University of Campania L. Vanvitelli, Napoli 80138, Campania, Italy
| | - Maria Paola Belfiore
- Department of Precision Medicine, University of Campania L. Vanvitelli, Napoli 80138, Campania, Italy
| | - Giovanni Del Sorbo
- Department of Translational Medical Sciences, University of Campania L. Vanvitelli, Napoli 80138, Campania, Italy
| | - Gabriele De Sena
- Department of Translational Medical Sciences, University of Campania L. Vanvitelli, Napoli 80138, Campania, Italy
| | - Vincenzo Napolitano
- Department of Translational Medical Sciences, University of Campania L. Vanvitelli, Napoli 80138, Campania, Italy
| | - Alessio Ruggiero
- Department of Translational Medical Sciences, University of Campania L. Vanvitelli, Napoli 80138, Campania, Italy
| | - Gennaro Galizia
- Department of Translational Medical Sciences, University of Campania L. Vanvitelli, Napoli 80138, Campania, Italy
| | - Francesca Cardella
- Department of Translational Medical Sciences, University of Campania L. Vanvitelli, Napoli 80138, Campania, Italy
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Yau T, Tai D, Chan SL, Huang YH, Choo SP, Hsu C, Cheung TT, Lin SM, Yong WP, Lee J, Leung T, Shum T, Yeung CS, Tai AYP, Law ALY, Cheng AL, Chen LT. Systemic Treatment of Advanced Unresectable Hepatocellular Carcinoma after First-Line Therapy: Expert Recommendations from Hong Kong, Singapore, and Taiwan. Liver Cancer 2022; 11:426-439. [PMID: 36158587 PMCID: PMC9485972 DOI: 10.1159/000525582] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 05/25/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Asia has a high burden of hepatocellular carcinoma (HCC) due to the high rates of chronic hepatitis B infection and accounts for 70% of HCC cases globally. In the past 20 years, the systemic treatment landscape of advanced HCC has evolved substantially - from tyrosine kinase inhibitors to immune-oncology agents plus anti-vascular endothelial growth factor agents. The appropriate sequence of therapies has become critical in optimizing patient outcomes given the increase in systemic therapeutic options. This article evaluates the evidence and provides expert recommendations for the use of systemic therapies after first-line treatment in patients with advanced HCC. SUMMARY Based on three virtual meetings held in early 2021, a team of 17 experts comprising oncologists, a hepatologist, and a hepatobiliary surgeon from Hong Kong, Singapore, and Taiwan reviewed available data about systemic treatments for HCC after first line and formulated 28 statements. These statements aimed to provide expert guidance on selecting first and subsequent lines of therapies as well as recommending therapies in special circumstances, such as poor liver function, posttransplantation, recent gastrointestinal bleeding, or autoimmune diseases. Data supporting the statements were drawn from clinical trials and real-world studies. The 28 statements were then evaluated anonymously using a 5-point Likert scale, and 24 reached consensus, predefined as achieving 75% agreement. Statements generated covered the selection of first-line systemic therapy, considerations and goals of second-line systemic therapies, treatment selection following first-line therapy, and treatment recommendations following first-line tyrosine kinase inhibitors, immune-oncology monotherapy, or immune-oncology combination therapy. The authors also shared expert opinion on the use of second-line systemic therapy in patients with liver dysfunction, liver transplantation, and recent gastrointestinal or autoimmune disease. KEY MESSAGES These expert statements summarize the latest data and expert opinion on selecting systemic treatment following first-line therapy in patients with unresectable advanced or metastatic HCC.
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Affiliation(s)
- Thomas Yau
- Department of Medicine, The University of Hong Kong, Hong Kong, China,*Thomas Yau,
| | - David Tai
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Stephen Lam Chan
- Department of Clinical Oncology, The Chinese University of Hong Kong, Hong Kong, China
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, Taipei, Taiwan,Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | | | - Chiun Hsu
- Department of Medical Oncology, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Tan To Cheung
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Shi-Ming Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkuo, Taiwan
| | - Wei Peng Yong
- Department of Haematology-Oncology, National University of Singapore, Singapore, Singapore
| | - Joycelyn Lee
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Thomas Leung
- Department of Medical Oncology, Hong Kong Sanatorium & Hospital, Hong Kong, China
| | - Tracy Shum
- Department of Oncology, Princess Margaret Hospital, Hong Kong, China
| | | | - Anna Yin-Ping Tai
- Department of Clinical Oncology, Queen Elizabeth Hospital, Hong Kong, China
| | | | - Ann-Lii Cheng
- Department of Internal Medicine and Oncology, National Taiwan University Hospital, Taipei, Taiwan,Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Li-Tzong Chen
- National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan,Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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Roy S, Giles T, Majid A. Portal vein stenting in the management of duodenal varices due to malignant obstruction: A case report and literature review. Int J Surg Case Rep 2022; 95:107246. [PMID: 35661928 PMCID: PMC9163501 DOI: 10.1016/j.ijscr.2022.107246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/20/2022] [Accepted: 05/21/2022] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Ectopic varices of the small bowel are a rare complication of portal hypertension. There are various aetiologies that can cause portal vein hypertension such as portal vein obstruction. Each of these pathologies has their own management strategies. Currently, there is a paucity of literature demonstrating the best management for patients with malignant portal vein obstruction leading to these varices. CASE PRESENTATION This report presents a case of a 66-year-old female who presented with recurrent per-rectal bleeding. Computed tomography angiography diagnosed duodenal varices in the context of malignant obstruction of the portal vein. Due to being a poor operative candidate, she underwent trans-hepatic portal vein stenting leading to resolution of her symptoms. CLINICAL DISCUSSION To date, the management of portal vein obstruction due to various aetiologies has only been reported in case reports with no significant large-scale studies providing recommendations on the most appropriate treatment. This case demonstrates the role of palliative stenting for patients with portal hypertension due to malignant portal vein obstruction. CONCLUSION Duodenal varices are a rare complication of portal vein obstruction. This article contributes to the literature by demonstrating that patients with complications associated with portal vein obstruction can benefit from stenting. For those with malignant obstruction, palliative stenting serves as an important therapeutic option.
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Affiliation(s)
- Susmit Roy
- Department of General Surgery, Calvary Mater Hospital, Waratah, NSW 2298, Australia; Discipline of Surgery, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia; Department of General Surgery, John Hunter Hospital, New Lambton Heights, NSW 2305, Australia.
| | - Thomas Giles
- Department of General Surgery, John Hunter Hospital, New Lambton Heights, NSW 2305, Australia
| | - Adeeb Majid
- Department of General Surgery, Calvary Mater Hospital, Waratah, NSW 2298, Australia; Discipline of Surgery, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
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Demetiou G, Augoustaki A, Kalaitzakis E. Endoscopic management and outcome of non-variceal bleeding in patients with liver cirrhosis: A systematic review. World J Gastrointest Endosc 2022. [DOI: 10.4253/wjge.v14.i3.164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Demetriou G, Augoustaki A, Kalaitzakis E. Endoscopic management and outcome of non-variceal bleeding in patients with liver cirrhosis: A systematic review. World J Gastrointest Endosc 2022; 14:163-175. [PMID: 35432740 PMCID: PMC8984531 DOI: 10.4253/wjge.v14.i3.163] [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: 06/30/2021] [Revised: 10/08/2021] [Accepted: 02/10/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute non-variceal bleeding accounts for approximately 20% of all-cause bleeding episodes in patients with liver cirrhosis. It is associated with high morbidity and mortality therefore prompt diagnosis and endoscopic management are crucial.
AIM To evaluate available data on the efficacy of endoscopic treatment modalities used to control acute non-variceal gastrointestinal bleeding (GIB) in cirrhotic patients as well as to assess treatment outcomes.
METHODS Employing PRISMA methodology, the MEDLINE was searched through PubMed using appropriate MeSH terms. Data are reported in a summative manner and separately for each major non-variceal cause of bleeding.
RESULTS Overall, 23 studies were identified with a total of 1288 cirrhotic patients of whom 958/1288 underwent endoscopic therapy for acute non-variceal GIB. Peptic ulcer bleeding was the most common cause of acute non-variceal bleeding, followed by portal hypertensive gastropathy, gastric antral vascular ectasia, Mallory-Weiss syndrome, Dieaulafoy lesions, portal hypertensive colopathy, and hemorrhoids. Failure to control bleeding from all-causes of non-variceal GIB accounted for less than 3.5% of cirrhotic patients. Rebleeding (range 2%-25%) and mortality (range 3%-40%) rates varied, presumably due to study heterogeneity. Rebleeding was usually managed endoscopically and salvage therapy using arterial embolisation or surgery was undertaken in very few cases. Mortality was usually associated with liver function deterioration and other organ failure or infections rather than uncontrolled bleeding. Endoscopic treatment-related complications were extremely rare. Lower acute non-variceal bleeding was examined in two studies (197/1288 patients) achieving initial hemostasis in all patients using argon plasma coagulation for portal hypertensive colopathy and endoscopic band ligation or sclerotherapy for bleeding hemorrhoids (rebleeding range 10%-13%). Data on the efficacy of endoscopic therapy of cirrhotic patients vs non-cirrhotic controls with acute GIB are very scarce.
CONCLUSION Endotherapy seems to be efficient as a means to control non-variceal hemorrhage in cirrhosis, although published data are very limited, particularly those comparing cirrhotics with non-cirrhotics and those regarding acute bleeding from the lower gastrointestinal tract. Rebleeding and mortality rates appear to be relatively high, although firm conclusions may not be drawn due to study heterogeneity. Hopefully this review may stimulate further research on this subject and help clinicians administer optimal endoscopic therapy for cirrhotic patients.
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Affiliation(s)
- Georgios Demetriou
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion 71500, Greece
| | - Aikaterini Augoustaki
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion 71500, Greece
| | - Evangelos Kalaitzakis
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion 71500, Greece
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Tangcheewinsirikul N, Moonla C, Uaprasert N, Pittayanon R, Rojnuckarin P. Viscoelastometric versus standard coagulation tests to guide periprocedural transfusion in adults with cirrhosis: A meta-analysis of randomized controlled trials. Vox Sang 2021; 117:553-561. [PMID: 34911140 DOI: 10.1111/vox.13225] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/23/2021] [Accepted: 11/08/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Due to rebalanced haemostasis in cirrhosis, viscoelastometric testing (VET) is more accurate than standard coagulation tests (SCTs) in preprocedural haemostatic evaluation, resulting in decreased unnecessary transfusion. We aimed to determine the impact of VET-guided strategy on postprocedural bleeding, periprocedural transfusion rates and quantities, transfusion-related adverse events (TRAEs), lengths of stay (LOS) and mortality from randomized controlled trials (RCTs) of cirrhotic patients. METHODS PubMed and EMBASE were searched for RCTs comparing VET-guided with SCT-guided transfusion in cirrhotic adults undergoing esophagogastroduodenoscopy, liver transplantation or other invasive interventions. Using random-effects models, the pooled risk ratios (RRs) and/or mean differences (MDs) of postprocedural bleeding-free events and the other outcomes were estimated alongside 95% confidence intervals (CIs). RESULTS Of seven included RCTs (n = 421; 72.2% men; mean age 49.1 years), VET-guided transfusion did not change postprocedural bleeding-free statuses (RR 1.05; 95% CI 0.94-1.17). However, VET-based algorithms decreased the rates of fresh frozen plasma (FFP; RR 0.52; 95% CI 0.35-0.77) and platelet transfusions (RR 0.34; 95% CI 0.16-0.73), the quantities of transfused FFP (MD -1.39 units; 95% CI -2.18 to -0.60), platelets (MD -1.06 units; 95% CI -2.01 to -0.12) and cryoprecipitate (MD -7.13 units; 95% CI -14.20 to -0.07) and the risk of TRAEs (RR 0.42; 95% CI 0.27-0.65). The overall mortality rates and LOS were not significantly different between two groups. CONCLUSION Compared with conventional SCT-guided, VET-guided strategy decreases periprocedural plasma and platelet transfusions and TRAEs, without increasing haemorrhagic complications, LOS or mortality in cirrhosis.
