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Vidal-González J, Martínez J, Mulay A, López M, Baiges A, Elmahdy A, Lampichler K, Maleux G, Chang J, Poncela M, Low G, Ghigliazza G, Zipprich A, Picón C, Shah R, Llop E, Darnell A, Maurer MH, Bonne L, Ramón E, Quiroga S, Abraldes JG, Krag A, Trebicka J, Ripoll C, La Mura V, Tandon P, García-Martínez R, Praktiknjo M, Laleman W, Reiberger T, Berzigotti A, Hernández-Gea V, Calleja JL, Tsochatzis EA, Albillos A, Simón-Talero M, Genescà J. Evolution of spontaneous portosystemic shunts over time and following aetiological intervention in patients with cirrhosis. JHEP Rep 2024; 6:100977. [PMID: 38283756 PMCID: PMC10820312 DOI: 10.1016/j.jhepr.2023.100977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/27/2023] [Accepted: 11/10/2023] [Indexed: 01/30/2024] Open
Abstract
Background & Aims Spontaneous portosystemic shunts (SPSS) develop frequently in cirrhosis. Changes over time and the effect of aetiological interventions on SPSS are unknown, so we aimed to explore the effect of these variables on SPSS evolution. Methods Patients with cirrhosis from the Baveno VI-SPSS cohort were selected provided a follow-up abdominal CT or MRI scan was available. Clinical and laboratory data were collected at baseline and follow-up. Imaging tests were reviewed to evaluate changes in the presence and size of SPSS (large (L)-SPSS was ≥8 mm) over time. Regarding alcohol- or HCV-related cirrhosis, two populations were defined: cured patients (abstinent from alcohol or successful HCV therapy), and non-cured patients. Results A total of 617 patients were included. At baseline SPSS distribution was 22% L-SPSS, 30% small (S)-SPSS, and 48% without (W)-SPSS. During follow-up (median follow-up of 63 months), SPSS distribution worsened: L-SPSS 26%, S-SPSS 32%, and W-SPSS 42% (p <0.001). Patients with worse liver function during follow-up showed a simultaneous aggravation in SPSS distribution. Non-cured patients (n = 191) experienced a significant worsening in liver function, more episodes of liver decompensation and lower transplant-free survival compared to cured patients (n = 191). However, no differences were observed regarding SPSS distribution at inclusion and at follow-up, with both groups showing a trend to worsening. Total shunt diameter increased more in non-cured (52%) than in cured patients (28%). However, total shunt area (TSA) significantly increased only in non-cured patients (74 to 122 mm2, p <0.001). Conclusions The presence of SPSS in cirrhosis increases over time and parallels liver function deterioration. Aetiological intervention in these patients reduces liver-related complications, but SPSS persist although progression is decreased. Impact and implications There is no information regarding the evolution of spontaneous portosystemic shunts (SPSS) during the course of cirrhosis, and especially after disease regression with aetiological interventions, such as HCV treatment with direct-acting antivirals or alcohol abstinence. These results are relevant for clinicians dealing with patients with cirrhosis and portal hypertension because they have important implications for the management of cirrhosis with SPSS after disease regression. From a practical point of view, physicians should be aware that in advanced cirrhosis with portal hypertension, after aetiological intervention, SPSS mostly persist despite liver function improvement, and complications related to SPSS may still develop.
