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Liu HH, Yen CL, Jeng WJ, Hung CC, Hsiao CC, Tian YC, Chen KH. Fibrosis-4 Score Is Associated with Mortality in Hemodialysis Patients with Chronic Viral Hepatitis: A Retrospective Study. Diagnostics (Basel) 2024; 14:2048. [PMID: 39335727 PMCID: PMC11431842 DOI: 10.3390/diagnostics14182048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2024] [Revised: 09/03/2024] [Accepted: 09/12/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND Chronic hepatitis B and C infections are major causes of morbidity and mortality in end-stage kidney disease (ESKD) patients on hemodialysis (HD). The Fibrosis-4 (FIB-4) score is a non-invasive method to evaluate chronic liver disease. However, it is unclear whether there is a connection between the FIB-4 score and major adverse cardiovascular events (MACEs) and mortality in patients on HD. This study investigates the relationship between FIB-4 scores, MACEs, and mortality in HD patients. METHODS A 5-year retrospective study included 198 HD patients with chronic hepatitis B and C from Chang Gung Memorial Hospital. FIB-4 scores were categorized into high (>2.071), middle (1.030~2.071), and low (<1.030) tertiles for cross-sectional analyses. MACEs and mortality were tracked longitudinally. RESULTS Patients with high FIB-4 scores had lower hemoglobin and albumin levels. Cox multivariate analysis showed that high FIB-4 scores (aHR: 1.589) and diabetes mellitus (aHR: 5.688) were significant factors for all-cause mortality. The optimal FIB-4 score for 5-year mortality was 2.942. FIB-4 scores were not significant for predicting 5-year MACEs. CONCLUSIONS High FIB-4 scores are associated with increased 5-year all-cause mortality risk in HD patients with chronic hepatitis virus infection.
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Affiliation(s)
- Hao-Hsuan Liu
- Department of Nephrology, New Taipei Municipal TuCheng Hospital, New Taipei City 236043, Taiwan
- Kidney Research Center, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, Taoyuan 333423, Taiwan
| | - Chieh-Li Yen
- Kidney Research Center, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, Taoyuan 333423, Taiwan
| | - Wen-Juei Jeng
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333423, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333323, Taiwan
| | - Cheng-Chieh Hung
- Kidney Research Center, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, Taoyuan 333423, Taiwan
| | - Ching-Chung Hsiao
- Department of Nephrology, New Taipei Municipal TuCheng Hospital, New Taipei City 236043, Taiwan
| | - Ya-Chung Tian
- Kidney Research Center, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, Taoyuan 333423, Taiwan
| | - Kuan-Hsing Chen
- Kidney Research Center, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, Taoyuan 333423, Taiwan
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Tonon M, D'Ambrosio R, Calvino V, Tosetti G, Barone A, Incicco S, Gambino C, Gagliardi R, Borghi M, Zeni N, Piano S, Lampertico P, Angeli P. A new clinical and prognostic characterization of the patterns of decompensation of cirrhosis. J Hepatol 2024; 80:603-609. [PMID: 38110003 DOI: 10.1016/j.jhep.2023.12.005] [Citation(s) in RCA: 5] [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: 07/26/2023] [Revised: 11/21/2023] [Accepted: 12/04/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND & AIMS The prognostic impact of acute decompensation (AD), i.e. the development of complications that require hospitalization, has recently been assessed. However, complications of cirrhosis do not necessarily require hospitalization and can develop progressively, as in the recently defined non-acute decompensation (NAD). Nevertheless, there is no data regarding the incidence and prognostic impact of NAD. The aim of the study was to evaluate the incidence and the prognostic impact of NAD and AD in outpatients with cirrhosis. METHODS A total of 617 outpatients with cirrhosis from two Italian tertiary centers (Padua and Milan) were enrolled from January 2003 to June 2021 and followed prospectively until the end of the study, death or liver transplantation. The complications registered during follow-up were considered as AD if they required hospitalization, or NAD if managed at the outpatient clinic. RESULTS During follow-up, 154 patients (25.0% of total patients) developed complications, 69 patients (44.8%) developed NAD and 85 (55.2%) developed AD, while 29 patients with NAD (42.0%) developed a further episode of AD during follow-up. Sixty-month survival was significantly higher in patients with no decompensation than in patients with NAD or AD. On multivariable analysis, AD (hazard ratio [HR] 21.07, p <0.001), NAD (HR 7.13, p <0.001), the etiological cure of cirrhosis (HR 0.38, p <0.001) and model for end-stage liver disease score (HR 1.12, p = 0.003) were found to be independent predictors of mortality. CONCLUSIONS The first decompensation is non-acute in almost 50% of outpatients, though such events are still associated with decreased survival compared to no decompensation. Patients who develop NAD must be treated with extreme care and monitored closely to prevent the development of AD. IMPACT AND IMPLICATIONS This multicenter study is the first to investigate the role of non-acute decompensation (NAD) in patients with cirrhosis. In fact, while the unfavorable impact of acute decompensation is well known, there is currently a dearth of evidence on NAD, despite it being a common occurrence in clinical practice. Our data show that almost half of decompensations in patients with cirrhosis can be considered NAD and that such events are associated with a higher risk of mortality than no decompensation. This study has important clinical implications because it highlights the need to carefully consider patients who develop NAD, in order to prevent further decompensation and reduce mortality.
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Affiliation(s)
- Marta Tonon
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Roberta D'Ambrosio
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Calvino
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Giulia Tosetti
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Barone
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Simone Incicco
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Carmine Gambino
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Roberta Gagliardi
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Marta Borghi
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Zeni
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Pietro Lampertico
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; CRC "A. M. and A. Migliavacca" Centre for Liver Disease, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy.
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Pfisterer N, Unger LW, Reiberger T. Clinical algorithms for the prevention of variceal bleeding and rebleeding in patients with liver cirrhosis. World J Hepatol 2021; 13:731-746. [PMID: 34367495 PMCID: PMC8326161 DOI: 10.4254/wjh.v13.i7.731] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/14/2021] [Accepted: 07/07/2021] [Indexed: 02/06/2023] Open
Abstract
Portal hypertension (PH), a common complication of liver cirrhosis, results in development of esophageal varices. When esophageal varices rupture, they cause significant upper gastrointestinal bleeding with mortality rates up to 20% despite state-of-the-art treatment. Thus, prophylactic measures are of utmost importance to improve outcomes of patients with PH. Several high-quality studies have demonstrated that non-selective beta blockers (NSBBs) or endoscopic band ligation (EBL) are effective for primary prophylaxis of variceal bleeding. In secondary prophylaxis, a combination of NSBB + EBL should be routinely used. Once esophageal varices develop and variceal bleeding occurs, standardized treatment algorithms should be followed to minimize bleeding-associated mortality. Special attention should be paid to avoidance of overtransfusion, early initiation of vasoconstrictive therapy, prophylactic antibiotics and early endoscopic therapy. Pre-emptive transjugular intrahepatic portosystemic shunt should be used in all Child C10-C13 patients experiencing variceal bleeding, and potentially in Child B patients with active bleeding at endoscopy. The use of carvedilol, safety of NSBBs in advanced cirrhosis (i.e. with refractory ascites) and assessment of hepatic venous pressure gradient response to NSBB is discussed. In the present review, we give an overview on the rationale behind the latest guidelines and summarize key papers that have led to significant advances in the field.