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Affiliation(s)
- Nuanrat Tangcheewinsirikul
- Division of Haematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Research Unit in Translational Haematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Chatphatai Moonla
- Research Unit in Translational Haematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Division of General Internal Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Noppacharn Uaprasert
- Division of Haematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Research Unit in Translational Haematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Rapat Pittayanon
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Ponlapat Rojnuckarin
- Division of Haematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Research Unit in Translational Haematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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10
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Zullo A, Soncini M, Bucci C, Marmo R. Clinical outcomes in cirrhotics with variceal or nonvariceal gastrointestinal bleeding: A prospective, multicenter cohort study. J Gastroenterol Hepatol 2021; 36:3219-3223. [PMID: 34189770 DOI: 10.1111/jgh.15601] [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: 04/23/2021] [Revised: 06/14/2021] [Accepted: 06/26/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Upper gastrointestinal bleeding (UGIB) is associated with a distinct mortality in cirrhotics. We evaluated whether the rate of mortality and other outcomes differs between variceal and nonvariceal UGIB. METHODS This was a prospective, multicenter, cohort study on UGIB cirrhotics observed in 50 hospitals. Variceal or nonvariceal UGIB were diagnosed at endoscopy. The 6-week mortality rate, need of blood transfusion, intensive care unit (ICU) admission, radiologic or surgical intervention, rebleeding rate, and length of stay in hospital were the main clinical outcomes compared. Data were analyzed at univariate and multivariate analysis, and odds ratio (OR) with their 95% confidence interval (CI) was calculated. RESULTS The study enrolled 706 cirrhotics, including 516 (73%) variceal and 190 (27%) nonvariceal UGIB. There were 78 (11%; 95% CI = 8.7-13.4) deceases, without any difference between variceal (11.0%) and nonvariceal (11.0%) groups. Child-Pugh score C (OR: 6.99; 95% CI = 2.58-18.95), and development of either hepatorenal syndrome (OR: 16.5; 95% CI = 7.02-38.9) or hepatic encephalopathy (OR: 2.38; 95% CI = 1.25-4.5) were independent predictors of mortality. Transfusions and onset of hepatic encephalopathy were significantly more frequent in variceal, whereas ICU admission rate was higher in nonvariceal bleedings. Overall, antibiotic prophylaxis was eventually administered in only 392 (55.5%) patients. CONCLUSIONS Data found that the overall mortality rate in cirrhotics with UGIB seems to be reducing and that the value did not differ between variceal and nonvariceal types. Prevention of both hepatorenal syndrome and hepatic encephalopathy and implementation of antibiotic prophylaxis could improve survival in these patients.
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Affiliation(s)
- Angelo Zullo
- Gastroenterology Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Marco Soncini
- Department of Internal Medicine, "A. Manzoni" Hospital, Lecco, Italy
| | - Cristina Bucci
- Gastroenterology Unit, L. Curto Hospital, Polla, Salerno, Italy
| | - Riccardo Marmo
- Gastroenterology Unit, L. Curto Hospital, Polla, Salerno, Italy
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11
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High Rate of Gastrointestinal Bleeding in Patients with Secondary Sclerosing Cholangitis in Critically Ill Patients (SC-CIP). J Clin Med 2021; 10:jcm10091925. [PMID: 33946877 PMCID: PMC8125451 DOI: 10.3390/jcm10091925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/21/2021] [Accepted: 04/27/2021] [Indexed: 11/26/2022] Open
Abstract
Secondary sclerosing cholangitis in critically ill patients (SC-CIP) is a rare cholestatic liver disease triggered by long-term intensive care treatment. The aim of this study was to evaluate the frequency and characteristics of gastrointestinal bleeding in SC-CIP. Patients with diagnosed SC-CIP were retrospectively identified and compared to a control group of patients with cardiac surgery and intensive care treatment but without the development of SC-CIP. Fifty-three patients with SC-CIP and 19 controls were included in the study. The frequency of gastrointestinal bleeding was 30% in SC-CIP (16 patients) and 5% in the control group (1 patient) (p = 0.03). Bleeding occured in the mean 13 months after admission to an intensive care unit in SC-CIP, three patients (19%) suffered bleeding during intensive care treatment. Three SC-CIP patients (19%) had cirrhosis at the time of bleeding, five (31%) had splenomegaly, and four (25%) received oral anticoagulation. In SC-CIP, 13 bleedings were identified in the upper gastrointestinal tract, two in the lower, and one remained unknown. The most common reasons for bleeding were gastroduodenal ulcers. In total, 80% of patients needed blood units, and one death due to bleeding occurred in SC-CIP. In conclusion, gastrointestinal bleeding is a frequent complication in patients with SC-CIP. Whether the liver disease itself or cofactors cause the susceptibility for bleeding remains unclear.
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12
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Kothari HG, Gupta SJ, Gaikwad NR, Sankalecha TH, Samarth AR. Role of non-invasive markers in prediction of esophageal varices and variceal bleeding in patients of alcoholic liver cirrhosis from central India. TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 30:1036-1043. [PMID: 31854309 DOI: 10.5152/tjg.2019.18334] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND/AIMS Alcohol is the leading cause of liver cirrhosis, which results in portal hypertension and subsequently, culminates into esophageal varices and esophgeal variceal bleeding. Esophagogastroduodenoscopy is gold standard for diagnosis of varices. Non-invasive markers based on clinical, laboratory - ultrasonographic parameters can be utilised for prediction of risk of esophageal varices - variceal bleed in alcoholic cirrhosis from central India. MATERIALS AND METHODS This was a cross sectional observational study. Child Turcot Pugh scores, MELD, AST ALT Ratio(AAR), AST Platelet Ratio Index(APRI), FIB-4 index and Platelet count-Spleen diameter(PC/SD) ratio were calculated for all patients and correlated with esophagogastroduodenoscopy findings. Short term follow up was done for variceal bleeding. RESULTS Total 202 male patients were included with mean age of 43.77±9.95 years. 188(93%) patients had esophageal varices. 61(30.19%) patients had variceal bleeding. On univariate analysis platelet count, APRI, spleen bipolar diameter, and PC/SD ratio were significantly associated with varices. For prediction of esophageal varices, only PC/SD ratio was significant and showed area under the curve of 65.6% at cut-off of <997. CTP score, FIB-4, APRI, and PC/SD ratio were significant for variceal bleeding. At cut-off <985 PC/SD ratio had sensitivity of 82% and specificity of 63% with AUC of 78% for prediction of variceal bleeding. Also, FIB-4 and APRI had diagnostic accuracy of 64% and 61% with AUC of 74% and 72% respectively for bleed. CONCLUSION FIB-4 and PC/SD may be useful among armamentarium of non-invasive markers for predicting esophageal varices and risk of variceal bleeding in alcoholic liver cirrhosis.
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Affiliation(s)
- Harit Goverdhan Kothari
- Department of Gastroenterology, Government Medical College - Superspeciality Hospital, Nagpur, Maharashtra, India
| | - Sudhir Jagdishoprasad Gupta
- Department of Gastroenterology, Government Medical College - Superspeciality Hospital, Nagpur, Maharashtra, India
| | - Nitin Rangrao Gaikwad
- Department of Gastroenterology, Government Medical College - Superspeciality Hospital, Nagpur, Maharashtra, India
| | - Tushar Hiralal Sankalecha
- Department of Gastroenterology, Government Medical College - Superspeciality Hospital, Nagpur, Maharashtra, India
| | - Amol Rajendra Samarth
- Department of Gastroenterology, Government Medical College - Superspeciality Hospital, Nagpur, Maharashtra, India
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13
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Lee YR, Park SY, Tak WY. Treatment Outcomes and Prognostic Factors of Acute Variceal Bleeding in Patients with Hepatocellular Carcinoma. Gut Liver 2020; 14:500-508. [PMID: 31816673 PMCID: PMC7366146 DOI: 10.5009/gnl19155] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/08/2019] [Accepted: 08/27/2019] [Indexed: 12/12/2022] Open
Abstract
Background/Aims The treatment outcomes and prognostic markers of acute variceal bleeding (AVB) in hepatocellular carcinoma (HCC) patients remain unclear. Therefore, we evaluated the clinical outcomes and prognostic factors of AVB in HCC patients. Methods Cirrhotic patients with endoscopically confirmed AVB between 2007 and 2013 were enrolled in this prospective study. Prognostic factors were identified by multivariate Cox proportional hazards regression analysis. Results Among the 329 enrolled patients, 125 patients (38.0%) were diagnosed with HCC. The 6-week mortality rates of all enrolled AVB patients and the HCC subgroup were 14.9% and 26.4%. The 5-day treatment failure, 6-week mortality, cirrhosis-related complications, and duration of hospitalization were greater in HCC patients than in non-HCC patients (all p<0.05). In the HCC subgroup, the Model for End-Stage Liver Disease (MELD) score (hazard ratio [HR], 1.145; p=0.001) and Barcelona Clinic Liver Cancer (BCLC) stage (C-D vs 0-B) (HR, 3.096; p=0.019) were independent predictors of 6-week mortality. Our study revealed that 85% of HCC patients with both a MELD score ≥15.5 and BCLC stage C-D died within 6 weeks, and the 6-week mortality risk was 21-fold higher in this group than in the group with a lower MELD score and earlier HCC stage (p<0.001). Conclusions The 5-day treatment failure and 6-week mortality rates were significantly higher among AVB patients with HCC than those without HCC. The MELD score and the presence and stage of HCC are strong predictors of 6-week mortality in patients with AVB.
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Affiliation(s)
- Yu Rim Lee
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Soo Young Park
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Won Young Tak
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
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14
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Allaire M, Walter A, Sutter O, Nahon P, Ganne-Carrié N, Amathieu R, Nault JC. TIPS for management of portal-hypertension-related complications in patients with cirrhosis. Clin Res Hepatol Gastroenterol 2020; 44:249-263. [PMID: 31662286 DOI: 10.1016/j.clinre.2019.09.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 08/25/2019] [Accepted: 09/13/2019] [Indexed: 02/04/2023]
Abstract
Portal hypertension is primarily due to liver cirrhosis, and is responsible for complications that include variceal bleeding, ascites and hepatorenal syndrome. The transjugular intrahepatic portosystemic shunt (TIPS) is a low-resistance channel between the portal vein and the hepatic vein, created by interventional radiology, that aims to reduce portal pressure. TIPS is a potential treatment for severe portal-hypertension-related complications, including esophageal and gastric variceal bleeding. TIPS is currently indicated as salvage therapy in this setting when patients fail to respond to standard endoscopic and medical treatment. More recently, early TIPS has been shown to be effective in decreasing risk of rebleeding after variceal hemorrhage and mortality in Child-Pugh B patients with active hemorrhage at endoscopy, and in Child-Pugh C patients. TIPS is also an efficient treatment for refractory ascites and hepatic hydrothorax. In contrast, the role of TIPS in the hepatorenal syndrome has not been precisely defined. The aim of this review was to specifically describe the current role of TIPS in management of portal hypertension in patients with cirrhosis.