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Affiliation(s)
- Judit Vidal-González
- Liver Unit, Digestive Diseases Department, Vall d’Hebron University Hospital, Vall d’Hebron Institute of Research (VHIR), Vall d’Hebron Barcelona Hospital Campus. Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Javier Martínez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Akhilesh Mulay
- Sheila Sherlock Liver Unit and University College London Institute for Liver and Digestive Health, Royal Free Hospital and University College London, London, UK
| | - Marta López
- Liver Unit, Hospital U. Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
| | - Anna Baiges
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Ahmed Elmahdy
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Katharina Lampichler
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Geert Maleux
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Johannes Chang
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Marta Poncela
- Liver Unit, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Gavin Low
- Department of Radiology, University of Alberta, Edmonton, Alberta, Canada
| | - Gabriele Ghigliazza
- Foundation I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi and Thrombosis center, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alexander Zipprich
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Internal Medicine IV. Jena University Hospital, Jena Germany
| | - Carmen Picón
- Department of Radiology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, Spain
| | - Rushabh Shah
- Royal Free Hospital Radiology Department, Royal Free Hospital and University College London, London, UK
| | - Elba Llop
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
- Liver Unit, Hospital U. Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
| | - Anna Darnell
- Department of Radiology, Hospital Clínic, Universitat de Barcelona, Barcelona Spain
| | - Martin H. Maurer
- Department of Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - Lawrence Bonne
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Enrique Ramón
- Digestive Radiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Sergi Quiroga
- Radiology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juan G. Abraldes
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Canada
| | - Aleksander Krag
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jonel Trebicka
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
- Department of Internal Medicine B, University of Münster, Münster, Germany
| | - Cristina Ripoll
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Internal Medicine IV. Jena University Hospital, Jena Germany
| | - Vincenzo La Mura
- Foundation I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi and Thrombosis center, Milan, Italy
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Puneeta Tandon
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Canada
| | - Rita García-Martínez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
- Liver Unit, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Michael Praktiknjo
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
- Department of Internal Medicine B, University of Münster, Münster, Germany
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Virginia Hernández-Gea
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - José Luis Calleja
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
- Liver Unit, Hospital U. Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
| | - Emmanuel A. Tsochatzis
- Sheila Sherlock Liver Unit and University College London Institute for Liver and Digestive Health, Royal Free Hospital and University College London, London, UK
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Macarena Simón-Talero
- Liver Unit, Digestive Diseases Department, Vall d’Hebron University Hospital, Vall d’Hebron Institute of Research (VHIR), Vall d’Hebron Barcelona Hospital Campus. Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Joan Genescà
- Liver Unit, Digestive Diseases Department, Vall d’Hebron University Hospital, Vall d’Hebron Institute of Research (VHIR), Vall d’Hebron Barcelona Hospital Campus. Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - for the Baveno VI-SPSS group from the Baveno Cooperation
- Liver Unit, Digestive Diseases Department, Vall d’Hebron University Hospital, Vall d’Hebron Institute of Research (VHIR), Vall d’Hebron Barcelona Hospital Campus. Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
- Sheila Sherlock Liver Unit and University College London Institute for Liver and Digestive Health, Royal Free Hospital and University College London, London, UK
- Liver Unit, Hospital U. Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
- Liver Unit, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
- Department of Radiology, University of Alberta, Edmonton, Alberta, Canada
- Foundation I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi and Thrombosis center, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Internal Medicine IV. Jena University Hospital, Jena Germany
- Department of Radiology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, Spain
- Royal Free Hospital Radiology Department, Royal Free Hospital and University College London, London, UK
- Department of Radiology, Hospital Clínic, Universitat de Barcelona, Barcelona Spain
- Department of Radiology, Inselspital, University of Bern, Bern, Switzerland
- Digestive Radiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
- Radiology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Canada
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Internal Medicine B, University of Münster, Münster, Germany
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- Division of Gastroenterology and Hepatology, Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
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3
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Sengupta S, Anand A, Lopez R, Weleff J, Wang PR, Bellar A, Attaway A, Welch N, Dasarathy S. Emergency services utilization by patients with alcohol-associated hepatitis: An analysis of national trends. ALCOHOL, CLINICAL & EXPERIMENTAL RESEARCH 2024; 48:98-109. [PMID: 38193831 PMCID: PMC10783841 DOI: 10.1111/acer.15223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/10/2023] [Accepted: 11/03/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Hospitalization and mortality in patients with alcohol-associated hepatitis (AH), a severe form of liver disease, continue to increase over time. Given the severity of the illness, most hospitalized patients with AH are admitted from the emergency department (ED). However, there are no data on ED utilization by patients with AH. Thus, the Nationwide Emergency Department Sample (NEDS) dataset was analyzed to determine the ED utilization for AH. METHODS Temporal trends (2016-2019) and outcomes of ED visits for AH were determined. Primary or secondary AH diagnoses were based on coding priority. Numbers of patients evaluated in the ED, severity of disease, complications of liver disease, and discharge disposition were analyzed. Crude and adjusted rates were examined, and temporal trends evaluated using logistic regression with orthogonal polynomial contrasts for each year. RESULTS There were 466,014,370 ED visits during 2016-2019, of which 448,984 (0.096%) were for AH, 85.0% of which required hospitalization. The rate of visits for AH (primary and secondary) between 2016 and 2019 increased from 85 to 106.8/100,000 ED visits. The rate of secondary AH increased more than the rate of primary AH (from 68.6 to 86.5 vs. from 16.4 to 20.3/100,000 ED visits). Patients aged 45-64 years had the highest rate of ED visits for AH, which decreased during the study period, while the rate of ED visits for AH increased in those aged 25-44 years (from 38.5% to 42.9%). The severity of disease (ascites, hepatic encephalopathy, and acute kidney injury) also increased over time. Medicaid and private insurance were the most common payors for patients seeking care in the ED for AH. CONCLUSIONS Temporal trends show an overall increase in ED utilization rates for AH, more patients requiring hospitalization, and an increase in the proportion of younger patients presenting to the ED with AH.