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Affiliation(s)
- Nikolaus Pfisterer
- Medizinische Abteilung für Gastroenterologie und Hepatologie, Klinik Landstraße/Krankenanstalt Rudolfstiftung, Vienna 1030, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna 1090, Austria
| | - Lukas W Unger
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna 1090, Austria
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, University of Cambridge, Cambridge CB2 0AW, United Kingdom.
| | - Thomas Reiberger
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna 1090, Austria
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna 1090, Austria
- Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna 1090, Austria
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Drolz A, Schramm C, Seiz O, Groth S, Vettorazzi E, Horvatits T, Wehmeyer MH, Schramm C, Goeser T, Roesch T, Lohse AW, Kluwe J. Risk factors associated with bleeding after prophylactic endoscopic variceal ligation in cirrhosis. Endoscopy 2021; 53:226-234. [PMID: 32894867 DOI: 10.1055/a-1214-5355] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Prophylactic endoscopic variceal band ligation (EVL) is frequently performed in patients with liver cirrhosis. The aim of our study was to identify factors associated with early upper gastrointestinal bleeding (UGIB) in cirrhosis patients after prophylactic EVL. METHODS 787 nonemergency EVLs performed in 444 patients in two German University medical centers were analyzed retrospectively. RESULTS Within 30 days after EVL, 38 UGIBs were observed (4.8 % of all procedures). Bilirubin levels (hazard ratio [HR] 1.5, 95 % confidence interval [CI] 1.2-2.0 for a 2-fold increase) and presence of varices grade III/IV according to Paquet (HR 2.6, 95 %CI 1.3-5.0 compared with absence or smaller sized varices) were independently associated with UGIB following EVL. International normalized ratio (INR) was associated with bleeding events in the univariate analysis but did not reach statistical significance after adjustment for bilirubin and presence of varices grade III/IV (HR 1.2, 95 %CI 0.9-1.6 for an increase by 0.25). There was no statistically significant association between platelet count or fibrinogen levels and UGIB. Substitution of coagulation products did not affect incidence of bleeding after EVL, which also applied to patients with "coagulopathy" (INR > 1.5 and/or platelet count < 50 × 109/L). No association between proton pump inhibitor therapy and post-EVL UGIB was observed. CONCLUSIONS EVL is a safe procedure and immediate bleeding complications are rare. Serum bilirubin levels and size of varices, rather than coagulation indices, are associated with UGIB after EVL. Our data do not support the preventive substitution of blood or coagulation products.
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Affiliation(s)
- Andreas Drolz
- Department of Internal Medicine I, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Christoph Schramm
- Department of Gastroenterology and Hepatology, University Hospital Cologne, Cologne, Germany
| | - Oliver Seiz
- Department of Internal Medicine I, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Stefan Groth
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Medical Center, Hamburg, Germany
| | - Thomas Horvatits
- Department of Internal Medicine I, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Malte H Wehmeyer
- Department of Internal Medicine I, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Christoph Schramm
- Department of Internal Medicine I, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Tobias Goeser
- Department of Gastroenterology and Hepatology, University Hospital Cologne, Cologne, Germany
| | - Thomas Roesch
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Ansgar W Lohse
- Department of Internal Medicine I, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Johannes Kluwe
- Department of Internal Medicine I, University Medical Center Hamburg Eppendorf, Hamburg, Germany
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Lim J, Kim HI, Kim E, Kim J, An J, Chang S, Kim SO, Lee HC, Lee YS, Shim JH. Variceal bleeding is aggravated by portal venous invasion of hepatocellular carcinoma: a matched nested case-control study. BMC Cancer 2021; 21:11. [PMID: 33402105 PMCID: PMC7786454 DOI: 10.1186/s12885-020-07708-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 12/03/2020] [Indexed: 02/07/2023] Open
Abstract
Background We hypothesized that portal vein tumor thrombosis (PVTT) in hepatocellular carcinoma (HCC) increases portal pressure and causes esophageal varices and variceal bleedings. We examined the incidence of high-risk varices and variceal bleeding and determined the indications for variceal screening and prophylaxis. Methods This study included 1709 asymptomatic patients without any prior history of variceal hemorrhage or endoscopic prophylaxis who underwent upper endoscopy within 30 days before or after initial anti-HCC treatment. Of these patients, 206 had PVTT, and after 1:2 individual matching, 161 of them were matched with 309 patients without PVTT. High-risk varices were defined as large/medium varices or small varices with red-color signs and variceal bleeding. Bleeding rates from the varices were compared between matched pairs. Risk factors for variceal bleeding in the entire set of patients with PVTT were also explored. Results In the matched-pair analysis, the proportion of high-risk varices at screening (23.0% vs. 13.3%; P = 0.003) and the cumulative rate of variceal bleeding (4.5% vs. 0.4% at 1 year; P = 0.009) were significantly greater in the PVTT group. Prolonged prothrombin time, lower platelet count, presence of extrahepatic metastasis, and Vp4 PVTT were independent risk factors related to high-risk varices in the total set of 206 patients with PVTT (Adjusted odds ratios [95% CIs], 1.662 [1.151–2.401]; 0.985 [0.978–0.993]; 4.240 [1.783–10.084]; and 3.345 [1.457–7.680], respectively; Ps < 0.05). During a median follow-up of 43.2 months, 10 patients with PVTT experienced variceal bleeding episodes, 9 of whom (90%) had high-risk varices. Presence of high-risk varices and sorafenib use for HCC treatment were significant predictors of variceal bleeding in the complete set of patients with PVTT (Adjusted hazard ratios [95% CIs], 26.432 [3.230–216.289]; and 5.676 [1.273–25.300], respectively; Ps < 0.05). Conclusions PVTT in HCC appears to increase the likelihood of high-risk varices and variceal bleeding. In HCC patients with PVTT, endoscopic prevention could be considered, at least in high-risk variceal carriers taking sorafenib.
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Affiliation(s)
- Jihye Lim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Ha Il Kim
- Gastroenterology, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Eunju Kim
- Gastroenterology, Department of Internal Medicine, Haeundae Paik Hospital, College of Medicine, Inje University, Busan, Republic of Korea
| | - Jiyoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Jihyun An
- Gastroenterology, Hanyang University College of Medicine, Guri, Gyeonggi-do, Republic of Korea
| | - Seheon Chang
- Internal Medicine, Myongji St. Mary's Hospital, Seoul, Republic of Korea
| | - Seon-Ok Kim
- Biostatistics and Clinical Epidemiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Han Chu Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.,Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yung Sang Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.,Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ju Hyun Shim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea. .,Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Alvi H, Zuberi BF, Rasheed T, Ibrahim MA. Evaluation of endoscopic variceal band ligation sessions in obliteration of esophageal varices. Pak J Med Sci 2020; 36:37-41. [PMID: 32063928 PMCID: PMC6994916 DOI: 10.12669/pjms.36.2.1144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To determine number of sessions of Endoscopic variceal band ligation required to obliterate the esophageal varices. Methods: This study was conducted at Civil Hospital Karachi between June 2018 to April 2019. All patients undergoing endoscopic Variceal Band Ligation (EVBL) were inducted. Number of sessions of band ligation required to obliterate the varices were recorded. Number of EVBL sessions were correlated with Child-Pugh’s Score and etiology of CLD by χ2 test, while it was compared with duration of Chronic Liver Disease (CLD) by One-way ANOVA test. Results: One hundred ninety-two patients fulfilling selection criteria were admitted after informed consent. These included 101 (52.6%) males and 91 (47.4%) females. Most common cause of cirrhosis was HCV (66.7%) in our patients. Most of the patients were in Child Class-B (71.9%). Majority of patients (52.6%) underwent 3 sessions of EVBL while 68 (35.4%) underwent 4 sessions of EVBL. Duration of CLD was analyzed with number of sessions of EVBL by One-Way ANOVA test and it showed significant more sessions of EVBL were done with longer duration of CLD (p <0.001). Conclusion: Most patients underwent 3-4 sessions of EVBL for obliteration of varices. Number of EVBL sessions increased significantly with duration of disease.
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Affiliation(s)
- Haris Alvi
- Haris Alvi, Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Bader Faiyaz Zuberi
- Bader Faiyaz Zuberi, Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Tazeen Rasheed
- Tazeen Rasheed, Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Muhammad Asad Ibrahim
- Muhammad Asad Ibrahim, Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
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Comparison of Efficacy of Laparoscopic and Open Splenectomy Combined With Selective and Nonselective Pericardial Devascularization in Portal Hypertension Patients. Surg Laparosc Endosc Percutan Tech 2019; 28:401-403. [PMID: 30260914 DOI: 10.1097/sle.0000000000000581] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Recent advances in laparoscopic techniques have demonstrated that laparoscopy is superior for managing portal hypertension. This study aimed to compare the efficacy of laparoscopic splenectomy plus selective pericardial devascularization (LSSD) and open splenectomy and nonselective pericardial devascularization (OSD) in patients with portal hypertension. METHODS A total of 127 patients with portal hypertension underwent either LSSD or OSD at Jingzhou Central Hospital from January 2014 to December 2016. A total of, 55 patients received LSSD, including 29 male and 26 female individuals (age, 56.0±11.6 y); 72 patients received OSD, including 45 male and 27 female individuals (age, 53.4±10.9 y). The parameters of operation and outcomes were measured and compared. RESULTS Intraoperative blood loss, postoperative complications, and hospital stay were significantly lower in LSSD group but operation time was significantly lower in OSD group. Postoperative Child-Pugh score was significantly lower in LSSD group than in OSD group. CONCLUSIONS LSSD is a safe and effective treatment for liver cirrhosis patients with portal hypertension.