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Affiliation(s)
- Manon Allaire
- Service d'hépato-gastroentérologie, CHU Côte-de-Nacre, Caen, France
| | - Aurélie Walter
- Service d'hépato-gastroentérologie, CHU Côte-de-Nacre, Caen, France
| | - Olivier Sutter
- Service de radiologie, hôpital Jean-Verdier, hôpitaux universitaires Paris-Seine-Saint-Denis, Assistance publique Hôpitaux de Paris, Bondy, France
| | - Pierre Nahon
- Service d'hépatologie, hôpital Jean-Verdier, hôpitaux universitaires Paris-Seine-Saint-Denis, Assistance publique des Hôpitaux de Paris, 93143 Bondy, France; Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris 13, Laboratoire génomique fonctionnelle des tumeurs solides, 75006 Paris, France; Unité de formation et de recherche santé médecine et biologie humaine, université Paris 13, communauté d'universités et établissements Sorbonne Paris Cité, Paris, France
| | - Nathalie Ganne-Carrié
- Service d'hépatologie, hôpital Jean-Verdier, hôpitaux universitaires Paris-Seine-Saint-Denis, Assistance publique des Hôpitaux de Paris, 93143 Bondy, France; Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris 13, Laboratoire génomique fonctionnelle des tumeurs solides, 75006 Paris, France; Unité de formation et de recherche santé médecine et biologie humaine, université Paris 13, communauté d'universités et établissements Sorbonne Paris Cité, Paris, France
| | - Roland Amathieu
- Unité de formation et de recherche santé médecine et biologie humaine, université Paris 13, communauté d'universités et établissements Sorbonne Paris Cité, Paris, France; Réanimation polyvalente, hôpital Jean-Verdier, hôpitaux universitaires Paris-Seine-Saint-Denis, Assistance publique des Hôpitaux de Paris, Bondy, France
| | - Jean-Charles Nault
- Service d'hépatologie, hôpital Jean-Verdier, hôpitaux universitaires Paris-Seine-Saint-Denis, Assistance publique des Hôpitaux de Paris, 93143 Bondy, France; Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris 13, Laboratoire génomique fonctionnelle des tumeurs solides, 75006 Paris, France; Unité de formation et de recherche santé médecine et biologie humaine, université Paris 13, communauté d'universités et établissements Sorbonne Paris Cité, Paris, France.
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15
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Patients with Liver Cirrhosis as Frequent Attenders of Emergency Departments. Emerg Med Int 2020; 2020:8289275. [PMID: 32104605 PMCID: PMC7036124 DOI: 10.1155/2020/8289275] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 12/17/2019] [Accepted: 01/11/2020] [Indexed: 01/07/2023] Open
Abstract
Objectives Frequent attendance for nonemergency problems to emergency departments (EDs) contributes to ED overcrowding, resulting in medical care delays, increased medical errors, and social and economic burdens. Most studies regarding frequent attenders of EDs examine general patients without classifying certain subgroups. This study aimed to investigate patients with liver cirrhosis who present repeatedly to the ED. Methods This was a retrospective, observational cohort study of adult patients with a history of liver cirrhosis presenting to the ED from January 2011 to December 2015. We included patients with cirrhosis whose first ED visit occurred during the study period. We went far back for 20 years and excluded patients with any ED visits (including both cirrhosis and noncirrhosis-related ones) before the study period. We categorized frequent attenders as patients with more than 4 ED visits within 12 months after the first ED visit; infrequent attenders were those who did not meet this criterion. Results A total of 3513 patients with cirrhosis were included in this retrospective cohort study. Compared with the infrequent attenders, frequent attenders had a higher rate of presentations due to hepatic encephalopathy (15.2% vs 13.7%, P < 0.001) and ascites (10% vs 4%, P < 0.001) and ascites (10% vs 4%, P < 0.001) and ascites (10% vs 4%. Conclusions Hepatic encephalopathy and ascites account for more ED visits in frequent than in infrequent attenders. Our findings provide information for those planning outpatient support for patients with cirrhosis. Further research is warranted.
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16
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Chen W, Zhu XN, Wang J, Zhu LL, Gan T, Yang JL. Risk factors for Mallory-Weiss Tear during endoscopic submucosal dissection of superficial esophageal neoplasms. World J Gastroenterol 2019; 25:5174-5184. [PMID: 31558865 PMCID: PMC6747285 DOI: 10.3748/wjg.v25.i34.5174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 06/15/2019] [Accepted: 06/25/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Adverse events during endoscopic submucosal dissection (ESD) of superficial esophageal neoplasms, such as perforation and bleeding, have been well-documented. However, the Mallory-Weiss Tear (MWT) during esophageal ESD remains under investigation. AIM To investigate the incidence and risk factors of the MWT during esophageal ESD. METHODS From June 2014 to July 2017, patients with superficial esophageal neoplasms who received ESD in our institution were retrospectively analyzed. The clinicopathological characteristics of the patients were collected. Patients were divided into an MWT group and non-MWT group based on whether MWT occurred during ESD. The incidence of MWTs was determined, and the risk factors for MWT were then further explored. RESULTS A total of 337 patients with 373 lesions treated by ESD were analyzed. Twenty patients developed MWTs during ESD (5.4%). Multivariate analysis identified that female sex (OR = 5.36, 95%CI: 1.47-19.50, P = 0.011) and procedure time longer than 88.5 min (OR = 3.953, 95%CI: 1.497-10.417, P = 0.005) were independent risk factors for an MWT during ESD. The cutoff value of the procedure time for an MWT was 88.5 min (sensitivity, 65.0%; specificity, 70.8%). Seven of the MWT patients received endoscopic hemostasis. All patients recovered satisfactorily without surgery for the laceration. CONCLUSION The incidence of MWTs during esophageal ESD was much higher than expected. Although most cases have a benign course, fatal conditions may occur. We recommend inspection of the stomach during and after the ESD procedure for timely management in cases of bleeding MWTs or even perforation outside of the procedure region.
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Affiliation(s)
- Wei Chen
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xiao-Nan Zhu
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jin Wang
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Lin-Lin Zhu
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Tao Gan
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jin-Lin Yang
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
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17
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Optimal endoscopy timing according to the severity of underlying liver disease in patients with acute variceal bleeding. Dig Liver Dis 2019; 51:993-998. [PMID: 30803858 DOI: 10.1016/j.dld.2019.01.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 12/10/2018] [Accepted: 01/14/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Current guidelines recommend endoscopic therapy to be performed within 12 h for acute variceal bleeding (AVB). However, the optimal timing of endoscopic therapy for AVB remains unclear. AIMS To examine the relationship between the endoscopy timing and clinical outcomes in AVB, with emphasis on liver function and endoscopy timing. METHODS From January 2010 to June 2017, cirrhotic patients with AVB confirmed by endoscopy were evaluated. The primary outcome was a composite of 6-week rebleeding and mortality. We stratified patients according to the MELD score. RESULTS In 411 patients, the overall composite outcome rate was 30.9% (n = 127) at 6 week. Patients who underwent urgent endoscopy (≤12 h) had a significantly higher composite outcome than patients who underwent non-urgent endoscopy (>12 h) (34.4% vs. 19.1%; P = 0.005). Low-risk patients who underwent urgent endoscopy were more likely to reach the composite outcome (adjusted OR, 0.84 per 4 h; 95% CI, 0.73-0.98; P = 0.027). These findings persisted even after adjustment for baseline characteristics between the urgent and non-urgent groups. CONCLUSIONS Urgent endoscopy is significantly associated with a poorer outcome in patients with AVB, especially in low-risk patients. Our result provides a treatment strategy according to the severity of underlying liver disease in patients with AVB.
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18
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Hernández-Gea V, Procopet B, Giráldez Á, Amitrano L, Villanueva C, Thabut D, Ibañez-Samaniego L, Silva-Junior G, Martinez J, Genescà J, Bureau C, Trebicka J, Llop E, Laleman W, Palazon JM, Castellote J, Rodrigues S, Gluud LL, Noronha Ferreira C, Barcelo R, Cañete N, Rodríguez M, Ferlitsch A, Mundi JL, Gronbaek H, Hernández-Guerra M, Sassatelli R, Dell'Era A, Senzolo M, Abraldes JG, Romero-Gómez M, Zipprich A, Casas M, Masnou H, Primignani M, Krag A, Nevens F, Calleja JL, Jansen C, Robic MA, Conejo I, Catalina MV, Albillos A, Rudler M, Alvarado E, Guardascione MA, Tantau M, Bosch J, Torres F, Garcia-Pagán JC. Preemptive-TIPS Improves Outcome in High-Risk Variceal Bleeding: An Observational Study. Hepatology 2019; 69:282-293. [PMID: 30014519 DOI: 10.1002/hep.30182] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 06/26/2018] [Indexed: 12/11/2022]
Abstract
Patients admitted with acute variceal bleeding (AVB) and Child-Pugh C score (CP-C) or Child-Pugh B plus active bleeding at endoscopy (CP-B+AB) are at high risk for treatment failure, rebleeding, and mortality. A preemptive transjugular intrahepatic portosystemic shunt (p-TIPS) has been shown to improve survival in these patients, but its use in clinical practice has been challenged and not routinely incorporated. The present study aimed to further validate the role of preemptive TIPS in a large number of high-risk patients. This multicenter, international, observational study included 671 patients from 34 centers admitted for AVB and high risk of treatment failure. Patients were managed according to current guidelines, and use of drugs and endoscopic therapy (D+E) or p-TIPS was based on individual center policy. p-TIPS in the setting of AVB is associated with a lower mortality in CP-C patients compared with D+E (1 year mortality 22% vs. 47% in D+E group; P = 0.002). Mortality rate in CP-B+AB patients was low, and p-TIPS did not improve it. In CP-C and CP-B+AB patients, p-TIPS reduced treatment failure and rebleeding (1-year cumulative incidence function probability of remaining free of the composite endpoint: 92% vs. 74% in the D+E group; P = 0.017) and development of de novo or worsening of previous ascites without increasing rates of hepatic encephalopathy. Conclusion: p-TIPS must be the treatment of choice in CP-C patients with AVB. Because of the strong benefit in preventing further bleeding and ascites, p-TIPS could be a good treatment strategy for CP-B+AB patients.
