Variceal hemorrhage: Analysis of 9987 cases from a Japanese nationwide database

A meta-analysis of combined generic-covered stent-graft with or without bare-metal stent for refractory variceal bleeding

Objectives:

The meta-analysis was conducted to systematically assess the efficacy and safety of generic stent-graft/bare-stent combination compared with Fluency stent alone in transjugular intrahepatic portosystemic shunt procedure for refractory variceal bleeding.

Methods:

PubMed, EMBASE, Scopus, Web of Science and the Cochrane Database were searched for relevant studies from January 1990 to September 2020; outcome measures studied were primary patency, hepatic encephalopathy, survival, re-bleeding and portal venous pressure.

Results:

Four studies (1 randomised controlled trial and 3 retrospective studies) with 449 subjects (157 patients in the combined stent group and 292 patients in the covered stent group) were included. No significant difference was observed in the incidence of mortality (hazard ratio [HR] = 1.069, 95% confidence interval [CI] [0.524, 2.178]), hepatic encephalopathy (odds ratio [OR] = 0.860, 95% CI [0.341, 2.169], P = 0.750) and re-bleeding (OR = 1.049, 95% CI [0.226, 4.881], P = 0.951). Compared with Fluency stent alone, combination therapy was associated with moderate decrease in outcomes on the post-operative portal venous pressure (standard mean difference [SMD] −0.210, 95% CI [−0.418, −0.001], P = 0.049) and was not associated with significant decrease in outcomes on the pre-operative portal venous pressure (SMD − 0.129, 95% CI [−0.336, 0.078], P = 0.223). The primary patency was significantly lower in the Fluency/bare-stent combination group (HR = 0.473, 95% CI [0.288, 0.776]).

Conclusions:

Generic stent-graft/bare-stent combination therapy was associated with significantly lower primary patency compared to Fluency stent alone.

Combined Use of Transjugular Intrahepatic Portosystemic Shunt and Transarterial Chemoembolization in the Treatment of Esophageal and Gastric Variceal Bleeding: A Retrospective Study of 80 Patients with Hepatocellular Carcinoma and Portal Hypertension

Background

The main cause of death in patients with hepatocellular carcinoma (HCC) with portal hypertension is esophageal and gastric variceal bleeding caused by severe portal hypertension; therefore, the treatment of portal hypertension is particularly important to prolong the survival of patients. The therapeutic efficacy and safety of transarterial chemoembolization (TACE) combined with a transjugular intrahepatic portosystemic shunt (TIPS) for HCC with esophageal and gastric variceal bleeding has been rarely reported. The aim of this study was to analyze the clinical efficacy of TIPS combined with TACE in the treatment of HCC with esophageal and gastric variceal bleeding.

Material/Methods

A total of 80 patients with HCC with esophageal and gastric variceal bleeding from July 2015 to November 2019 were retrospectively investigated. Clinical outcomes, biochemical indexes, and complications were compared between TIPS plus TACE and endoscopy plus TACE treatments.

Results

Gastrointestinal rebleeding and adverse reactions (P<0.05) after TIPS combined with TACE were lower than that after endoscopy combined with TACE treatment. Furthermore, TIPS plus TACE had superior clinical outcomes than endoscopy plus TACE, which was associated with promising progression-free survival, overall survival, objective response rate, and disease control rate, and improved liver function.

Conclusions

TIPS combined with TACE was better than endoscopy combined with TACE in the treatment of patients with HCC and esophageal and gastric variceal bleeding. TIPS combined with TACE had a better therapeutic effect on improving liver function and prolonging patient survival time.

Endoscopic injection sclerotherapy improves liver function compared with endoscopic variceal ligation

Liver function is a most important prognostic factor in patients with liver cirrhosis. Also, portal hypertension is a fatal complication of liver cirrhosis and variceal treatment is indispensable. However, changes of liver functions after endoscopic variceal treatments are unknown. The aim of this study was to evaluate prognosis and liver functions after endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL). A total of liver cirrhotic 103 patients who underwent prophylactic EIS and EVL were enrolled. Overall survival rate was higher in EIS group than EVL group (p = 0.03). Multivariate analysis showed that EIS was a negative factor for death (HR: 0.46, 95% confidence interval: 0.24–0.88, p = 0.02). Liver functions were assessed by blood test taken at before and 3 months after treatment. In EIS group, albumin and prothrombin time improved (p < 0.01), leading to improvement of Child–Pugh score, ALBI score and MELD score (p < 0.05). However, these did not improve in EVL group. EIS was a significant factor related to the elevated value of albumin after treatment in linear regression analysis (estimated regression coefficient: 0.17, 95% confidence interval: 0.05–0.29, p = 0.005). These results revealed that EIS could improve liver functions and prognosis.