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Tian S, Li R, Guo Y, Jia X, Dong W. Carvedilol vs endoscopic band ligation for the prevention of variceal bleeding: a meta-analysis. Ther Clin Risk Manag 2019; 15:191-200. [PMID: 30774355 PMCID: PMC6357905 DOI: 10.2147/tcrm.s193196] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE Variceal hemorrhage is the primary driver of mortality in patients with portal hypertension. Recent guidelines recommended that patients with esophageal varices should receive endoscopic band ligation (EBL) or carvedilol as prophylaxis of variceal bleeding. Several clinical trials have compared carvedilol use with EBL intervention, yielding controversial results. The present study aimed to perform a meta-analysis of randomized controlled trials (RCTs) evaluating the benefits and harms of carvedilol vs EBL for the prevention of variceal bleeding. METHODS Studies were searched on Pubmed, Embase, Medline, and Cochrane library databases up to August 2018. Main outcomes in selected studies (variceal bleeding, all-cause deaths, bleeding-related deaths, and adverse events) were pooled into a meta-analysis. RESULTS Seven RCTs were identified in this meta-analysis, including a total of 703 patients. A total of 359 patients were randomized to carvedilol group and 354 were randomized to EBL group. No significant difference in variceal bleeding was observed between carvedilol use and EBL groups (relative ratio [RR] =0.86, 95% CI =0.60-1.23, I 2=11%), without publication bias. No significant difference was found neither for all-cause deaths (RR =0.82, 95% CI =0.44-1.53, I 2=66%) nor for bleeding-related deaths (RR =0.85, 95% CI =0.39-1.87, I 2=42%) in four included studies. Moreover, no reduced trend was observed toward adverse events in carvedilol group compared with that in EBL group (RR =1.32, 95% CI =0.75-2.31, I 2=81%). CONCLUSION There is no significant difference between carvedilol use and EBL intervention for the prophylaxis of variceal bleeding in patient with esophageal varices. Large-scale clinical trials are further needed to make a confirmed conclusion.
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Affiliation(s)
- Shan Tian
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China,
| | - Ruixue Li
- Department of Gastroenterology, Renmin Hospital of Macheng City, Macheng, Hubei, People's Republic of China
| | - Yingyun Guo
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China,
| | - Xuemei Jia
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China,
| | - Weiguo Dong
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China,
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9
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EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; 69:406-460. [PMID: 29653741 DOI: 10.1016/j.jhep.2018.03.024] [Citation(s) in RCA: 1571] [Impact Index Per Article: 261.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023]
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10
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Giannini EG. Editorial: a step forward in refining prognostication for patients with HIV-associated hepatocellular carcinoma. Aliment Pharmacol Ther 2018; 47:133-134. [PMID: 29226414 DOI: 10.1111/apt.14374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- E G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
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11
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Balogh J, Gordon-Burroughs S, Schwarz P, Galati J, McFadden R, Cusick M, Snyder M, Bailey H, Weiner M, Wong A, Ochoa R, Saharia A, Gaber A, Ghobrial R. Treatment of Refractory Gastrointestinal Bleeding in Patients With Portal Hypertension: A Case Series and Treatment Algorithm. Transplant Proc 2017; 49:1864-1869. [DOI: 10.1016/j.transproceed.2017.06.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 06/16/2017] [Indexed: 12/29/2022]
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12
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Tian L, He Y, Li D, Zhang H. Surgical shunts compared with endoscopic sclerotherapy for the treatment of variceal bleeding in adults with portal hypertension: a systematic review and meta-analysis. Postgrad Med J 2017; 94:7-14. [PMID: 28756406 DOI: 10.1136/postgradmedj-2016-134750] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 06/21/2017] [Accepted: 06/26/2017] [Indexed: 12/15/2022]
Abstract
AIM Portal hypertension is a common complication of chronic liver disease and can cause variceal bleeding which is associated with high mortality. Choices for the treatment of variceal bleeding include surgical shunts and endoscopic sclerotherapy. The aim of this study was to compare the efficacy of surgical shunts and endoscopic sclerotherapy in treating variceal bleeding due to portal hypertension. DESIGN Systematic review and meta-analysis. SETTING Medline, PubMed, Cochrane and Google Scholar databases were searched until 12 February 2015, for relevant randomised control trials. Twenty studies with a total of 1540 participants were included. PATIENTS Patients with variceal bleeding due to portal hypertension. INTERVENTIONS Surgical shunts compared to endoscopic sclerotherapy. MAIN OUTCOME MEASURES Rates of rebleeding, survival and hepatoencephalopathy, and length of hospital stay. RESULTS Pooled data for 17 studies showed that the rate of rebleeding was significantly more frequent with sclerotherapy compared with surgical shunt therapy (OR 3.99, 95% CI 2.98 to 5.33, p<0.001). The sclerotherapy patient group compared with the shunt group was less likely to develop hepatoencephalopathy (15 studies: pooled OR 0.53, 95% CI 0.31 to 0.91, p=0.021) and had shorter hospital stays (pooled mean difference-4.32, 95% CI- 7.97 to -0.66, p=0.021). No significant difference in the survival rate was observed between the two groups (seven studies: OR 1.01, 95% CI 0.63 to 1.62, p=0.964). CONCLUSION This analysis indicated that the two types of treatment have similar mortality rates but differed with respect to rebleeding rate, incidence of hepatoencephalopathy and length of hospital stay.
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Affiliation(s)
- Lu Tian
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yunjun He
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Donglin Li
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Hongkun Zhang
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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Kobayashi K, Maruyama H, Kiyono S, Sekimoto T, Kondo T, Shimada T, Takahashi M, Okugawa H, Yokosuka O. Portal response related to shunt occlusion by balloon-occluded retrograde transvenous obliteration may determine the prognosis of cirrhosis. Hepatol Res 2016; 46:1321-1329. [PMID: 26931092 DOI: 10.1111/hepr.12690] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 02/21/2016] [Accepted: 02/28/2016] [Indexed: 12/21/2022]
Abstract
AIM To determine the prognostic effect of portal hemodynamic responses after balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices (GV) in cirrhosis patients. METHODS This retrospective study consisted of 37 cirrhosis patients (aged 62.5 ± 9.7 years) with medium- or large-grade GV treated with B-RTO. Portal hemodynamic response was assessed by the changes in flow volume in the portal trunk (PFV, mL/min) before and after the treatment. Group I showed increased PFV and group II showed no increase in PFV. The median observation period was 49.8 months (range, 4.7-150.3 months). RESULTS All patients showed complete embolization of GV without any recurrence. There were 30 patients in group I and 7 patients in group II (decreased PFV in 6 and unchanged PFV in 1). The PFV at baseline was significantly lower in the former (583.5 ± 232.0 mL/min) than in the latter (880.7 ± 345.9 mL/min; P = 0.009). The survival rate was significantly lower in group II (83.3% at 1 year and 66.7% at 3 years) than in group I (96.7% at 1 year, 81.5% at 3 years, and 61.8% at 5 years; P = 0.012). The incidence of deterioration of the esophageal varices was 18/30 (60%) in group I and 5/7 (71.4%; P = 0.687) in group II. Multivariate analysis identified only no increase in portal response (hazard ratio, 8.086; P = 0.005) as an independent factor for poor prognosis. CONCLUSION Balloon-occluded retrograde transvenous obliteration for GV may result in a poor prognosis when portal hemodynamics shows no increase in portal response.