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Affiliation(s)
- Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi I i Sunyer, IMDIM, University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas, Madrid, Spain
| | - Bogdan Procopet
- Regional Institute of Gastroenterology and Hepatology "Octavian Fodor", Hepatology Department and "Iuliu Hatieganu" University of Medicine and Pharmacy, 3rd Medical Clinic, Cluj-Napoca, Romania
| | - Álvaro Giráldez
- Clinical Management Unit of Digestive Diseases, University Hospital Virgen del Rocio, Seville, Spain
| | - Lucio Amitrano
- Gastroenterology Unit, Ospedale A Cardarelli, Naples, Italy
| | - Candid Villanueva
- Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas, Madrid, Spain.,Servei de Patologia Digestiva, Hospital de la Santa Creu i Sant Pau and CIBERehd, Barcelona, Spain
| | - Dominique Thabut
- Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Paris, France
| | - Luis Ibañez-Samaniego
- Servicio de Medicina de Aparato Digestivo Gregorio Marañón, Hospital General Universitario Gregorio Marañón, liSGM, CIBERehd, Barcelona, Spain
| | - Gilberto Silva-Junior
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi I i Sunyer, IMDIM, University of Barcelona, Barcelona, Spain
| | - Javier Martinez
- Department of Gastroenterology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Alcalá, CIBERehd, Madrid, Spain
| | - Joan Genescà
- Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas, Madrid, Spain.,Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona and CIBERehd, Barcelona, Spain
| | - Christophe Bureau
- Department of Hepato-Gastroenterology, Purpan Hospital, CHU Toulouse, INSERM U858, University of Toulouse, France, Toulouse, France
| | - Jonel Trebicka
- Department of Internal Medicine I, University of Bonn, Bonn, Germany.,European Foundation for the Study of Chronic Liver Failure (EF-Clif), Barcelona, Spain.,Institute for Bioengineering of Catalonia, Barcelona, Spain.,Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Elba Llop
- Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas, Madrid, Spain.,Liver Unit, Hospital U, Puerta de Hierro. Universidad Autònoma de Madrid, CIBERehd, Madrid, Spain
| | - Wim Laleman
- Department of Liver and Biliopancreatic Disorders, University of Leuven, Leuven, Belgium
| | | | - Jose Castellote
- Gastroenterology Department, Hepatology Unit, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, Barcelona, Spain
| | - Susana Rodrigues
- Gastroenterology and Hepatology Department, Centro Hospitalar São João, Porto, Portugal
| | - Lise L Gluud
- Gastrounit, Medical Division, University Hospital of Hvidovre, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Carlos Noronha Ferreira
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Rafael Barcelo
- Medical Statistics Core Facility, Institut D'Investigacions Biomédiques August Pi i Sunyer, Hospital Clinic Barcelona, Barcelona, Spain
| | - Nuria Cañete
- Liver Section, Gastroenterology Department, Hospital del Mar, Universitat Autònoma de Barcelona, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Manuel Rodríguez
- Department of Gastroenterology, Hospital Central de Asturias, Oviedo, Spain
| | - Arnulf Ferlitsch
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Jose Luis Mundi
- Department of Gastroenterology, University Hospital San Cecilio, Granada, Spain
| | - Henning Gronbaek
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Manuel Hernández-Guerra
- Gastroenterology Department, University Hospital of the Canary Islands, La Laguna, Tenerife, Spain
| | - Romano Sassatelli
- Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Alessandra Dell'Era
- Gastroenterology Unit, ASST Fatebenefratelli Sacco, Department of Clinical and Biomedical Sciences, University of the Studies of Milan, Milan, Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Juan G Abraldes
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), CEGIIR, University of Alberta, Edmonton, Canada
| | - Manuel Romero-Gómez
- Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas, Madrid, Spain.,Unidad de Hepatología, Hospital Universitario de Valme, CIBERehd, Sevilla, Spain
| | - Alexander Zipprich
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Meritxell Casas
- Hepatology Unit, Digestive Disease Department Hospital de Sabadell, Universitat Autónoma de Barcelona, Sabadell, Spain
| | - Helena Masnou
- Hospital Universitari Germans Trias i Pujol, Universitat Autònoma Barcelona, Badalona, Spain
| | - Massimo Primignani
- Division of Gastroenterology and Hepatology, IRCCS Ca' Granda Maggiore Hospital Foundation, University of Milan, Milan, Italy
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Frederik Nevens
- Department of Liver and Biliopancreatic Disorders, University of Leuven, Leuven, Belgium
| | - Jose Luis Calleja
- Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas, Madrid, Spain.,Liver Unit, Hospital U, Puerta de Hierro. Universidad Autònoma de Madrid, CIBERehd, Madrid, Spain
| | - Christian Jansen
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Marie Angèle Robic
- Department of Hepato-Gastroenterology, Purpan Hospital, CHU Toulouse, INSERM U858, University of Toulouse, France, Toulouse, France
| | - Irene Conejo
- Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas, Madrid, Spain.,Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona and CIBERehd, Barcelona, Spain
| | - Maria-Vega Catalina
- Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas, Madrid, Spain.,Servicio de Medicina de Aparato Digestivo Gregorio Marañón, Hospital General Universitario Gregorio Marañón, liSGM, CIBERehd, Barcelona, Spain
| | - Agustin Albillos
- Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Alcalá, CIBERehd, Madrid, Spain
| | - Marika Rudler
- Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Paris, France
| | - Edilmar Alvarado
- Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas, Madrid, Spain.,Servei de Patologia Digestiva, Hospital de la Santa Creu i Sant Pau and CIBERehd, Barcelona, Spain
| | | | - Marcel Tantau
- Regional Institute of Gastroenterology and Hepatology "Octavian Fodor", Hepatology Department and "Iuliu Hatieganu" University of Medicine and Pharmacy, 3rd Medical Clinic, Cluj-Napoca, Romania
| | - Jaime Bosch
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi I i Sunyer, IMDIM, University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas, Madrid, Spain.,Swiss Liver Centre, Inselspital, Bern University, Bern, Switzerland
| | - Ferran Torres
- Medical Statistics Core Facility, Institut D'Investigacions Biomédiques August Pi i Sunyer, Hospital Clinic Barcelona, Barcelona, Spain.,Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Carlos Garcia-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi I i Sunyer, IMDIM, University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas, Madrid, Spain
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Lee CH, Yoon H, Choi YJ, Jang ES, Kim J, Shin CM, Park YS, Hwang JH, Kim JW, Jeong SH, Kim N, Lee DH, Kim JS. Predictive factors of therapeutic intervention in on-call endoscopy for suspected gastrointestinal bleeding. Scand J Gastroenterol 2018; 53:958-963. [PMID: 30134741 DOI: 10.1080/00365521.2018.1493533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Performing an endoscopy out of hours confer significant burdens on limited health-care resources. However, not all on-call endoscopies lead to therapeutic interventions. The purpose of the present study was to analyze predictive factors for performing therapeutic intervention in patients with suspected gastrointestinal bleeding. METHODS We reviewed and analyzed electronic medical records regarding on-call endoscopy that were prospectively collected for quality control. The subjects were patients with suspected gastrointestinal bleeding who underwent on-call endoscopies at night, on weekends and on holidays between April 2013 and January 2017 in Seoul National University Bundang Hospital. To determine predictive factors for performing therapeutic intervention, the following variables were analyzed: symptoms, patient status, coexisting disease, laboratory findings and medications. To clarify the association between the likelihood of therapeutic intervention in on-call endoscopy and AIMS65 score, the included variables were divided by cutoffs. RESULTS A total of 270 patients (male: 72.6%, mean age: 62.6 years) with suspected gastrointestinal bleeding had on-call endoscopies and 153 (56.7%) patients had therapeutic intervention. Gastroscopy, colonoscopy and both endoscopic techniques were performed in 215, 42 and 13 patients, respectively. In the multivariate analysis, hematemesis (p < .001, odds ratio [OR], 2.484) and prolonged prothrombin time-international normalized ratio (PT-INR) (p = .033; OR, 1.958) were correlated with performing therapeutic intervention in on-call endoscopy. AIMS65 score with a cutoff of 2 was associated with the likelihood of intervention (p = .043). CONCLUSIONS Hematemesis and prolonged PT-INR were predictive factors of therapeutic intervention when on-call endoscopy was performed in patients with suspected gastrointestinal bleeding.
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Affiliation(s)
- Chan Hyung Lee
- a Department of Internal Medicine and Liver Research Institute , Seoul National University College of Medicine , Seoul , South Korea.,b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Hyuk Yoon
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Yoon Jin Choi
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Eun Sun Jang
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Jaihwan Kim
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Cheol Min Shin
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Young Soo Park
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Jin-Hyeok Hwang
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Jin-Wook Kim
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Sook-Hayng Jeong
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Nayoung Kim
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Dong Ho Lee
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Joo Sung Kim
- a Department of Internal Medicine and Liver Research Institute , Seoul National University College of Medicine , Seoul , South Korea
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20
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Abstract
Acute variceal bleeding should be suspected in all patients with cirrhosis presenting with upper gastrointestinal bleeding. Vasoactive drugs and prophylactic antibiotics must be started as soon as possible, even before performing the diagnostic endoscopy. Once the patient is hemodynamically stable, upper gastrointestinal endoscopy should be performed in order to confirm the diagnosis and provide endoscopic therapy (preferably banding ligation). After this initial approach, the most appropriate therapy to prevent both early and late rebleeding must be instituted following a risk stratification strategy. The present chapter will focus on the initial management of patients with acute variceal bleeding, including general management and hemostatic therapies, as well as the available treatments in case of failure to control bleeding or development of rebleeding.
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21
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Risk Factors for an Iatrogenic Mallory-Weiss Tear Requiring Bleeding Control during a Screening Upper Endoscopy. Gastroenterol Res Pract 2017; 2017:5454791. [PMID: 28348579 PMCID: PMC5350415 DOI: 10.1155/2017/5454791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 01/30/2017] [Accepted: 01/31/2017] [Indexed: 01/13/2023] Open
Abstract
Background and Aim. In some cases of iatrogenic Mallory-Weiss tears (MWTs), hemostasis is needed due to severe mucosal tearing with bleeding. Therefore, we aimed to evaluate the risk factors for severe iatrogenic MWTs and the methods of endoscopic bleeding control. Materials and Methods. Between January 2008 and December 2012, 426,085 cases of screening upper endoscopy were performed at the Asan Medical Center. We retrospectively analyzed the risk factors for severe iatrogenic MWTs requiring an endoscopic procedure and the treatment modalities of bleeding control. Results. Iatrogenic MWTs occurred in 546 cases (0.13%) of screening upper endoscopy in 539 patients. Bleeding control due to severe bleeding was applied in 71 cases (13.0%), and rebleeding after initial bleeding control occurred in 1 case. Multivariate analysis showed that old age, a history of distal gastrectomy, and a less-experienced endoscopist (fewer than 2,237.5 endoscopic procedures at the time of the MWT) were associated with severe iatrogenic MWTs requiring an endoscopic procedure. Among 71 cases requiring bleeding control, a hemoclip was used in 81.7% (58 cases). Conclusions. Screening endoscopy procedures should be carefully performed when patients are in their old age and have a history of distal gastrectomy, particularly if the endoscopist is less experienced.
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Budimir I, Gradišer M, Nikolić M, Baršić N, Ljubičić N, Kralj D, Budimir I. Glasgow Blatchford, pre-endoscopic Rockall and AIMS65 scores show no difference in predicting rebleeding rate and mortality in variceal bleeding. Scand J Gastroenterol 2016; 51:1375-9. [PMID: 27356670 DOI: 10.1080/00365521.2016.1200138] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To compare the performance of the Glasgow Blatchford score (GBS), pre-endoscopic Rockall score (PRS) and AIMS65 score in predicting specific clinical endpoints following variceal upper gastrointestinal hemorrhage (UGIH). MATERIAL AND METHODS Between January 2008 and December 2013, we retrospectively analyzed 225 consecutive hospitalized patients managed for endoscopically confirmed UGIH. RESULTS A total of 225 patients (mean age 61.3 years), mostly diagnosed with alcoholic cirrhosis (195/86.7%), presented with variceal UGIH during the study period. Rebleeding occurred in 22 (9.8%) patients and 30-day mortality was 39 (17.3%). Initial hemostasis was achieved with N-butyl cyanoacrylate (151/79.1%) and endoscopic variceal ligation (40/20.9%), while secondary rebleeding prophylaxis in 110 (48.9%) patients was accomplished using endoscopic variceal ligation (92%). The majority of patients died from the underlying disease, while 12 (30.8%) died from bleeding. Median hospital stay was 6 (1-35) days. There was no statistically significant difference among AIMS65, GBS and PRS in predicting mortality (AUROC 0.70 vs. 0.64 vs. 0.66) or rebleeding rates (AUROC 0.74 vs. 0.60 vs. 0.67). The GBS was superior in predicting the need for blood transfusion compared to AIMS65 score (AUROC 0.75 vs. 0.61, p = 0.01) and PRS (AUROC 0.75 vs. 0.58, p = 0.009). CONCLUSIONS The AIMS65, GBS and PRS scores are comparable but not useful for predicting outcome in patients with variceal UGIH because of poor discriminative ability. The GBS is superior in predicting the need for transfusion compared to AIMS65 score and PRS.