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Affiliation(s)
- Shreya Sengupta
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Akhil Anand
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH, USA
- Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Rocio Lopez
- Center for Populations Health Research, Cleveland Clinic, Cleveland, OH, USA
| | - Jeremy Weleff
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH, USA
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, New Haven, CT, 06511, USA
| | - Philip R Wang
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Annette Bellar
- Inflammation and Immunity, Cleveland Clinic, Cleveland, OH, USA
| | - Amy Attaway
- Pulmonary Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Nicole Welch
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
- Inflammation and Immunity, Cleveland Clinic, Cleveland, OH, USA
| | - Srinivasan Dasarathy
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
- Inflammation and Immunity, Cleveland Clinic, Cleveland, OH, USA
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5
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Vizzutti F, Celsa C, Calvaruso V, Enea M, Battaglia S, Turco L, Senzolo M, Nardelli S, Miraglia R, Roccarina D, Campani C, Saltini D, Caporali C, Indulti F, Gitto S, Zanetto A, Di Maria G, Bianchini M, Pecchini M, Aspite S, Di Bonaventura C, Citone M, Guasconi T, Di Benedetto F, Arena U, Fanelli F, Maruzzelli L, Riggio O, Burra P, Colecchia A, Villa E, Marra F, Cammà C, Schepis F. Mortality after transjugular intrahepatic portosystemic shunt in older adult patients with cirrhosis: A validated prediction model. Hepatology 2023; 77:476-488. [PMID: 35921493 DOI: 10.1002/hep.32704] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/22/2022] [Accepted: 07/31/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND AIMS Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) improves survival in patients with cirrhosis with refractory ascites and portal hypertensive bleeding. However, the indication for TIPS in older adult patients (greater than or equal to 70 years) is debated, and a specific prediction model developed in this particular setting is lacking. The aim of this study was to develop and validate a multivariable model for an accurate prediction of mortality in older adults. APPROACH AND RESULTS We prospectively enrolled 411 consecutive patients observed at four referral centers with de novo TIPS implantation for refractory ascites or secondary prophylaxis of variceal bleeding (derivation cohort) and an external cohort of 415 patients with similar indications for TIPS (validation cohort). Older adult patients in the two cohorts were 99 and 76, respectively. A cause-specific Cox competing risks model was used to predict liver-related mortality, with orthotopic liver transplant and death for extrahepatic causes as competing events. Age, alcoholic etiology, creatinine levels, and international normalized ratio in the overall cohort, and creatinine and sodium levels in older adults were independent risk factors for liver-related death by multivariable analysis. CONCLUSIONS After TIPS implantation, mortality is increased by aging, but TIPS placement should not be precluded in patients older than 70 years. In older adults, creatinine and sodium levels are useful predictors for decision making. Further efforts to update the prediction model with larger sample size are warranted.