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Affiliation(s)
- Kazufumi Kobayashi
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hitoshi Maruyama
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Soichiro Kiyono
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tadashi Sekimoto
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takayuki Kondo
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Taro Shimada
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Masanori Takahashi
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hidehiro Okugawa
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Osamu Yokosuka
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
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Ali SM, Wu S, Xu H, Liu H, Hao J, Qin C. A Prospective Study of Endoscopic Injection Sclerotherapy and Endoscopic Variceal Ligation in the Treatment of Esophageal Varices. J Laparoendosc Adv Surg Tech A 2016; 27:333-341. [PMID: 28221819 DOI: 10.1089/lap.2016.0436] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION The aim of this study was to compare the effectiveness and safety of endoscopic injection sclerotherapy (EIS) with endoscopic variceal ligation (EVL) in the management of esophageal variceal bleeding (EVB). PATIENTS AND METHODS In this prospective study, we compared the EIS and EVL in 124 patients who had endoscopically proved bleeding from esophageal varices. According to different treatment methods, they were randomly divided into the EIS and the EVL groups. Sixty-four patients were treated with sclerotherapy and 60 with ligation. The patients were followed for a mean of 2 years, during which we determined the incidence of complications and recurrences of bleeding and the number of treatment sessions needed to eradicate varices, mortality, and survival. RESULTS Active bleeding at the first treatment was controlled by EIS in 19 of 19 patients and by EVL in 16 of 16 patients. The likelihood of early rebleeding was slightly smaller in the patients treated with EIS (7.8% versus 11.7%, P = .47). However, late rebleeding rate was slightly more in EIS patients (28.1% versus 23.3%, P = .54) without statistical significance. The rate of eradication of varices in the EIS group was slightly lower than in the EVL group (79.7% versus 86.7%, P = .30). There were also no statistically significant differences in mortality (1.6% versus 3.3%, P = .61) or survival rate (71.9% versus 78.3%, P = .41) (all P > .05) after EIS and EVL. However, fever in the EIS group was significantly higher compared to that of in the EVL group (n = 17, 26.6% versus n = 6, 10.0%, P = .02). CONCLUSIONS Both EIS and EVL produce excellent results, are safe, effective, feasible, and acceptable for EVB with minimum complications and obviate need for subsequent procedures in the short term. To make better choice, we should consider the hospital conditions, operator experience, and the characteristics of esophageal varices.
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Affiliation(s)
- Syed Mohsin Ali
- 1 Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University , Jinan, China
| | - Shanbin Wu
- 2 Qianfoshan Hospital Affiliated to Shandong University , Jinan, China
| | - Hongwei Xu
- 1 Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University , Jinan, China
| | - Hui Liu
- 1 Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University , Jinan, China
| | - Jinghua Hao
- 1 Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University , Jinan, China
| | - Chengyong Qin
- 1 Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University , Jinan, China
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Carneiro FOAA, Retes FA, Matuguma SE, Albers DV, Chaves DM, Dos Santos MEL, Herman P, Chaib E, Sakai P, Carneiro D'Albuquerque LA, Maluf Filho F. Role of EUS evaluation after endoscopic eradication of esophageal varices with band ligation. Gastrointest Endosc 2016; 84:400-7. [PMID: 26905936 DOI: 10.1016/j.gie.2016.02.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/02/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Variceal recurrence after endoscopic band ligation (EBL) for secondary prophylaxis is a frequent event. Some studies have reported a correlation between variceal recurrence and variceal rebleeding with the EUS features of paraesophageal vessels. A prospective observational study was conducted to correlate EUS evaluation of paraesophageal varices, azygos vein, and thoracic duct with variceal recurrence after EBL variceal eradication in patients with cirrhosis. METHODS EUS was performed before and 1 month after EBL variceal eradication. Paraesophageal varices, azygos vein, and thoracic duct maximum diameters were evaluated in predetermined anatomic stations. After EBL variceal eradication, patients were submitted to endoscopic examinations every 3 months for 1 year. We looked for EUS features that could predict variceal recurrence. RESULTS Thirty patients completed a 1-year endoscopic follow-up. Seventeen patients (57%) presented variceal recurrence. There was no correlation between azygos vein and thoracic duct diameter with variceal recurrence. Larger paraesophageal varices predicted variceal recurrence in both evaluation periods. Paraesophageal varices diameters that best correlated with variceal recurrence were 6.3 mm before EBL (52.9% sensitivity, 92.3% specificity, and .749 area under the receiver operating characteristic curve [AUROC]) and 4 mm after EBL (70.6% sensitivity, 84.6% specificity, and .801 AUROC). CONCLUSIONS We conclude that paraesophageal varices diameter measured by EUS predicts variceal recurrence within 1 year after EBL variceal eradication. Paraesophageal diameter after variceal eradication is a better recurrence predictor, because it has a lower cut-off parameter, higher sensitivity, and higher AUROC.
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Affiliation(s)
| | - Felipe Alves Retes
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | - Sérgio Eiji Matuguma
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | - Débora Vieira Albers
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | - Dalton Marques Chaves
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | | | - Paulo Herman
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | - Eleazar Chaib
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | - Paulo Sakai
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | | | - Fauze Maluf Filho
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
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Kimer N, Naver AV, Thiele M, Krag A, Gluud LL. Beta-blockers alone or in combination with isosorbide mononitrate for secondary prevention of bleeding from gastro-esophageal varices in adults with cirrhosis and gastro-oesophageal varices. Hippokratia 2016. [DOI: 10.1002/14651858.cd012127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Nina Kimer
- Medical Division, Copenhagen University Hospital Hvidovre; Gastrounit; Kettegaards Alle 30 Hvidovre Denmark
| | - Astrid Vinsand Naver
- Copenhagen University Hospital Hvidovre; Gastrounit, Medical Division; Hvidovre Denmark
| | - Maja Thiele
- Odense University Hospital; Department of Gastroenterology and Hepatology; Sdr. Boulevard 29, indgang 126 Odense Denmark 5000
| | - Aleksander Krag
- Odense University Hospital; Department of Gastroenterology S; Sdr. Boulevard 29, indgang 126 Odense C Denmark 5000
| | - Lise Lotte Gluud
- Copenhagen University Hospital Hvidovre; Gastrounit, Medical Division; Hvidovre Denmark
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Nadelson J, Satapathy SK, Nair S. Glycated Hemoglobin Levels in Patients with Decompensated Cirrhosis. Int J Endocrinol 2016; 2016:8390210. [PMID: 27882051 PMCID: PMC5110874 DOI: 10.1155/2016/8390210] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/27/2016] [Accepted: 09/18/2016] [Indexed: 12/15/2022] Open
Abstract
Introduction. Aim of this study is to determine if HbA1c levels are a reliable predictor of glycemic control in patients with decompensated cirrhosis. Methods. 200 unique patients referred for liver transplantation at University of Tennessee/Methodist University Transplant Institute with a HbA1c result were included. Three glucose levels prior to the "measured" A1c (MA1c) were input into an HbA1c calculator from the American Diabetes Association website to determine the "calculated" A1c (CA1c). The differences between MA1c and CA1c levels were computed. Patients were divided into three groups: group A, difference of <0.5; group B, 0.51-1.5; and group C, >1.5. Results. 97 (49%) patients had hemoglobin A1c of less than 5%. Discordance between calculated and measured HbA1c of >0.5% was seen in 47% (n = 94). Higher level of discordance of greater than >1.5 was in 12% of patients (n = 24). Hemoglobin was an independent predictor for higher discordance (odds ratio 0.77 95%, CI 0.60-0.99, and p value 0.04). HbA1c was an independent predictor of occurrence of HCC (OR 2.69 955, CI 1.38-5.43, and p value 0.008). Conclusion. HbA1c is not a reliable predictor of glycemic control in patients with decompensated cirrhosis, especially in those with severe anemia.
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Affiliation(s)
- Jeffrey Nadelson
- Division of Gastroenterology and Hepatology, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Sanjaya K. Satapathy
- Methodist Transplant Institute, Division of Surgery, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Satheesh Nair
- Methodist Transplant Institute, Division of Surgery, University of Tennessee Health Sciences Center, Memphis, TN, USA
- *Satheesh Nair:
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Maruyama H, Kondo T, Sekimoto T, Kiyono S, Shimada T, Takahashi M, Okugawa H, Yokosuka O. Hyponatremia: a significant factor in a poor prognosis for cirrhosis with Child A/B after variceal eradication. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015. [PMID: 26202665 DOI: 10.1002/jhbp.282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND To identify prognostic factors prospectively in cirrhosis after the eradication of esophageal varices (EV). METHODS There were 52 cirrhosis patients (Child-Pugh A 24, B 28) who showed the eradication of EV after the endoscopic sclerotherapy (median observation period, 25.5 months). RESULTS Eighteen patients showed a recurrence of EV. The cumulative overall survival rate was 92.2% at 1 year, 70.9% at 3 years, and 47.2% at 5 years. Univariate analysis showed that serum sodium concentration (hazard ratio [HR] 0.724, P = 0.0006), serum aspartate transaminase (HR 1.019, P = 0.0075), serum alanine transaminase (HR 1.025, P = 0.0239), and serum creatinine (HR 11.311, P = 0.044) levels before treatment were significant factors for a poor prognosis. Multivariate analysis revealed that serum sodium concentration (HR 0.711, P = 0.0022) was the only significant factor. The cumulative survival rate was lower in patients with hyponatremia (<135 mEq/l, a best cut-off value; 83.3% at 1 year, and 33.3% at 3 years), than in those without (93.3% at 1 year, 77.3% at 3 years and 47.2% at 5 years). CONCLUSIONS Pre-treatment hyponatremia is a significant prognostic factor in cirrhosis with Child A/B after the eradication of EV by the endoscopic sclerotherapy.