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Affiliation(s)
- Ivan Budimir
- a Division of Gastroenterology, Department of Internal Medicine , "Sestre Milosrdnice" University Hospital Centre, School of Medicine and Dental Medicine, University of Zagreb , Zagreb , Croatia
| | - Marina Gradišer
- b Department of Internal Medicine , County Hospital Čakovec , Čakovec , Croatia
| | - Marko Nikolić
- a Division of Gastroenterology, Department of Internal Medicine , "Sestre Milosrdnice" University Hospital Centre, School of Medicine and Dental Medicine, University of Zagreb , Zagreb , Croatia
| | - Neven Baršić
- a Division of Gastroenterology, Department of Internal Medicine , "Sestre Milosrdnice" University Hospital Centre, School of Medicine and Dental Medicine, University of Zagreb , Zagreb , Croatia
| | - Neven Ljubičić
- a Division of Gastroenterology, Department of Internal Medicine , "Sestre Milosrdnice" University Hospital Centre, School of Medicine and Dental Medicine, University of Zagreb , Zagreb , Croatia
| | - Dominik Kralj
- a Division of Gastroenterology, Department of Internal Medicine , "Sestre Milosrdnice" University Hospital Centre, School of Medicine and Dental Medicine, University of Zagreb , Zagreb , Croatia
| | - Ivan Budimir
- c Magdalena - Clinic for Cardiovascular Diseases of the Faculty of Osijek , Krapinske Toplice , Croatia
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Lee S, Ahn JY, Jung HY, Jung KW, Lee JH, Kim DH, Choi KD, Song HJ, Lee GH, Kim JH, Kim SO. Effective endoscopic treatment of Mallory-Weiss syndrome using Glasgow-Blatchford score and Forrest classification. J Dig Dis 2016; 17:676-684. [PMID: 27624697 DOI: 10.1111/1751-2980.12409] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 09/07/2016] [Accepted: 09/12/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVES There is limited data on whether scoring systems can be used to predict clinical outcomes in patients with upper gastrointestinal bleeding due to Mallory-Weiss syndrome (MWS). We aimed to evaluate whether the Glasgow-Blatchford score (GBS) could be effective in predicting clinical outcomes of bleeding MWS and to investigate the predictive ability of the Forrest classification for rebleeding and assess the effective endoscopic modalities for bleeding control in MWS. METHODS From January 2004 to December 2012 168 patients were diagnosed with MWS in the Asan Medical Center Emergency Department. We analyzed their clinical outcomes, including endoscopic treatment, transfusion and admission as well as the rates of rebleeding and mortality using GBS and the Forrest classification, retrospectively. RESULTS Endoscopic treatment was applied to patients. The GBS was significantly higher in patients treated with endoscopic therapy than in the conservative treatment group (6.8 ± 3.7 vs 5.1 ± 4.7, P = 0.011). In patients with a GBS of >6 the rates of endoscopic treatment and rebleeding and the need for transfusion and admission were significantly higher (all P < 0.05). The Forrest classification was able to predict recurrent bleeding (area under the receiver operating characteristic curve 0.723, 95% confidence interval 0.609-0.836, P = 0.025). Hemoclip-based therapy and band ligation achieved higher success rates than did injection therapy alone in preventing rebleeding (96.4%, 88.9% and 71.4%, P = 0.013). CONCLUSION In MWS, GBS might be useful for predicting clinical outcomes and the Forrest classification in predicting recurrent bleeding.
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Affiliation(s)
- Sunpyo Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, Seoul, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, Seoul, Korea
| | - Kee Don Choi
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, Seoul, Korea
| | - Ho June Song
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, Seoul, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, Seoul, Korea
| | - Jin-Ho Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, Seoul, Korea
| | - Seon-Ok Kim
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, Seoul, Korea
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Origin, Clinical Characteristics and 30-Day Outcomes of Severe Hematochezia in Cirrhotics and Non-cirrhotics. Dig Dis Sci 2016; 61:2732-40. [PMID: 27286877 PMCID: PMC5602600 DOI: 10.1007/s10620-016-4198-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 05/10/2016] [Indexed: 12/09/2022]
Abstract
BACKGROUND The sites of origin, causes and outcomes of severe hematochezia have not been compared between cirrhotics and non-cirrhotics. In cirrhotics versus non-cirrhotics presenting with severe hematochezia, we aimed at (1) identifying the site and etiology of gastro-intestinal bleeding and independent predictors of bleeding from the upper gastrointestinal tract versus small bowel or the colon, (2) comparing 30-day clinical outcomes, and (3) proposing an algorithm for management of severe hematochezia. METHODS In this cohort study from two university-based medical centers, 860 consecutive patients with severe hematochezia admitted from 1995 to 2011 were prospectively enrolled with 160 (18.6 %) cirrhotics. We studied (a) general clinical and laboratory characteristics of cirrhotics versus non-cirrhotics, (b) predictors of bleeding sites in each patient group by multiple variable regression analysis, and compared (c) 30-day outcomes, including rebleeding, surgery and deaths. RESULTS Cirrhosis independently predicted an upper gastrointestinal source of bleeding (OR 3.47; 95 % CI 2.01-5.96) as well as history of hematemesis, melena in the past 30 days, positive nasogastric aspirate, prior upper gastrointestinal bleeding or use of aspirin or non-steroidal anti-inflammatory. The most prevalent diagnoses were esophageal varices (20 %) in cirrhotics and colon diverticular bleeding (27.1 %) in non-cirrhotics. Thirty-day rates of rebleeding, surgical interventions and deaths were 23.1 versus 15 % (P = 0.01), 14.4 versus 6.4 % (P < 0.001), and 17.5 versus 4.1 % (P < 0.001), in cirrhotics versus non-cirrhotics, respectively. CONCLUSIONS Cirrhosis predicted an upper gastrointestinal site of bleeding in patients presenting with severe hematochezia. The 30-day rates of rebleeding, surgery, and death were significantly higher in cirrhotics than in non-cirrhotics.
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Upper Gastrointestinal Bleeding in Chronic Kidney Disease Patients. CURRENT HEALTH SCIENCES JOURNAL 2016; 42:226-230. [PMID: 30581576 PMCID: PMC6269606 DOI: 10.12865/chsj.42.03.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 09/01/2016] [Indexed: 11/24/2022]
Abstract
Aim: To investigate upper GI bleeding as a particular complication in chronic kidney disease patients. Material and methhod: 30 chronic kidney disease patients admitted to the Nephrology Department for upper gastrointestinal bleeding over a period of 5 years. Results: 16 patients were undergoing hemodialysis (53.3%) and 14 patients were not in a hemodialysis program. There were no patients undergoing peritoneal dialysis. Very high comorbidity rate for all patients, most important being cardiovascular diseases. Only 10% of patients had oral anticoagulant treatment prior to GI bleeding. Conservative treatment was successful for all patients; no endoscopic or surgical haemostasis was needed. Conclusion: Although chronic disease kidney patients have a high risk of upper GI bleeding compared to the general population, the conservative treatment applied has a very high rate of success in stopping the bleeding without the need for endoscopic or surgical haemostasis treatment.
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Nojkov B, Cappell MS. Distinctive aspects of peptic ulcer disease, Dieulafoy's lesion, and Mallory-Weiss syndrome in patients with advanced alcoholic liver disease or cirrhosis. World J Gastroenterol 2016; 22:446-466. [PMID: 26755890 PMCID: PMC4698507 DOI: 10.3748/wjg.v22.i1.446] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/11/2015] [Accepted: 11/24/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To systematically review the data on distinctive aspects of peptic ulcer disease (PUD), Dieulafoy’s lesion (DL), and Mallory-Weiss syndrome (MWS) in patients with advanced alcoholic liver disease (aALD), including alcoholic hepatitis or alcoholic cirrhosis.
METHODS: Computerized literature search performed via PubMed using the following medical subject heading terms and keywords: “alcoholic liver disease”, “alcoholic hepatitis”,“ alcoholic cirrhosis”, “cirrhosis”, “liver disease”, “upper gastrointestinal bleeding”, “non-variceal upper gastrointestinal bleeding”, “PUD”, ‘‘DL’’, ‘‘Mallory-Weiss tear”, and “MWS’’.
RESULTS: While the majority of acute gastrointestinal (GI) bleeding with aALD is related to portal hypertension, about 30%-40% of acute GI bleeding in patients with aALD is unrelated to portal hypertension. Such bleeding constitutes an important complication of aALD because of its frequency, severity, and associated mortality. Patients with cirrhosis have a markedly increased risk of PUD, which further increases with the progression of cirrhosis. Patients with cirrhosis or aALD and peptic ulcer bleeding (PUB) have worse clinical outcomes than other patients with PUB, including uncontrolled bleeding, rebleeding, and mortality. Alcohol consumption, nonsteroidal anti-inflammatory drug use, and portal hypertension may have a pathogenic role in the development of PUD in patients with aALD. Limited data suggest that Helicobacter pylori does not play a significant role in the pathogenesis of PUD in most cirrhotic patients. The frequency of bleeding from DL appears to be increased in patients with aALD. DL may be associated with an especially high mortality in these patients. MWS is strongly associated with heavy alcohol consumption from binge drinking or chronic alcoholism, and is associated with aALD. Patients with aALD have more severe MWS bleeding and are more likely to rebleed when compared to non-cirrhotics. Pre-endoscopic management of acute GI bleeding in patients with aALD unrelated to portal hypertension is similar to the management of aALD patients with GI bleeding from portal hypertension, because clinical distinction before endoscopy is difficult. Most patients require intensive care unit admission and attention to avoid over-transfusion, to correct electrolyte abnormalities and coagulopathies, and to administer antibiotic prophylaxis. Alcoholics should receive thiamine and be closely monitored for symptoms of alcohol withdrawal. Prompt endoscopy, after initial resuscitation, is essential to diagnose and appropriately treat these patients. Generally, the same endoscopic hemostatic techniques are used in patients bleeding from PUD, DL, or MWS in patients with aALD as in the general population.
CONCLUSION: Nonvariceal upper GI bleeding in patients with aALD has clinically important differences from that in the general population without aALD, including: more frequent and more severe bleeding from PUD, DL, or MWS.
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Gabr MA, Tawfik MAER, El-Sawy AAA. Non-variceal upper gastrointestinal bleeding in cirrhotic patients in Nile Delta. Indian J Gastroenterol 2016; 35:25-32. [PMID: 26884125 DOI: 10.1007/s12664-016-0622-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 01/20/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND STUDY AIMS Acute upper gastrointestinal bleeding (AUGIB) in cirrhotic patients occurs mainly from esophageal and gastric varices; however, quite a large number of cirrhotic patients bleed from other sources as well. The aim of the present work is to determine the prevalence of non-variceal UGIB as well as its different causes among the cirrhotic portal hypertensive patients in Nile Delta. METHODS Emergency upper gastrointestinal (UGI) endoscopy for AUGIB was done in 650 patients. Out of these patients, 550 (84.6%) patients who were proved to have cirrhosis were the subject of the present study. RESULTS From all cirrhotic portal hypertensive patients, 415 (75.5%) bled from variceal sources (esophageal and gastric) while 135 (24.5%) of them bled from non-variceal sources. Among variceal sources of bleeding, esophageal varices were much more common than gastric varices. Peptic ulcer was the most common non-variceal source of bleeding. CONCLUSIONS Non-variceal bleeding in cirrhosis was not frequent, and sources included peptic ulcer, portal hypertensive gastropathy, and erosive disease of the stomach and duodenum.