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Affiliation(s)
- Francesco Vizzutti
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Ciro Celsa
- Department of Health Promotion, Mother and Child Care , Internal Medicine and Medical Specialties , PROMISE, Gastroenterology and Hepatology Unit , University of Palermo , Palermo , Sicilia , Italy
- Department of Surgical, Oncological, and Oral Sciences (Di.Chir.On.S.) , University of Palermo , Palermo , Italy
| | - Vincenza Calvaruso
- Department of Health Promotion, Mother and Child Care , Internal Medicine and Medical Specialties , PROMISE, Gastroenterology and Hepatology Unit , University of Palermo , Palermo , Sicilia , Italy
| | - Marco Enea
- Department of Health Promotion, Mother and Child Care , Internal Medicine and Medical Specialties , PROMISE, Gastroenterology and Hepatology Unit , University of Palermo , Palermo , Sicilia , Italy
| | - Salvatore Battaglia
- Department of Economics, Business, and Statistics (SEAS) , University of Palermo , Palermo , Italy
| | - Laura Turco
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
- Internal Medicine Unit for the Treatment of Severe Organ Failure , Dipartimento medico chirurgico delle malattie digestive, epatiche ed endocrino-metaboliche , Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna , Policlinico di Sant'Orsola , Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit-Gastroenterology , Department of Surgery, Oncology, and Gastroenterology , Padua University Hospital , Padua , Italy
| | - Silvia Nardelli
- Department of Translational and Precision Medicine , Sapienza University of Rome , Rome , Italy
| | - Roberto Miraglia
- Radiology Unit, Diagnostic and Therapeutic Services , IRCCS ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies) , Palermo , Italy
| | - Davide Roccarina
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Claudia Campani
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Dario Saltini
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Cristian Caporali
- Radiology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Federica Indulti
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Stefano Gitto
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Alberto Zanetto
- Multivisceral Transplant Unit-Gastroenterology , Department of Surgery, Oncology, and Gastroenterology , Padua University Hospital , Padua , Italy
| | - Gabriele Di Maria
- Department of Health Promotion, Mother and Child Care , Internal Medicine and Medical Specialties , PROMISE, Gastroenterology and Hepatology Unit , University of Palermo , Palermo , Sicilia , Italy
| | - Marcello Bianchini
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Maddalena Pecchini
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Silvia Aspite
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Chiara Di Bonaventura
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Michele Citone
- Department of Radiology, Interventional Radiology Unit , Careggi Hospital , Florence , Italy
| | - Tomas Guasconi
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit , University of Modena and Reggio Emilia , Modena , Italy
| | - Umberto Arena
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Fabrizio Fanelli
- Department of Radiology, Interventional Radiology Unit , Careggi Hospital , Florence , Italy
| | - Luigi Maruzzelli
- Radiology Unit, Diagnostic and Therapeutic Services , IRCCS ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies) , Palermo , Italy
| | - Oliviero Riggio
- Department of Translational and Precision Medicine , Sapienza University of Rome , Rome , Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit-Gastroenterology , Department of Surgery, Oncology, and Gastroenterology , Padua University Hospital , Padua , Italy
| | - Antonio Colecchia
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Erica Villa
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Fabio Marra
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
- Center for Research, High Education and Transfer DENOThe , University of Florence , Florence , Italy
| | - Calogero Cammà
- Department of Health Promotion, Mother and Child Care , Internal Medicine and Medical Specialties , PROMISE, Gastroenterology and Hepatology Unit , University of Palermo , Palermo , Sicilia , Italy
| | - Filippo Schepis
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
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8
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Reiberger T, Bucsics T, Paternostro R, Pfisterer N, Riedl F, Mandorfer M. Small Esophageal Varices in Patients with Cirrhosis-Should We Treat Them? CURRENT HEPATOLOGY REPORTS 2018; 17:301-315. [PMID: 30546995 PMCID: PMC6267385 DOI: 10.1007/s11901-018-0420-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW The natural history and classification systems of small varices (≤ 5 mm in diameter) in cirrhotic patients with portal hypertension are summarized. Studies that assessed the course of and therapeutic intervention for small varices are discussed. RECENT FINDINGS Current non-invasive methods show suboptimal sensitivity to detect small varices in patients with cirrhosis. Next to etiological therapy, hepatic venous pressure gradient (HVPG)-guided non-selective betablocker or carvedilol treatment has shown to impact on natural history of small varices. SUMMARY The main therapeutic focus in cirrhotic patients with small varices is the cure of the underlying etiology. The optimal management of small varices should include measurement of HVPG. A pharmacological decrease in HVPG by non-selective betablocker therapy of ≥ 10% reduces the risk of progression to large varices, first variceal bleeding, and hepatic decompensation. If HVPG is not available, we would recommend carvedilol 12.5 mg q.d. for treatment of small varices in compensated patients without severe ascites. Only if small esophageal varices (EV) are not treated or in hemodynamic non-responders, follow-up endoscopies should be performed in 1-2 years of intervals considering the activity of liver disease or if hepatic decompensation occurs.
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Affiliation(s)
- Thomas Reiberger
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology & Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Theresa Bucsics
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology & Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology & Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Nikolaus Pfisterer
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology & Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - Florian Riedl
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology & Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology, Medicine II, Universitätsklinikum St. Pölten, St. Pölten, Austria
| | - Mattias Mandorfer
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- Division of Gastroenterology & Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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