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Affiliation(s)
- Hitoshi Maruyama
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Takayuki Kondo
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Tadashi Sekimoto
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Soichiro Kiyono
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Taro Shimada
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Masanori Takahashi
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Hidehiro Okugawa
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Osamu Yokosuka
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
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Abraldes JG, Tandon P. Therapies: Drugs, Scopes and Transjugular Intrahepatic Portosystemic Shunt--When and How? Dig Dis 2015; 33:524-33. [PMID: 26159269 DOI: 10.1159/000374101] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Variceal bleeding is the most serious complication of portal hypertension. All cirrhotic patients should be screened endoscopically for varices which are present in about 30% of compensated and 60% of decompensated patients at diagnosis. In patients without varices, endoscopy surveillance should be continued every 2 years. Patients with high-risk varices (moderate or large in size, or with red color signs, or in Child-Pugh C patients) should be treated with a nonselective β-blocker to prevent bleeding (propranolol, nadolol or carvedilol). Endoscopic banding ligation is also effective for the prevention of first bleeding, and it is the first choice in patients with contraindications or intolerance to β-blockers. Acute variceal hemorrhage still has a high mortality rate (around 15%) and requires intensive care management and conservative blood transfusion policy. Treatment is based on the combined use of vasoactive drugs, endoscopic band ligation and prophylactic antibiotics. Failures are best managed by transjugular intrahepatic portosystemic shunt (TIPS). Balloon tamponade or specifically designed covered esophageal stents can be used as a bridge to definitive therapy in unstable patients. Early, preemptive TIPS might be the first choice in patients at high risk of failure (Child-Pugh B with active bleeding or Child-Pugh C up to 13 points). Patients surviving a variceal bleeding are at high risk of rebleeding. A combination of β-blockers and endoscopic band ligation is the most effective therapeutic approach. Preliminary data suggest that the addition of simvastatin increases survival in these patients.
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Genotoxicity and subchronic toxicity of Sophorae radix in rats: Hepatotoxic and genotoxic potential. Regul Toxicol Pharmacol 2015; 71:379-87. [DOI: 10.1016/j.yrtph.2015.01.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 01/07/2015] [Accepted: 01/26/2015] [Indexed: 01/11/2023]
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Debernardi Venon W, Elia C, Stradella D, Bruno M, Fadda M, DeAngelis C, Rizzetto M, Saracco G, Marzano A. Prospective randomized trial: endoscopic follow up 3 vs 6 months after esophageal variceal eradication by band ligation in cirrhosis. Eur J Intern Med 2014; 25:674-9. [PMID: 25018142 DOI: 10.1016/j.ejim.2014.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 06/09/2014] [Accepted: 06/13/2014] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Endoscopic variceal ligation (EVL) is recommended to treat esophageal varices (EV) in cirrhosis and portal hypertension. A program of endoscopic surveillance is not clearly established. The aim of this prospective randomized trial was to assess the most effective timing of endoscopic monitoring after variceal eradication and its impact on the patient's outcome and on the costs. METHODS A hundred and two cirrhotic patients with esophageal varices treated by EVL were evaluated. After variceal eradication patients were randomized to receive first endoscopic control at 3 (Group 1) and 6 (Group 2) months respectively. RESULTS Variceal obliteration was achieved in all patients. Variceal recurrence was observed in 28 cases at the first control (29.1%) without difference between the two groups (32% vs 29% in group 1 and 2 respectively, p=0.75). The incidence of large varices is similar in the two groups (33% vs 38% respectively). Using a multivariate analysis, medical therapy with B blockers was the only independent predictor of lowest risk of variceal recurrence [OR 2.30, 95% CI (1.68-3.26)]. Bleeding related to recurrent varices occurred in 3.1% of cases and was associated with portal thrombosis. Child Pugh score ≥8 was the only predictor of mortality (p=0.0002). CONCLUSIONS Recurrence of varices after banding ligation is not rare but it is associated with a low risk of variceal progression and bleeding. Accordingly, a first endoscopic control at 6 months after variceal eradication associated with a good risk stratification might be a cost-effective strategy of monitoring.
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Affiliation(s)
| | - Chiara Elia
- Gastro-Hepatology Unit, San Giovanni Battista Hospital, University of Turin, Italy.
| | - Davide Stradella
- Gastro-Hepatology Unit, San Giovanni Battista Hospital, University of Turin, Italy.
| | - Mauro Bruno
- Gastro-Hepatology Unit, San Giovanni Battista Hospital, University of Turin, Italy.
| | - Maurizio Fadda
- Clinical Nutrition and Dietetics Unit, San Giovanni Battista Hospital, University of Turin, Italy.
| | - Claudio DeAngelis
- Gastro-Hepatology Unit, San Giovanni Battista Hospital, University of Turin, Italy.
| | - Mario Rizzetto
- Gastro-Hepatology Unit, San Giovanni Battista Hospital, University of Turin, Italy.
| | - Giorgio Saracco
- Gastroenterology Unit, San Luigi Gonzaga Hospital, University of Turin, Italy.
| | - Alfredo Marzano
- Gastro-Hepatology Unit, San Giovanni Battista Hospital, University of Turin, Italy.
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Nijhawan S, Chander S, Nijhawan M. Black rubber band or yellow latex band for endoscopic variceal ligation: which is better? Indian J Gastroenterol 2013; 32:415-6. [PMID: 23881798 DOI: 10.1007/s12664-013-0346-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2012] [Accepted: 06/30/2013] [Indexed: 02/04/2023]
Affiliation(s)
- Sandeep Nijhawan
- Department of Gastroenterology, Sawai Man Singh Medical College, J L N Marg, Jaipur, 302 004, India,
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Kong DR, Ma C, Wang M, Wang JG, Chen C, Zhang L, Hao JH, Li P, Xu JM. Effects of propranolol or propranolol plus isosorbide-5-mononitrate on variceal pressure in schistosomiasis. World J Gastroenterol 2013; 19:4228-4233. [PMID: 23864788 PMCID: PMC3710427 DOI: 10.3748/wjg.v19.i26.4228] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 03/29/2013] [Accepted: 06/06/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the effects of propranolol (PR) to that of PR plus isosorbide-5-mononitrate (ISMN) on variceal pressure in patients with schistosomiasis.
METHODS: Forty-eight patients with schistosomiasis who had no previous variceal bleeding were treated with PR alone or PR plus ISMN. Seven patients refused variceal pressure manometry (3 receiving PR and 4 receiving PR plus ISMN). One patient withdrew from the trial due to headache after taking ISMN. At the time of termination, twenty patients were randomly assigned to treatment with PR plus ISMN or PR alone. The dose of PR was adjusted until the resting heart rate had been reduced by 25% or was less than 55 bpm. In the PR plus ISMN group, after PR was titrated to the same target, the dose of ISMN was increased up to 20 mg orally twice a day. Variceal pressure was measured using a noninvasive endoscopic balloon technique at the end of the 6-mo treatment period.
RESULTS: In 40 patients (20 in the PR group and 20 in the PR plus ISMN group), variceal pressure was measured before treatment and at the end of the 6-mo treatment period. PR or PR plus ISMN treatment caused a significant reduction in variceal pressure (PR group: from 24.15 ± 6.05 mmHg to 22.68 ± 5.70 mmHg, P = 0.001; PR plus ISMN group: from 25.69 ± 5.26 mmHg to 20.48 ± 5.43 mmHg; P < 0.001). The percentage decrease in variceal pressure was significant after PR plus ISMN compared with that after PR alone (15.93% ± 8.37% vs 6.05% ± 3.67%, P = 0.01). One patient in the PR plus ISMN group and two patients in the PR group had variceal bleeding during follow-up. There were no significant differences between the two groups regarding the incidence of variceal bleeding. In the PR plus ISMN group, three patients had headache and hypotension. The headache was mild and transient and promptly disappeared after continuation of the relevant drug in two patients. Only one patient withdrew from the trial due to severe and lasting headache after taking ISMN. No side effects occurred in the PR group.
CONCLUSION: PR plus ISMN therapy may be an alternative treatment for patients with schistosomiasis who have a high risk of bleeding.