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Affiliation(s)
- Mamdouh Ahmed Gabr
- Hepatogastroenterology and Endoscopy Unit, Internal Medicine Department, Tanta University Hospital, Tanta, Egypt
| | - Mohamed Abd El-Raouf Tawfik
- Hepatogastroenterology and Endoscopy Unit, Internal Medicine Department, Tanta University Hospital, Tanta, Egypt.
| | - Abd Allah Ahmed El-Sawy
- Hepatogastroenterology and Endoscopy Unit, Internal Medicine Department, Tanta University Hospital, Tanta, Egypt
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Higher free serum cortisol is associated with worse survival in acute variceal bleeding because of cirrhosis: a prospective study. Eur J Gastroenterol Hepatol 2014; 26:1125-32. [PMID: 25089543 DOI: 10.1097/meg.0000000000000158] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Critical illness-related corticosteroid insufficiency has been reported in acute variceal bleeding (AVB). In cirrhosis, free serum cortisol (FC) is considered optimal to assess adrenal function. Salivary cortisol (SC) is considered a surrogate for FC. We evaluated FC and its prognostic role in AVB. METHODS Total serum cortisol, SC, cortisol-binding globulin, and FC (Coolens' formula) were evaluated in AVB (n=38) and in stable cirrhosis (CC) (n=31). A Cox proportional hazards model was evaluated for 6-week survival. RESULTS In AVB, the median FC and SC levels were higher with worse liver dysfunction [Child-Pugh (CP) A/B/C: 1.59/2.62/3.26 μg/dl, P=0.019; CPA/B/C: 0.48/0.897/1.81 μg/ml, P<0.001, respectively]. In AVB compared with CC, median total serum cortisol: 24.3 versus 11.6 μg/dl (P<0.001), SC: 0.86 versus 0.407 μg/ml (P<0.001); FC 2.4 versus 0.57 μg/dl (P<0.001). In AVB, 5-day rebleeding was 10.5%, and 6-week and total mortality were 21.1 and 23.7%, respectively. Independent associations with 6-week mortality in AVB were FC at least 3.2 μg/dl (P<0.001), hepatocellular carcinoma (P<0.001), CPC (P<0.001), and early rebleeding (P<0.001). Among patients with normal cortisol-binding globulin (n=14) and albumin (n=31), the factors were hepatocellular carcinoma (P=0.003), CP (P=0.003), and FC (P=0.036). SC was also found to be an independent predictor of 6-week mortality (P<0.001). Area under the curve of FC for predicting 6-week mortality was 0.79. CONCLUSION Higher FC is present in cirrhosis with AVB compared with CC and is associated independently with bleeding-related mortality. However, whether high FC solely indicates the severity of illness or whether there is significant adrenal insufficiency cannot be discerned.
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A risk scoring system to predict in-hospital mortality in patients with cirrhosis presenting with upper gastrointestinal bleeding. J Clin Gastroenterol 2014; 48:712-20. [PMID: 24172184 DOI: 10.1097/mcg.0000000000000014] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
GOALS We aimed to develop a simple and practical risk scoring system to predict in-hospital mortality in cirrhotics presenting with upper gastrointestinal (GI) bleeding. STUDY Extensive clinical data were captured in patients with documented cirrhosis who underwent endoscopic evaluation for upper GI bleeding between January 1, 2003 and June 30, 2011 at Parkland Memorial Hospital. Predictors of mortality were identified by multivariate regression analysis. RESULTS A total of 884 patients with cirrhosis admitted for upper GI bleeding were identified; 809 patients survived and 75 died (8.4%). The etiology of bleeding was similar in both groups, with bleeding attributed to esophageal varices in 59% of survivors and 60% of non-survivors (ulcer disease and other etiologies of bleeding accounted for the other causes of bleeding). Mortality was 8.6% and 8.3% in patients with variceal bleeding and nonvariceal bleeding, respectively. While survivors and those who died were similarly matched with regard to gender, age, ethnicity and etiology of cirrhosis, patients who died had lower systolic blood pressures, higher pulse rates and lower mean arterial pressures at admission than patients who survived. Non-survivors were more likely to be Childs C (61% vs. 19%, P<0.001). Multivariate regression analysis identified the following 4 predictors of in-hospital mortality: use of vasoactive pressors, number of packed red blood cells transfused, model for end-stage liver disease (MELD) score, and serum albumin. A receiver operating characteristic curve including these 4 variables yielded an area under the receiver operating characteristic (AUROC) curve of 0.94 (95% confidence interval, 0.91-0.98). Classification and Regression Tree analysis yielded similar results, identifying vasoactive pressors and then MELD>21 as the most important decision nodes for predicting death. By comparison, using the Rockall scoring system in the same patients, the AUROC curve was 0.70 (95% confidence interval, 0.64-0.76 and the comparison of the University of Texas Southwestern model to the Rockall model revealed P<0.0001). A validation set comprised of 150 unique admissions between July 1, 2011 and July 31, 2012, had an AUROC of 0.92, and the outcomes of 97% of the subjects in this set were accurately predicted by the risk score model. CONCLUSIONS Use of vasoactive agents, packed red blood cell transfusion, albumin, and MELD score were highly predictive of in-hospital mortality in cirrhotics presenting with upper GI bleeding. These variables were used to formulate a clinical risk scoring system for in-hospital mortality, which is available at: http://medweb.musc.edu/LogisticModelPredictor.
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Jairath V, Rehal S, Logan R, Kahan B, Hearnshaw S, Stanworth S, Travis S, Murphy M, Palmer K, Burroughs A. Acute variceal haemorrhage in the United Kingdom: patient characteristics, management and outcomes in a nationwide audit. Dig Liver Dis 2014; 46:419-26. [PMID: 24433997 DOI: 10.1016/j.dld.2013.12.010] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 12/03/2013] [Accepted: 12/07/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite advances in treatment, acute variceal haemorrhage remains life-threatening. AIM To describe contemporary characteristics, management and outcomes of patients with cirrhosis and acute variceal haemorrhage and risk factors for rebleeding and mortality. METHODS Multi-centre clinical audit conducted in 212 UK hospitals. RESULTS In 526 cases of acute variceal haemorrhage, 66% underwent endoscopy within 24h with 64% (n=339) receiving endoscopic therapy. Prior to endoscopy, 57% (n=299) received proton pump inhibitors, 44% (n=232) vasopressors and 27% (n=144) antibiotics. 73% (n=386) received red cell transfusion, 35% (n=184) fresh frozen plasma and 14% (n=76) platelets, with widely varying transfusion thresholds. 26% (n=135) experienced further bleeding and 15% (n=80) died by day 30. The Model for End Stage Liver Disease score was the best predictor of mortality (area under the receiver operating curve=0.74, P<0.001). Neither the clinical nor full Rockall scores were useful predictors of outcome. Coagulopathy was strongly associated with rebleeding (odds ratio 2.23, 95% CI 1.22-4.07, P=0.01, up to day 30) and mortality (odds ratio 3.06, 95% CI 1.29-7.26, P=0.01). CONCLUSIONS Although mortality has improved following acute variceal haemorrhage, rebleeding rates remain appreciably high. There are notable deficiencies in the use of vasopressors and endoscopic therapy. More work is needed to understand the optimum transfusion strategies. Better risk stratification tools are required to identify patients needing more intensive support.
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Affiliation(s)
- Vipul Jairath
- NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK; Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK.
| | | | - Richard Logan
- Division of Epidemiology and Public Health & Nottingham Digestive Disease Centre, University of Nottingham, UK
| | | | | | | | - Simon Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - Michael Murphy
- NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK
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Lu Y, Loffroy R, Lau JYW, Barkun A. Multidisciplinary management strategies for acute non-variceal upper gastrointestinal bleeding. Br J Surg 2013; 101:e34-50. [PMID: 24277160 DOI: 10.1002/bjs.9351] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2013] [Indexed: 01/12/2023]
Abstract
BACKGROUND The modern management of acute non-variceal upper gastrointestinal bleeding is centred on endoscopy, with recourse to interventional radiology and surgery in refractory cases. The appropriate use of intervention to optimize outcomes is reviewed. METHODS A literature search was undertaken of PubMed and the Cochrane Central Register of Controlled Trials between January 1990 and April 2013 using validated search terms (with restrictions) relevant to upper gastrointestinal bleeding. RESULTS Appropriate and adequate resuscitation, and risk stratification using validated scores should be initiated at diagnosis. Coagulopathy should be corrected along with blood transfusions, aiming for an international normalized ratio of less than 2·5 to proceed with possible endoscopic haemostasis and a haemoglobin level of 70 g/l (excluding patients with severe bleeding or ischaemia). Prokinetics and proton pump inhibitors (PPIs) can be administered while awaiting endoscopy, although they do not affect rebleeding, surgery or mortality rates. Endoscopic haemostasis using thermal or mechanical therapies alone or in combination with injection should be used in all patients with high-risk stigmata (Forrest I-IIb) within 24 h of presentation (possibly within 12 h if there is severe bleeding), followed by a 72-h intravenous infusion of PPI that has been shown to decrease further rebleeding, surgery and mortality. A second attempt at endoscopic haemostasis is generally made in patients with rebleeding. Uncontrolled bleeding should be treated with targeted or empirical transcatheter arterial embolization. Surgical intervention is required in the event of failure of endoscopic and radiological measures. Secondary PPI prophylaxis when indicated and Helicobacter pylori eradication are necessary to decrease recurrent bleeding, keeping in mind the increased false-negative testing rates in the setting of acute bleeding. CONCLUSION An evidence-based approach with multidisciplinary collaboration is required to optimize outcomes of patients presenting with acute non-variceal upper gastrointestinal bleeding.
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Affiliation(s)
- Y Lu
- Division of Gastroenterology and
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Simon EG, Chacko A, Dutta AK, Joseph AJ, George B. Acute nonvariceal upper gastrointestinal bleeding--experience of a tertiary care center in southern India. Indian J Gastroenterol 2013; 32:236-41. [PMID: 23526425 DOI: 10.1007/s12664-013-0305-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 02/02/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Over the last few decades, epidemiologic studies from the West have shown changing trends in etiology and clinical outcomes in patients with nonvariceal upper gastrointestinal bleed (NVUGIB). There are limited data from India on the current status of NVUGIB. The aim of this study therefore was to assess the etiological profile and outcomes of patients with NVUGIB at our center. METHODS We prospectively studied all patients (≥15 years) who presented with NVUGIB over a period of 1 year. The clinical and laboratory data, details of endoscopy, and course in hospital were systematically recorded. Outcome measures assessed were rebleeding rate, surgery, and mortality. RESULTS Two hundred and fourteen patients (age, ≥15 years) presented to us with NVUGIB during the study period. The mean age was 49.9 ± 16.8 years and 73.8 % were males. Peptic ulcer was the commonest cause (32.2 %) of NVUGIB. About one third of patients required endoscopic therapy. Rebleeding occurred in 8.9 % patients, surgery was required in 3.7 %, and mortality rate was 5.1 %. Rebleeding and mortality were significantly higher among inpatients developing acute NVUGIB compared to those presenting directly to the emergency room. CONCLUSIONS Peptic ulcer was the most common cause of NVUGIB. Outcomes (rebleed, surgery, and mortality) at our center appear similar to those currently being reported from the West.