Management of Early-Stage Esophageal Adenocarcinoma by Endoscopic Spray Cryotherapy in the Setting of Portal Hypertension With Varices

The use of endoscopic spray cryotherapy to manage pathological conditions of the esophagus has become increasingly common. This mucosal ablation technique is believed to carry a lower risk of bleeding than other modalities. A 71-year-old woman and a 64-year-old man with portal hypertension and varices were diagnosed with invasive esophageal adenocarcinoma during routine variceal surveillance. Staging by endoscopic ultrasound and computed tomography was uT1N0M0 in both patients. They each underwent mucosal ablation using liquid nitrogen cryosprays with no adverse events. Both cancers completely resolved with 2 treatments, and neither patient has shown recurrence of neoplasia during follow-up observations for up to 2 years.

C-reactive Protein Can Predict Patients with Cirrhosis at a High Risk of Early Mortality after Acute Esophageal Variceal Bleeding

Objective The aim of this study was to identify patients with a high risk of early mortality after acute esophageal variceal bleeding by measuring the C-reactive protein (CRP) level. Methods We retrospectively evaluated 154 consecutive cirrhotic patients admitted with acute esophageal variceal bleeding. Differences between categorical variables were assessed by the chi-square test. Continuous variables were compared using the Mann-Whitney U-test. Multivariate logistic regression analyses consisting of clinical laboratory parameters were performed to identify risk factors associated with the 6-week mortality. The discriminative ability and the best cut-off value were assessed by a receiver-operating characteristic (ROC) curve analysis. Results Child-Pugh C patients showed a significantly higher 6-week mortality than Child-Pugh A or B patients (38% vs. 6%, p<0.0001). The 6-week mortality in Child-Pugh C patients was associated with the age (p<0.0001), etiology of cirrhosis (p=0.003), hepatocellular carcinoma (p=0.0003), portal vein thrombosis (p=0.005), baseline creatinine (p=0.0001), albumin (p=0.001), white blood cell count (p=0.038), baseline CRP [p=0.0004; area under the ROC (AUROC)=0.765; optimum cut-off value at 1.30 mg/dL] and bacterial infection (p=0.019). We determined that CRP ≥1.30 mg/dL was an independent predictor for 6-week mortality in Child-Pugh C patients [odds ratio (OR)=8.789; 95% confidence interval (CI): 2.080-47.496; p=0.003], along with a creatinine level of 0.71 mg/dL (OR=17.628; 95% CI: 2.349-384.426; p=0.004) (73% mortality if CRP ≥1.30 mg/dL vs. 19% if CRP<1.30 mg/dL, p<0.0001). Conclusion In Child-Pugh C patients with esophageal variceal bleeding, a baseline CRP ≥1.30 mg/dL can help identify patients with an increased risk of mortality.

The trigger matters - outcome of hepatorenal syndrome vs. specifically triggered acute kidney injury in cirrhotic patients with ascites

BACKGROUND

Hepatorenal syndrome (HRS) represents a severe form of renal injury in cirrhotic patients with ascites in the absence of certain triggers.

METHODS

Patients with cirrhosis and ascites were longitudinally screened for renal dysfunction. HRS was diagnosed by an increase in serum creatinine (SCr) by ≥100% to ≥1.5 mg/dl. If specific triggers (i.e. nephrotoxins, parenchymal kidney damage, hypovolaemia, infections) were found, these cases were defined as specifically triggered acute kidney injury (sAKI).

RESULTS

Four hundred ninety-seven cirrhotic patients were screened for AKI and we identified 71 patients with HRS and 84 with sAKI. The most common triggers of sAKI were parenchymal damage in 33%, nephrotoxins in 30% and hypovolaemia in 29%. sAKI patients showed significantly more often complete remission than HRS patients (51% vs. 13%, P < 0.001), whereas persisting impairment of renal function was more common in HRS than in sAKI (56% vs. 37%, P = 0.006). Short-term (30 days) mortality was significantly higher in HRS than in sAKI (62% vs. 45%, P = 0.038). Remission rates and mortality varied between sAKI triggers. Transplant-free survival (TFS) was not significantly, but numerically lower in HRS than in sAKI [14 (IQR: 2-99) vs. 36 (IQR: 5-371) days; P = 0.102].

CONCLUSION

Patients with HRS show worse outcome and higher 30-day mortality than patients with severe triggered AKI. Different triggers of sAKI seem to influence prognosis. Prospective data are needed to implement effective screening and treatment algorithms for kidney injury in patients with cirrhosis and ascites.

Prevention of Rebleeding From Esophageal Varices in Patients With Cirrhosis Receiving Small-Diameter Stents Versus Hemodynamically Controlled Medical Therapy

BACKGROUND & AIMS

Patients with cirrhosis and variceal hemorrhage have a high risk of rebleeding. We performed a prospective randomized trial to compare the prevention of rebleeding in patients given a small-diameter covered stent vs those given hepatic venous pressure gradient (HVPG)-based medical therapy prophylaxis.