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Zhou J, Wu Z, Wu J, Peng B, Wang X, Wang M. Laparoscopic splenectomy plus preoperative endoscopic variceal ligation versus splenectomy with pericardial devascularization (Hassab's operation) for control of severe varices due to portal hypertension. Surg Endosc 2013; 27:4371-7. [PMID: 23846362 DOI: 10.1007/s00464-013-3057-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Accepted: 06/11/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND Our research was conducted to introduce a new, compound surgical method for laparoscopic splenectomy (LS) with preoperative endoscopic variceal ligation (EVL) and compare the new method's efficiency with that of Hassab's operation in patients with severe esophageal varices due to portal hypertension. METHODS Between March 2009 and March 2012, 47 patients with liver cirrhosis, portal hypertension, and severe esophageal varices were retrospectively analyzed. Of these patients, 19 received the combined preoperative EVL and LS (minimally invasive surgery, MIS group), and 28 patients received splenectomy with pericardial devascularization (Hassab's operation, H group). RESULTS Before surgery, there were no differences in the patient characteristics of the two groups. There were no significant differences in operating time, but significantly less intraoperative blood loss and shorter postoperative hospital stay were found in the MIS group compared with the H group. The mean follow-up periods of the MIS and H groups were 12.1 and 13.6 months, respectively. No deaths were documented during the follow-up period. Generally, hematological parameters and liver function variables eventually revealed considerable improvement in both groups. In the MIS group, the patients with varices improved significantly from severe to mild, and in some cases, the varices disappeared after treatment. Three patients in the H group suffered rebleeding and were treated with repeated EVL. No bleeding or rebleeding occurred in the MIS group. CONCLUSIONS The final results suggest that LS with preoperative EVL provides a restorative efficacy equivalent to that of Hassab's operation. Based on the recurrence rate and the rebleeding rate of severe esophageal varices, our surgical strategy (EVL and LS) is a safe and minimally invasive technique that appears satisfactory in comparison to other open procedures.
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Affiliation(s)
- Jin Zhou
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
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Lahbabi M, Mellouki I, Aqodad N, Elabkari M, Elyousfi M, Ibrahimi SA, Benajah DA. Esophageal variceal ligation in the secondary prevention of variceal bleeding: Result of long term follow-up. Pan Afr Med J 2013; 15:3. [PMID: 23847700 PMCID: PMC3708329 DOI: 10.11604/pamj.2013.15.3.2098] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 04/16/2013] [Indexed: 01/13/2023] Open
Abstract
Introduction Long-term outcome of patients after band ligation have been poorly defined. Therefore, we conducted a long-term follow-up study to delineate the outcome of ligation in patients with portal hypertension in the Hassan II university hospital, Fes, Morocco. Methods Over 118 months patients treated by endoscopic variceal ligation were received regular follow- up and detailed clinical assessment of at least 24 months. Results One hundred twenty five patients were followed up for a mean of 31 months (range 12-107 months). Obliteration of the varices was achieved in 89.6 % (N = 112) of patients, with 3 +/-1.99 (range 1-8) endoscopy sessions over a period of 14 + /-6.8 weeks (range 3-28). The percentage of variceal recurrence during follow-up after ligation was 20.5 % (N = 23). Recurrence were observed in a mean of 22 months +/- 7.3 (range 3-48). Bleeding rate from recurrent varices was 30.4 % (7/23). Rebleeding from esophageal ulcers occurred in 5.6 % (7/125) of patients. Portal hypertensive gastropathy before and after eradication of varices was 17.6% (N = 22) and 44.6% (N = 50) respectively; p< 0.05. Fundal gastric varices was 30.4% (N = 38) and 35.7% (N = 40) before and after eradication of varices respectively; p> 0.05. The overall mortality was 4 % (N = 5). Conclusion Band ligation was an effective technical approach for variceal obliteration with low rates of variceal recurrence, rebleeding and development of gastric varices. Furthermore, it was associated with frequent development of portal hypertensive gastropathy.
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Affiliation(s)
- Mounia Lahbabi
- Department of Hepato Gastroenterology Hassan II University Hospital Fez, Morocco
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Assessment of risk of bleeding from esophageal varices during management of biliary atresia in children. J Pediatr Gastroenterol Nutr 2013; 56:537-43. [PMID: 23263589 DOI: 10.1097/mpg.0b013e318282a22c] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The management of esophageal varices (EV) in children experiencing biliary atresia (BA) remains controversial. Recent studies in children proposed initiating a prophylactic treatment in patients with severe (grade III) EV and/or EV associated with red color signs. Our study was aimed at assessing the risk of bleeding from EV in a series of patients with BA, identifying risk factors for bleeding to develop a predictive model of bleeding. METHODS This was a retrospective study including 83 eligible patients with BA. Clinical, ultrasonographic, endoscopic, and laboratory parameters were studied from the beginning of medical management up to the occurrence of upper gastrointestinal bleeding. In patients not presenting any bleeding, data were analyzed until liver transplantation, endoscopic treatment of EV was performed, or last follow-up. Risk factors were investigated using univariate and multivariate statistical analyses. RESULTS Seventeen of 83 patients (20%) presented gastrointestinal bleeding, with a median age of 9.5 months (6-50 months). In univariate and multivariate analyses, high-grade EV, red color signs on endoscopic examination, and low fibrinogen levels, at first endoscopy, were identified as risk factors for bleeding. When tested in >10,000 different models, these 3 variables appeared to play the most significant role in predicting bleeding. CONCLUSIONS Our study confirmed that grade III EV and red color signs are risk factors for bleeding in patients followed up for BA. We identified low fibrinogen levels as an additional risk factor. The relevance of these 3 factors to predict bleeding from EV requires validation in a prospective study.
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Lahbabi M, Elyousfi M, Aqodad N, Elabkari M, Mellouki I, Ibrahimi SA, Benajah DA. Esophageal variceal ligation for hemostasis of acute variceal bleeding: efficacy and safety. Pan Afr Med J 2013; 14:95. [PMID: 23717711 PMCID: PMC3664877 DOI: 10.11604/pamj.2013.14.95.1847] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 08/11/2012] [Indexed: 12/29/2022] Open
Abstract
Introduction Endoscopic variceal ligation is widely accepted as the optimum endoscopic treatment for esophageal variceal hemorrhage. In Morocco, there are no data regarding the efficacy of this technique. Our aim was to evaluate the effectiveness and safety of endoscopic variceal ligation in the management of oesophageal variceal bleeding in cirrhosis in a located population in Morocco. Methods Via a retrospective study over 118 months (December 2001- October 2011), cirrhotic patients with endoscopically proven esophageal variceal hemorrhage were treated by endoscopic variceal ligation. We studied the rate of haemostasis, rebleeding, complications and mortality. Results 360 cirrhotic patients were included and 378 haemostatic variceal ligations were performed. Primary haemostasis was obtained in 96.5 % (N=365) of cases. Thirty three patients (8.7%) bled during follow-up. The rate of minor complications was 15.3 % (N=58). Retrosternal pain, fever, dysphagia and Overtube's migration developed in 8.4 % (N=32); 2.6 % (N=10); 3,7 % (N=14) and 0.5 % (N=2) of the patients respectively. Severity of these complications was mild and transient. The rate of oesophageal ulcers was 5 % (N=19), while the mortality rate by haemorrhage was 5 % (N=18). Conclusion Our data showed that band ligation is an effective and safe treatment modality of esophageal variceal bleeding with low rates of rebleeding and complications.
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Affiliation(s)
- Mounia Lahbabi
- Department of Hepato Gastroenterology Hassan II University Hospital Fez, Morocco
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Zhao S, Lv T, Gong G, Wang C, Huang B, Zhou W. Outcome of Laparoscopic Splenectomy with Sandwich Treatment Including Pericardial Devascularization and Limited Portacaval Shunt for Portal Hypertension Due to Liver Cirrhosis. J Laparoendosc Adv Surg Tech A 2013; 23:43-7. [PMID: 23248978 DOI: 10.1089/lap.2012.0388] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- Shaoyong Zhao
- Department of General Surgery, No. 2 People's Hospital of Yibin City, Yibin, China
| | - Tao Lv
- Department of General Surgery, No. 2 People's Hospital of Yibin City, Yibin, China
| | - Guang Gong
- Department of General Surgery, No. 2 People's Hospital of Yibin City, Yibin, China
| | - Changsong Wang
- Department of General Surgery, No. 2 People's Hospital of Yibin City, Yibin, China
| | - Bin Huang
- Department of General Surgery, No. 2 People's Hospital of Yibin City, Yibin, China
| | - Wenhao Zhou
- Department of General Surgery, No. 2 People's Hospital of Yibin City, Yibin, China
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Hobolth L, Bendtsen F, Møller S. Indications for portal pressure measurement in chronic liver disease. Scand J Gastroenterol 2012; 47:887-92. [PMID: 22809270 DOI: 10.3109/00365521.2012.706827] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Portal hypertension leads to development of serious complications such as esophageal varices, ascites, renal and cardiovascular dysfunction. The importance of the degree of portal hypertension has been substantiated within recent years. Measurement of the portal pressure is simple and safe and the hepatic venous pressure gradient (HVPG) independently predicts survival and development of complications such as ascites, HCC and bleeding from esophageal varices. Moreover, measurements of HVPG can be used to guide pharmacotherapy for primary and secondary prophylaxis for variceal bleeding. Assessment of HVPG should therefore be considered as a part of the general characterization of patients with portal hypertension in departments assessing and treating this condition.