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Affiliation(s)
- Ebby George Simon
- Clinical Gastroenterology and Hepatology, Christian Medical College, Vellore 632 004, India
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Jo YW, Choi JY, Ha CY, Min HJ, Lee OJ. The Clinical Features and Prognostic Factors of Nonvariceal Upper Gastrointestinal Bleeding in the Patients with Liver Cirrhosis. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2013. [DOI: 10.7704/kjhugr.2013.13.4.235] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Yoon-Won Jo
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Ja-Yoon Choi
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Chang-Yoon Ha
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
- Gyeongsang Institute of Health Sciences, Jinju, Korea
| | - Hyun-Ju Min
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
- Gyeongsang Institute of Health Sciences, Jinju, Korea
| | - Ok-Jae Lee
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
- Gyeongsang Institute of Health Sciences, Jinju, Korea
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Wang HY, Chen MJ, Lin CC, Chen CJ, Liu CY, Wang TE, Sun FJ, Lin SC, Shih SC. Gastric Variceal Bleeding in the Elderly. INT J GERONTOL 2012. [DOI: 10.1016/j.ijge.2012.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Non-variceal gastrointestinal bleeding in patients with liver cirrhosis: a review. Dig Dis Sci 2012; 57:2743-54. [PMID: 22661272 DOI: 10.1007/s10620-012-2229-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 05/01/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Non-variceal gastrointestinal (NVGI) bleeding in cirrhosis may be associated with life-threatening complications similar to variceal bleeding. AIM To review NVGI bleeding in cirrhosis. METHODS MEDLINE, Scopus, and ISI Web of Knowledge were searched, using the textwords "portal hypertensive gastropathy," "gastric vascular ectasia," "peptic ulcer," "Dieulafoy's," "Mallory-Weiss syndrome," "portal hypertensive enteropathy," "portal hypertensive colopathy," "hemorrhoids," and "cirrhosis." RESULTS Portal hypertensive gastropathy (PHG) and gastric vascular ectasia (GVE) are gastric lesions that most commonly present as chronic anemia; acute upper GI (UGI) bleeding is a rare manifestation. Management of PHG-related bleeding is mainly pharmacological, whereas endoscopic intervention is favored in GVE-related bleeding. Shunt therapies or more invasive techniques are restricted in refractory cases. Despite its high incidence in cirrhotic patients, peptic ulcer accounts for a relatively small proportion of UGI bleeding in this patient population. However, in contrary to general population, the pathogenetic role of Helicobacter pylori infection remains questionable. Finally, other causes of UGI bleeding include Dieulafoy's lesion, Mallory-Weiss syndrome, and portal hypertensive enteropathy. The most common non-variceal endoscopic findings reported in patients with lower gastrointestinal bleeding are portal hypertensive colopathy and hemorrhoids. However, the vast majority of studies are case reports and, therefore, the incidence, diagnosis, and risk of bleeding remain undefined. Endoscopic interventions, shunting procedures, and surgical techniques have been described in this setting. CONCLUSIONS The data on NVGI bleeding in liver cirrhosis are surprisingly scanty. Large, multicenter epidemiological studies are needed to better assess prevalence and incidence and, most importantly, randomized studies should be performed to evaluate the success rates of therapeutic algorithms.
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Hsu YC, Lin JT, Chen TT, Wu MS, Wu CY. Long-term risk of recurrent peptic ulcer bleeding in patients with liver cirrhosis: a 10-year nationwide cohort study. Hepatology 2012; 56:698-705. [PMID: 22378148 DOI: 10.1002/hep.25684] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Accepted: 02/15/2012] [Indexed: 02/06/2023]
Abstract
UNLABELLED Peptic ulcer bleeding leads to substantial morbidity and mortality in patients with liver cirrhosis, but their long-term risk of recurrent bleeding remains elusive. This nationwide cohort study aimed to elucidate the association between cirrhosis and recurrent peptic ulcer bleeding by analyzing the Taiwan National Health Insurance Research Database. We enrolled a total of 9,711 patients who had cirrhosis with clinical complications of portal hypertension from all patients (n = 271,030) hospitalized for peptic ulcer bleeding between January 1997 and December 2006, along with 38,844 controls who were matched at a 1:4 proportion for age, sex, and antisecretory agents. We accounted for death as the competing cause of risk when calculating the cumulative incidences and hazard ratios of recurrent bleeding during the 10-year study period. Overall, patients with cirrhosis had a significantly higher death-adjusted rebleeding rate compared with controls (1 year, 14.4% versus 11.3%; 5 years, 26.1% versus 22.5%; 10 years, 28.4% versus 27.1%; P < 0.001). The modified Cox proportional hazard model verified that cirrhosis was significantly associated with peptic ulcer rebleeding (adjusted hazard ratio, 3.19; 95% confidence interval, 2.62-3.88), but also uncovered a seemingly paradoxical interaction between cirrhosis and age. Multivariate stratified analysis further revealed that the rebleeding risk after adjustment for death diminished with age in patients with cirrhosis, whose risk of death far exceeded that of rebleeding when they grew old. CONCLUSION Liver cirrhosis is associated with long-term risk of recurrent peptic ulcer bleeding, although the risk declines with age because of death being the competing cause. Effective therapy should be sought to reduce this excessive risk in these critically ill patients, particularly for those at younger age with longer life expectancy.
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Affiliation(s)
- Yao-Chun Hsu
- Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
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Yang SC, Wu KL, Wang JH, Lee CH, Kuo YH, Tai WC, Chen CH, Chiou SS, Lu SN, Hu TH, Changchien CS, Chuah SK. The effect of systemic antibiotic prophylaxis for cirrhotic patients with peptic ulcer bleeding after endoscopic interventions. Hepatol Int 2012. [DOI: 10.1007/s12072-012-9378-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Yin A, Li Y, Jiang Y, Liu J, Luo H. Mallory-Weiss syndrome: clinical and endoscopic characteristics. Eur J Intern Med 2012; 23:e92-6. [PMID: 22560400 DOI: 10.1016/j.ejim.2012.02.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 02/07/2012] [Accepted: 02/08/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND Mallory-Weiss syndrome is defined by upper gastrointestinal bleeding from vomiting-induced mucosal lacerations at the esophago-gastric junction. This study was purposed to investigate the incidence, location, clinical manifestation, diagnosis and effectiveness of treatment (including endoscopic treatment and conservative medical treatment) of Mallory-Weiss syndrome in China. METHODS All patients who received emergency upper gastrointestinal endoscopy due to Mallory-Weiss syndrome from September 2007 to August 2011 at gastrointestinal endoscopy center of Renmin Hospital of Wuhan University were included in this study. The clinical presentation, medical history, location and characteristics of Mallory-Weiss syndrome methods and effectiveness of therapy of patients with Mallory-Weiss syndrome were retrospectively analyzed by chart reviews. Long-term follow-up data were collected at outpatient clinics or telephone interviews. RESULTS Sixteen patients were diagnosed with Mallory-Weiss syndrome, which account for 3.08% of 519 patients with acute non-variceal upper gastrointestinal bleeding. Common comorbidities were found in one patient with hepatic cirrhosis. Conservative medical treatment, local injection, hemoclipping, or multipolar electrocoagulation produced primary hemostasis in 87.5% (14/16) of patients. CONCLUSION Mallory-Weiss syndrome is uncommon in China in comparison with reported experience in the west when the same group of patients is selected. Different approaches to treatment are to be recommended depending on whether or not active hemorrhage is present.
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Affiliation(s)
- Anning Yin
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China.
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Zeitoun JD, Rosa-Hézode I, Chryssostalis A, Nalet B, Bour B, Arpurt JP, Denis J, Nahon S, Pariente A, Hagège H. Epidemiology and adherence to guidelines on the management of bleeding peptic ulcer: a prospective multicenter observational study in 1140 patients. Clin Res Hepatol Gastroenterol 2012; 36:227-34. [PMID: 22306054 DOI: 10.1016/j.clinre.2011.11.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Revised: 11/18/2011] [Accepted: 11/25/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Mortality of upper gastrointestinal bleeding seems declining. Whether practice guidelines for the management of peptic ulcer bleeding are followed is unknown. We aimed to update epidemiology of peptic ulcer bleeding and to assess the adherence to guidelines in the French community. METHODS Between March, 2005 and February, 2006, a prospective multicenter study was conducted including all patients with communautary upper gastrointestinal bleeding. Data from patients with peptic ulcer bleeding were extracted and analyzed. RESULTS Out of 3203 analyzable patients included, 1140 (35.6%) had a peptic ulcer bleeding and 965 of them a duodenal and/or gastric ulcer. Seven hundred and thirty-five were male (64.5%) and mean age was 66.4 years (±18.8). Overall, 699 patients (61.3%) were taking medication inducing upper gastrointestinal bleeding. Two-hundred and sixty-eight (23.5%) patients had endoscopic therapy, 190 (70.9%) of whom had epinephrine injection alone. Among the 349 patients with high risk stigmata on endoscopy (Forrest IA, IB, IIA), 209 (59.9%) underwent endoscopic therapy. One thousand one hundred and seven patients (97.1%) were given proton-pump inhibitors. One hundred and thirty-four patients (11.8%) experienced haemorrhagic recurrence. Forty-eight patients (4.2%) underwent surgery and 61 (5.4%) died. CONCLUSIONS Consistently with previous studies, mortality of upper gastrointestinal bleeding seems declining. Further progress lies above all in prevention but also probably in better adherence to therapeutic guidelines and management of comorbidities.
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Affiliation(s)
- Jean-David Zeitoun
- Department of gastroenterology, Henri-Mondor-hospital, 51, avenue du Maréchal-de-Lattre, 94010 Créteil, France.
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Lee YC, Chang CH, Lin JW, Chen HC, Lin MS, Lai MS. Non-steroidal anti-inflammatory drugs use and risk of upper gastrointestinal adverse events in cirrhotic patients. Liver Int 2012; 32:859-66. [PMID: 22226322 DOI: 10.1111/j.1478-3231.2011.02739.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 12/04/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIMS The upper gastrointestinal (GI) toxicity associated with non-steroidal anti-inflammatory drugs (NSAID) use among cirrhotic patients remains unclear. The objective of this study was to evaluate the risk of upper GI adverse events associated with celecoxib and oral and parenteral non-selective NSAIDs in cirrhotic patients. METHODS All the patients aged ≥ 20 years with a diagnosis of cirrhosis hospitalized for variceal bleeding and non-variceal upper GI adverse events (oesophageal, gastric, duodenal ulcer, bleeding; gastritis and duodenitis) in 2006 were identified using ICD-9-CM diagnosis codes from inpatient claims from the Taiwan National Health Insurance Database. In the case-crossover study design, the case period was defined as 1-30 days and the control period as 31-60 days before the date of hospitalization. The information for individual NSAID use was obtained from the outpatient pharmacy prescription database. Adjusted self-matched odds ratios (OR) and their 95% confidence intervals (CI) were estimated with a conditional logistic regression model. RESULTS A total of 4876 cirrhotic patients were included. The adjusted OR (95% CI) was 1.44 (0.89-2.31) for celecoxib, 1.87 (1.66-2.11) for oral non-selective NSAIDs and 1.90 (1.55-2.32) for parenteral NSAIDs overall. Risks were similar for variceal and non-variceal events. Concomitant use of proton pump inhibitors and histamine-2 receptor antagonists tended to decrease the upper GI toxicity associated with non-selective NSAIDs and celecoxib. CONCLUSION The use of nsNSAIDs but not celecoxib was associated with a two-fold increased risk of variceal and non-variceal upper GI events among cirrhotic patients.