METHODS

We performed an open-label study of patients with cirrhosis (92% Child class A or B, 70% alcoholic) treated at 10 medical centers in Germany. Patients were assigned randomly more than 5 days after variceal hemorrhage to groups given a small covered transjugular intrahepatic portosystemic stent-shunt (TIPS) (8 mm; n = 90), or medical reduction of portal pressure (propranolol and isosorbide-5-mononitrate; n = 95). HVPG was determined at the time patients were assigned to groups (baseline) and 2 weeks later. In the medical group, patients with an adequate reduction in HVPG (responders) remained on the drugs whereas nonresponders underwent only variceal band ligation. The study was closed 10 months after the last patient was assigned to a group. The primary end point was variceal rebleeding. Survival, safety (adverse events), and quality of life (based on the Short Form-36 health survey) were secondary outcome measures.

RESULTS

A significantly smaller proportion of patients in the TIPS group had rebleeding within 2 years (7%) than in the medical group (26%) (P = .002). A slightly higher proportion of patients in the TIPS group experienced adverse events, including encephalopathy (18% vs 8% for medical treatment; P = .05). Rebleeding occurred in 6 of 23 patients (26%) receiving medical treatment before hemodynamic control was possible. Per-protocol analysis showed that rebleeding occurred in a smaller proportion of the 32 responders (18%) than in nonresponders who received variceal band ligation (31%) (P = .06). Fifteen patients from the medical group (16%) underwent TIPS placement during follow-up evaluation, mainly for refractory ascites. Survival time and quality of life did not differ between both randomized groups.

CONCLUSIONS

Placement of a small-diameter, covered TIPS was straightforward and prevented variceal rebleeding in patients with Child A or B cirrhosis more effectively than drugs, which often required step-by-step therapy. However, TIPS did not increase survival time or quality of life and produced slightly more adverse events. Clinical Trial no: ISRCTN 16334693.

Thalidomide ameliorates portal hypertension via nitric oxide synthase independent reduced systolic blood pressure

AIM: Portal hypertension is a common complication of liver cirrhosis and significantly increases mortality and morbidity. Previous reports have suggested that the compound thalidomide attenuates portal hypertension (PHT). However, the mechanism for this action is not fully elucidated. One hypothesis is that thalidomide destabilizes tumor necrosis factor α (TNFα) mRNA and therefore diminishes TNFα induction of nitric oxide synthase (NOS) and the production of nitric oxide (NO). To examine this hypothesis, we utilized the murine partial portal vein ligation (PVL) PHT model in combination with endothelial or inducible NOS isoform gene knockout mice.

METHODS: Wild type, inducible nitric oxide synthase (iNOS)^-/- and endothelial nitric oxide synthase (eNOS)^-/- mice received either PVL or sham surgery and were given either thalidomide or vehicle. Serum nitrate (total nitrate, NOx) was measured daily for 7 d as a surrogate of NO synthesis. Serum TNFα level was quantified by enzyme-linked immunosorbent assay. TNFα mRNA was quantified in liver and aorta tissue by reverse transcription-polymerase chain reaction. PHT was determined by recording splenic pulp pressure (SPP) and abdominal aortic flow after 0-7 d. Response to thalidomide was determined by measurement of SPP and mean arterial pressure (MAP).

RESULTS: SPP, abdominal aortic flow (Qao) and plasma NOx were increased in wild type and iNOS^-/- PVL mice when compared to sham operated control mice. In contrast, SPP, Qao and plasma NOx were not increased in eNOS^-/- PVL mice when compared to sham controls. Serum TNFα level in both sham and PVL mice was below the detection limit of the commercial ELISA used. Therefore, the effect of thalidomide on serum TNFα levels was undetermined in wild type, eNOS^-/- or iNOS^-/- mice. Thalidomide acutely increased plasma NOx in wild type and eNOS^-/- mice but not iNOS^-/- mice. Moreover, thalidomide temporarily (0-90 min) decreased mean arterial pressure, SPP and Qao in wild type, eNOS^-/- and iNOS^-/- PVL mice, after which time levels returned to the respective baseline.

CONCLUSION: Thalidomide does not reduce portal pressure in the murine PVL model by modulation of NO biosynthesis. Rather, thalidomide reduces PHT by decreasing MAP by an undetermined mechanism.

[Application of the diagnosis procedure combination (DPC) data to clinical studies]

The Diagnosis Procedure Combination (DPC) is a case-mix classification system that is linked with a lump-sum payment system for inpatient care reimbursement. The key objectives of introducing the DPC system are to implement an electronic claim system and to provide transparency of hospital performance. The DPC data include discharge abstract and administrative claims data. The unique advantage of the DPC data is the inclusion of detailed process data and several clinical data that can be applied to clinical studies. In this report, we explain the structure and contents of the DPC database, and discuss the applicability of the DPC data to clinical studies, comparing them with the US Nationwide Inpatient Sample database.