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Affiliation(s)
- Lise Hobolth
- Gastro Unit, Medical Division 360, Hvidovre Hospital, Hvidovre, Denmark.
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Grønbaek H, Sandahl TD, Mortensen C, Vilstrup H, Møller HJ, Møller S. Soluble CD163, a marker of Kupffer cell activation, is related to portal hypertension in patients with liver cirrhosis. Aliment Pharmacol Ther 2012; 36:173-80. [PMID: 22591184 DOI: 10.1111/j.1365-2036.2012.05134.x] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 04/05/2012] [Accepted: 04/25/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Activation of Kupffer cells may be involved in the pathogenesis of portal hypertension by release of vasoconstrictive substances and fibrosis due to co-activation of hepatic stellate cells. AIM To study soluble plasma (s) CD163, a specific marker of activated macrophages, as a biomarker for portal hypertension in patients with liver cirrhosis. METHODS We measured sCD163 concentration and the hepatic venous pressure gradient (HVPG) by liver vein catheterisation in 81 cirrhosis patients (Child-Pugh CP-A: n = 26, CP-B: n = 29, CP-C: n = 26) and 22 healthy subjects. We also measured their cardiac output (CO), cardiac index and systemic vascular resistance (SVR). Liver status was examined by Child-Pugh and MELD-score. RESULTS In cirrhosis, sCD163 concentration was nearly three times higher than in controls (4.7 ± 2.5 vs. 1.6 ± 0.5 mg/L, P < 0.001). sCD163 was also higher, as measured in steps by CP-score (P < 0.001). The HVPG rose steeply to an asymptote of 22 mmHg with sCD163 up to about 5 mg/L and not to higher values with higher sCD163. In a multivariate analysis, sCD163 was the only independent predictor of the HVPG but did not predict any of the systemic circulatory findings. sCD163 > 3.95 mg/L (upper normal limit) predicted HVPG ≥ 10 mmHg with a positive predictive value of 0.99. CONCLUSIONS Circulating sCD163 originating from activated Kupffer cells is increased in cirrhosis with increasing Child-Pugh score and with increasing HVPG, and it is an independent predictor for HVPG. These findings support a primary role of macrophage activation in portal hypertension, and may indicate a target for biological intervention.
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Affiliation(s)
- H Grønbaek
- Department of Medicine V, Aarhus University Hospital, Denmark
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Chang CC, Lee WS, Huang HC, Lee FY, Wang SS, Lin HC, Nong JY, Lee SD. Aliskiren reduces portal pressure in portal hypertensive rats. Eur J Clin Invest 2012; 42:526-33. [PMID: 22023532 DOI: 10.1111/j.1365-2362.2011.02611.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Aliskiren is a direct renin inhibitor used in the treatment for arterial hypertension. It can also augment nitric oxide (NO) production, which plays a crucial role in the pathogenesis of portal hypertension and modulation of porto-systemic collaterals. This study investigated the effects of aliskiren on portal pressure and porto-systemic collaterals of portal vein-ligated (PVL) rats. MATERIALS AND METHODS Sham-operated and PVL rats received aliskiren (50 mg/kg per day) or distilled water (control) treatment for 10 days. The mean arterial pressure and portal pressure were measured by catheterization of the right femoral artery and mesenteric vein, while the superior mesenteric arterial blood flow was measured by Doppler technique. The left adrenal vein and superior mesentery artery were dissected for mRNA study. The PVL rats also underwent preincubation with (i) Krebs solution (control); (ii) 10(-4) M aliskiren; or (iii) 10(-4) M aliskiren plus nonselective NO inhibitor N(ω)-nitro-L-arginine (10(-4) M), followed by the addition of arginine vasopressin (AVP) to evaluate the collateral vascular responsiveness. RESULTS Aliskiren had systemic arterial pressure- and portal pressure-lowering effects in PVL rats. Superior mesentery arterial resistance also decreased. The constitutive NO synthase was enhanced in the left adrenal vein and superior mesentery artery after aliskiren treatment. Aliskiren attenuated the collateral vasoconstrictive effects of AVP, but the vasodilatory effects were abolished after nonselective NO synthase inhibition. CONCLUSIONS Chronic aliskiren use reduces portal pressure in portal hypertensive rats partly due to the modulation of splanchnic and collateral NO synthase.
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Affiliation(s)
- Ching-Chih Chang
- Division of General Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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Pinter M, Sieghart W, Reiberger T, Rohr-Udilova N, Ferlitsch A, Peck-Radosavljevic M. The effects of sorafenib on the portal hypertensive syndrome in patients with liver cirrhosis and hepatocellular carcinoma--a pilot study. Aliment Pharmacol Ther 2012; 35:83-91. [PMID: 22032637 DOI: 10.1111/j.1365-2036.2011.04896.x] [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] [Indexed: 12/20/2022]
Abstract
BACKGROUND Increased intrahepatic vascular resistance and hyperperfusion in the splanchnic circulation are the principal mechanisms leading to portal hypertension in cirrhosis. Several preclinical studies have demonstrated a beneficial effect of the multikinase inhibitor sorafenib on the portal hypertensive syndrome. AIM To investigate the effect of sorafenib on hepatic venous pressure gradient (HVPG), systemic hemodynamics and intrahepatic mRNA expression of proangiogenic, profibrogenic and proinflammatory genes. METHODS Patients with liver fibrosis/cirrhosis and hepatocellular carcinoma were treated with sorafenib 400 mg b.d. HVPG measurement and transjugular liver biopsy were performed at baseline and at week 2. Changes in HVPG and intrahepatic mRNA expression of vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), RhoA, tumour necrosis factor-alpha (TNF-α) and placental growth factor (PlGF) were evaluated. RESULTS Thirteen patients (m/f = 12/1; Child-Pugh class A/B = 10/3) were included. The most common aetiology of liver disease was alcohol consumption (n = 7). Eleven patients had an elevated portal pressure, including eight patients with clinically significant portal hypertension. A significant decrease of HVPG (≥ 20% from baseline) was observed in four subjects. In HVPG responders, we observed mRNA downregulation of VEGF, PDGF, PlGF, RhoA kinase and TNF-α, while no substantial mRNA decrease was found in nonresponders in any of the five genes. In two of the four HVPG responders we observed a dramatic (43-85%) mRNA decrease of all five investigated genes. CONCLUSION Larger controlled clinical trials are needed to demonstrate any potential beneficial effect of sorafenib on portal hypertension in patients with cirrhosis.
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Affiliation(s)
- M Pinter
- Abteilung für Gastroenterologie & Hepatologie, AKH & Medizinische Universität Wien, Austria
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Endoscopic band ligation versus pharmacological therapy for variceal bleeding in cirrhosis: a meta-analysis. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2011; 25:147-55. [PMID: 21499579 DOI: 10.1155/2011/346705] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To conduct a meta-analysis of published, full-length, randomized controlled trials evaluating the efficacy of endoscopic band ligation (EBL) versus pharmacological therapy for the primary and secondary prophylaxis of variceal hemorrhage in patients with cirrhosis. METHODS Literature searches were conducted using the PubMed, EMBASE and Cochrane Library databases. Eighteen randomized clinical trials that fulfilled the inclusion criteria were further pooled into a meta-analysis. RESULTS Among 1023 patients in 12 trials comparing EBL with beta-blockers for primary prevention, there was no significant difference in gastrointestinal bleeding (RR 0.79 [95% CI 0.61 to 1.02]), all-cause deaths (RR 1.06 [95% CI 0.86 to 1.30]) or bleeding-related deaths (RR 0.66 [95% CI 0.38 to 1.16]). There was a reduced trend toward significance in variceal bleeding with EBL compared with betablockers (RR 0.72 [95% CI 0.54 to 0.96]). However, variceal bleeding was not significantly different between the two groups in high-quality trials (RR 0.84 [95% CI 0.60 to 1.17]). Among 687 patients from six trials comparing EBL with beta-blockers plus isosorbide mononitrate for secondary prevention, there was no effect on either gastrointestinal bleeding (RR 0.95 [95% CI 0.65 to 1.40]) or variceal bleeding (RR 0.89 [95% CI 0.53 to 1.49]). The risk for all-cause deaths in the EBL group was significantly higher than in the medical group (RR 1.25 [95% CI 1.01 to 1.55]); however, the rate of bleeding related deaths was unaffected (RR 1.16 [95% CI 0.68 to 1.97]). CONCLUSIONS Both EBL and beta-blockers may be considered first-line treatments to prevent first variceal bleeding, whereas betablockers plus isosorbide mononitrate may be the best choice for the prevention of rebleeding.