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Affiliation(s)
- Yen-Chieh Lee
- Department of Family Medicine, Cathay General Hospital, Taipei, Taiwan
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Meneses DG, Pinto EALC, Tommaso AMAD. Uso de octreotida na hemorragia digestiva alta secundária à hipertensão portal em pacientes pediátricos: experiência de um serviço terciário. REVISTA PAULISTA DE PEDIATRIA 2011. [DOI: 10.1590/s0103-05822011000400021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJETIVO: Descrever a evolução clínica dos episódios de hemorragia digestiva em crianças portadoras de hipertensão portal, com e sem cirrose, tratadas com octreotida. MÉTODOS: Estudo retrospectivo e descritivo de 26 episódios de sangramento digestivo em 17 pacientes (média de idade: 8,6 anos; variação: sete meses a 18,9 anos), no período de 1998 a 2006, num hospital terciário universitário. O diagnóstico de hipertensão portal foi estabelecido por ultrassonografia e a cirrose foi confirmada pela histologia e classificada quanto à gravidade pelo escore de Child-Pugh. RESULTADOS: As causas da hipertensão portal foram: obstrução extra-hepática da veia porta em 11/17 casos (65%) e cirrose hepática em 6/17 (35%). O sangramento foi controlado em 14/17 pacientes (82%). O tempo de infusão da droga necessário para controle do sangramento foi semelhante entre cirróticos e não cirróticos, mas o declínio nos níveis de hemoglobina, o volume transfusional requerido e o tempo de internação foram maiores nos pacientes com cirrose, embora sem diferença estatística. Essas mesmas variáveis não se modificaram em relação aos dois diferentes esquemas de infusão da droga: com dose de ataque ou iniciando com dose de manutenção. Insucesso terapêutico foi observado com maior frequência entre os pacientes cirróticos (33%). Hiperglicemia foi o único efeito colateral detectado durante a infusão. CONCLUSÕES: A administração de octreotida em crianças e adolescentes com sangramento digestivo por hipertensão portal foi segura e efetiva no controle do sangramento agudo, independente da causa da hipertensão portal e do esquema de infusão.
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Epidemiology and demographics of upper gastrointestinal bleeding: prevalence, incidence, and mortality. Gastrointest Endosc Clin N Am 2011; 21:567-81. [PMID: 21944411 DOI: 10.1016/j.giec.2011.07.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Despite major advances in diagnosis, prevention, and treatment, nonvariceal upper gastrointestinal bleeding still is a serious problem in clinical practice. Current evidence indicates that most peptic ulcer bleeding-linked deaths are not a direct sequela of the bleeding ulcer itself. Instead, mortality derives from multiorgan failure, cardiopulmonary conditions, or terminal malignancy, suggesting that improving further current treatments for the bleeding ulcer may have a limited impact on mortality unless supportive therapies are developed for the global management of these patients.
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Almadi MA, Almessabi A, Wong P, Ghali PM, Barkun A. Ectopic varices. Gastrointest Endosc 2011; 74:380-8. [PMID: 21612777 DOI: 10.1016/j.gie.2011.03.1177] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Accepted: 03/14/2011] [Indexed: 12/13/2022]
Affiliation(s)
- Majid Abdulrahman Almadi
- Division of Gastroenterology, McGill University and the McGill University Health Centre, Montreal, Quebec, Canada
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Nonvariceal upper gastrointestinal bleeding in patients with liver cirrhosis. Clinical features, outcomes and predictors of in-hospital mortality. A prospective study. Ann Hepatol 2011. [PMID: 21677330 DOI: 10.1016/s1665-2681(19)31540-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
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Upper Gastrointestinal Haemorrhage: Predictive Factors of In-Hospital Mortality in Patients Treated in the Medical Intensive Care Unit. J Int Med Res 2011; 39:1016-27. [DOI: 10.1177/147323001103900337] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
This prospective, cohort study assessed the independent predictors of in-hospital mortality in patients with acute upper gastrointestinal haemorrhage admitted to the medical intensive care unit (MICU) at the University Clinical Centre Maribor, Slovenia. Using univariate, multivariate and logistic regression methods the predictors of mortality in 54 upper gastrointestinal haemorrhage patients (47 men, mean ± SD age 61.6 ± 14.2 years) were investigated. The mean ± SD duration of treatment in the MICU was 2.8 ± 2.9 days and the mortality rate was 31.5%. Significant differences between non-survivors and survivors were observed in haemorrhagic shock, heart failure, infection, diastolic blood pressure at admission, haemoglobin and red blood cell count at admission, and lowest haemoglobin and red blood cell count during treatment. Heart failure (odds ratio 59.13) was the most significant independent predictor of in-hospital mortality. Haemorrhagic shock and the lowest red blood cell count during treatment were also important independent predictive factors of in-hospital mortality.
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Kohn A, Ancona C, Belleudi V, Davoli M, Giglio L, Fusco D, Andreoli A, Perucci C, Prantera C. The impact of endoscopy and specialist care on 30-day mortality among patients with acute non-variceal upper gastrointestinal hemorrhage: an Italian population-based study. Dig Liver Dis 2010; 42:629-34. [PMID: 20646973 DOI: 10.1016/j.dld.2010.03.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Revised: 03/10/2010] [Accepted: 03/16/2010] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To analyze the effects of endoscopy and care in a gastroenterology ward on 30-day mortality among Italian patients hospitalized for acute non-variceal upper gastrointestinal hemorrhage (UGIH). METHODS We conducted a population-based study based on administrative data contained in the Regional Hospital Information System (RHIS) for the Lazio Region (Italy). We identified all hospitalizations with a main diagnosis of UGIH during period 2000-2005. Discharge data were analyzed for procedures performed, ward where the patient was cared for, comorbidities, vital status at discharge. Vital status 30 days after admission was cross-checked with the Regional Registry of Causes of Death. Logistic regression models were performed taking into account patients' risk factors (OR and C.I. 95%). RESULTS A total of 13,427 hospitalizations for UGIH (mean patient age, 68 years; 60% males) were identified. The 30-day mortality was 6.9%. Significantly lower rates were observed among hospitalizations that included endoscopy (OR 0.30, 95% C.I. 0.26-0.34), specialist care (OR 0.55, 95% C.I. 0.37-0.82), or both (OR 0.12, 95% C.I. 0.07-0.22). The protective effects of endoscopy and specialist care remained strong after adjustment for potential risk factors. CONCLUSIONS Endoscopy, per se, reduces mortality among patients hospitalized for UGIH, and care in a gastroenterology ward may offer additional protective effects.
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Affiliation(s)
- Anna Kohn
- Division of Gastroenterology AO San Camillo Forlanini, Circonvallazione gianicolense 87, 00152 Rome, Italy.
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Augustin S, González A, Genescà J. Acute esophageal variceal bleeding: Current strategies and new perspectives. World J Hepatol 2010; 2:261-74. [PMID: 21161008 PMCID: PMC2998973 DOI: 10.4254/wjh.v2.i7.261] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Revised: 06/14/2010] [Accepted: 06/21/2010] [Indexed: 02/06/2023] Open
Abstract
Management of acute variceal bleeding has greatly improved over recent years. Available data indicates that general management of the bleeding cirrhotic patient by an experienced multidisciplinary team plays a major role in the final outcome of this complication. It is currently recommended to combine pharmacological and endoscopic therapies for the initial treatment of the acute bleeding. Vasoactive drugs (preferable somatostatin or terlipressin) should be started as soon as a variceal bleeding is suspected (ideally during transfer to hospital) and maintained afterwards for 2-5 d. After stabilizing the patient with cautious fluid and blood support, an emergency diagnostic endoscopy should be done and, as soon as a skilled endoscopist is available, an endoscopic variceal treatment (ligation as first choice, sclerotherapy if endoscopic variceal ligation not feasible) should be performed. Antibiotic prophylaxis must be regarded as an integral part of the treatment of acute variceal bleeding and should be started at admission and maintained for at least 7 d. In case of failure to control the acute bleeding, rescue therapies should be immediately started. Shunt therapies (especially transjugular intrahepatic portosystemic shunt) are very effective at controlling treatment failures after an acute variceal bleeding. Therapeutic developments and increasing knowledge in the prognosis of this complication may allow optimization of the management strategy by adapting the different treatments to the expected risk of complications for each patient in the near future. Theoretically, this approach would allow the initiation of early aggressive treatments in high-risk patients and spare low-risk individuals unnecessary procedures. Current research efforts will hopefully clarify this hypothesis and help to further improve the outcomes of the severe complication of cirrhosis.
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Affiliation(s)
- Salvador Augustin
- Salvador Augustin, Antonio González, Joan Genescà, Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona 08035, Spain
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Abstract
Current recommendations for the treatment of acute variceal bleeding (AVB) are to combine hemodynamic stabilization, antibiotic prophylaxis, pharmacologic agents, and endoscopic treatment. However, despite the application of the current gold-standard pharmacologic and endoscopic treatment, failure to control bleeding or early rebleed within 5 days still occurs in 15% to 20% of patients with AVB. In case of treatment failure of the acute bleeding episode, if bleeding is mild and the patient is hemodynamically stable, a second endoscopic therapy may be attempted. If this fails, or if bleeding is severe, it is usually controlled temporarily with balloon tamponade until a definitive derivative treatment is applied. Transjugular intrahepatic portosystemic shunt is highly effective in this situation; however, despite the control of bleeding, a high proportion of these patients die of liver and multiorgan failure. Strategies intended to improve the prognosis of these patients should focus on identifying those high-risk patients in whom standard therapy is likely to fail, and who are therefore candidates for more aggressive therapies early after the development of AVB.
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Affiliation(s)
- Mario D'Amico
- Hospital Clinic, Institut d'Investigacions Biomediques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Spain
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Koseoglu Z, Ozkan OV, Semerci E, Aslan A, Yetim I, Ucar E, Kuvandik G, Temiz M, Borazan A. The relationship between mortality and inflammation in patients with gastrointestinal bleeding. J Int Med Res 2010; 37:1508-14. [PMID: 19930858 DOI: 10.1177/147323000903700528] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The objective of this study was to investigate the association between mortality and inflammation in patients who were admitted to the emergency room with gastrointestinal bleeding. Patients (n = 96) managed at two medical centres were included in the study. Initial levels of serum C-reactive protein (CRP), haemoglobin and albumin, and leucocyte and thrombocyte counts for 28 patients who died were compared with those for the 68 patients who survived and were successfully discharged. The data were analysed using the chi(2)-test. Serum levels of CRP and leucocyte counts were significantly higher, and albumin and haemoglobin were significantly lower in patients who died compared with patients who survived. The increased levels of serum CRP and leucocyte counts, and decreased levels of albumin and haemoglobin were found to be independent risk factors for mortality. It is concluded that increased serum CRP levels and leucocyte counts combined with decreased albumin and haemoglobin levels on admission to the emergency room may be used as predictive factors of mortality in patients with gastrointestinal bleeding.
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Affiliation(s)
- Zikret Koseoglu
- Department of Emergency Medicine, Adana Numune Education and Research Hospital, Adana, Turkey.
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Lecleire S, Antonietti M, Ducrotté P. [Mallory-Weiss syndrome: diagnosis and treatment]. Presse Med 2009; 39:640-4. [PMID: 19931377 DOI: 10.1016/j.lpm.2009.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Revised: 09/10/2009] [Accepted: 09/14/2009] [Indexed: 12/17/2022] Open
Abstract
Mallory-Weiss syndrome is relatively common and is involved in 3 to 10% of cases of upper gastrointestinal bleeding. Most of the time, the hemorrhage is mild and stops spontaneously. Clinical suspicion requires confirmation by an upper gastrointestinal endoscopy, which must be performed rapidly after the first hematemesis. Mallory-Weiss syndrome is diagnosed when it shows a longitudinal mucosal tear at the esophagogastric junction. Patients with active bleeding or signs of recent bleeding at endoscopy need immediate endoscopic treatment for hemostasis. Band ligation seems to be the most efficient procedure for primary hemostasis and for preventing recurrent bleeding. The use of proton pump inhibitors and antiemetics seems logical in all cases, although nothing in the literature demonstrates their efficacy.
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Affiliation(s)
- Stéphane Lecleire
- Unité d'endoscopie digestive, Département d'hépato-gastroentérologie et nutrition, Rouen Cedex, France.
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