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Ouakaa-Kchaou A, Kharrat J, Mir K, Houda B, Abdelli N, Ajmi S, Azzouz M, Ben Abdallah H, Ben Mami N, Bouzaidi S, Chouaib S, Golli L, Melki W, Najjar T, Saffar H, Belhadj N, Ghorbel A. Variceal band ligation in the prevention of variceal bleeding: a multicenter trial. Saudi J Gastroenterol 2011; 17:105-9. [PMID: 21372346 PMCID: PMC3099054 DOI: 10.4103/1319-3767.77238] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Accepted: 09/02/2010] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND/AIM Variceal bleeding is a life-threatening complication of portal hypertension with a high probability of recurrence. Treatment to prevent first bleeding or rebleeding is mandatory. The study has been aimed at investigating the effectiveness of endoscopic band ligation in preventing upper gastrointestinal bleeding in patients with portal hypertension and to establish the clinical outcome of patients. PATIENTS AND METHODS We analyzed in a multicenter trial, the efficacy and side effects of endoscopic band ligation for the primary and secondary prophylaxis of esophageal variceal bleeding. We assigned 603 patients with portal hypertension who were hospitalized to receive treatment with endoscopic ligation. Sessions of ligation were repeated every two to three weeks until the varices were eradicated. The primary end point was recurrent bleeding. RESULTS The median follow-up period was 32 months. A total of 126 patients had recurrent bleeding. All episodes were related to portal hypertension and 79 to recurrent variceal bleeding. There were major complications in 51 patients (30 had bleeding esophageal ulcers). Seventy-eight patients died, 26 deaths were related to variceal bleeding and 1 to bleeding esophageal ulcers. CONCLUSIONS A great improvement in the prevention of variceal bleeding has emerged over the last years. However, further therapeutic options that combine higher efficacy, better tolerance and fewer side effects are needed.
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Bittencourt PL, Farias AQ, Strauss E, Mattos AAD. Variceal bleeding: consensus meeting report from the Brazilian Society of Hepatology. ARQUIVOS DE GASTROENTEROLOGIA 2010; 47:202-16. [PMID: 20721469 DOI: 10.1590/s0004-28032010000200017] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Accepted: 08/17/2009] [Indexed: 02/06/2023]
Abstract
In the last decades, several improvements in the management of variceal bleeding have resulted in a significant decrease in morbidity and mortality of patients with cirrhosis and bleeding varices. Progress in the multidisciplinary approach to these patients has led to a better management of this disease by critical care physicians, hepatologists, gastroenterologists, endoscopists, radiologists and surgeons. In this respect, the Brazilian Society of Hepatology has, recently, sponsored a consensus meeting in order to draw evidence-based recommendations on the management of these difficult-to-treat subjects. An organizing committee comprised of four people was elected by the Governing Board and was responsible to invite 27 researchers from distinct regions of the country to make a systematic review of the subject and to present topics related to variceal bleeding, including prevention, diagnosis, management and treatment, according to evidence-based medicine. After the meeting, all participants met together for discussion of the topics and the elaboration of the aforementioned recommendations. The organizing committee was responsible for writing the final document. The meeting was held at Salvador, May 6th, 2009 and the present manuscript is the summary of the systematic review that was presented during the meeting, organized in topics, followed by the recommendations of the Brazilian Society of Hepatology.
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Costa G, Cruz RJ, Abu-Elmagd KM. Surgical shunt versus TIPS for treatment of variceal hemorrhage in the current era of liver and multivisceral transplantation. Surg Clin North Am 2010; 90:891-905. [PMID: 20637955 DOI: 10.1016/j.suc.2010.04.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Over the last 3 decades, management of acute variceal bleeding and measures to prevent recurrent episodes has evolved due to the introduction of new therapeutic modalities including innovative surgical and minimally invasive shunt procedures. Such an evolution has been compounded by the parallel progress that has been achieved in organ transplantation. This article focuses primarily on the commonly used surgical and radiologic shunt procedures. Liver and multivisceral transplantation are also briefly discussed as important parts of the algorithmic management of these complex patients, particularly those with hepatic decompensation and portomesenteric venous thrombosis.
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Affiliation(s)
- Guilherme Costa
- Intestinal Rehabilitation and Transplantation Center, Thomas East Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh Medical Center, UPMC Montefiore - 7 South, 3459 Fifth Avenue, Pittsburgh, PA 15213-2582, USA
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Lee JW. [Treatment update on portal hypertension and complications]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2010; 56:144-54. [PMID: 20847605 DOI: 10.4166/kjg.2010.56.3.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Current understanding of the pathophysiology of portal hypertension has resulted in therapeutic approaches aimed at correcting the increased splanchnic blood flow and some of which have been already used in clinical practice. Recently new perspectives opened and erstwhile paradigm has been changed to focus on increased resistance to portal blood flow and the formation of portosystemic collateralization. Several studies revealed the clear-cut mechanisms of hepatic endothelial dysfunction and abnormal angiogenesis contributing to the development of portal hypertension. Thus the modulations of hyperdynamic circulation or angiogenesis seem to be valuable therapeutic targets. In the current review update, we discuss the multidisciplinary management of modulating hepatic vascular resistance and abnormal angiogenesis associated with portal hypertension. However, these new pharmacological approaches are still under investigation and widescale clinical application are needed to develop effective strategies.
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Affiliation(s)
- Jin Woo Lee
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea.
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Sterling RK. Long-term effects of sustained virologic response on the development of esophageal varices in compensated cirrhosis: "is the bang worth the buck?". Hepatology 2010; 51:1891-3. [PMID: 20512983 DOI: 10.1002/hep.23601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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40
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Björnsson E, Aabakken L, Olafsson S, Bendtsen F, Bendtsen F. Are specific guidelines necessary for treatment of esophageal varices in the Nordic countries? Scand J Gastroenterol 2010; 44:1037-47. [PMID: 19565407 DOI: 10.1080/00365520903075170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Einar Björnsson
- Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Abstract
Anemia of diverse etiology is a common complication of chronic liver diseases. The causes of anemia include acute or chronic gastrointestinal hemorrhage, and hypersplenism secondary to portal hypertension. Severe hepatocellular disease predisposes to hemorrhage because of impaired blood coagulation caused by deficiency of blood coagulation factors synthesized by hepatocytes, and/or thrombocytopenia. Aplastic anemia, which is characterized by pancytopenia and hypocellular bone marrow, may follow the development of hepatitis. Its presentation includes progressive anemia and hemorrhagic manifestations. Hematological complications of combination therapy for chronic viral hepatitis include clinically significant anemia, secondary to treatment with ribavirin and/or interferon. Ribavirin-induced hemolysis can be reversed by reducing the dose of the drug or discontinuing it altogether. Interferons may contribute to anemia by inducing bone marrow suppression. Alcohol ingestion is implicated in the pathogenesis of chronic liver disease and may contribute to associated anemia. In patients with chronic liver disease, anemia may be exacerbated by deficiency of folic acid and/or vitamin B12 that can occur secondary to inadequate dietary intake or malabsorption.
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43
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44
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MacLaren R. Management of Cirrhosis and Associated Complications. J Pharm Pract 2009. [DOI: 10.1177/0897190008328693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Liver cirrhosis is the encapsulation or replacement of injured tissue by collagen, resulting in end-stage liver disease and portal hypertension. The consequences of cirrhosis are impaired hepatocyte function, increase intrahepatic circulatory resistance, portal hypertension, and the development of hepatocellular carcinoma. Complications include encephalopathy, coagulopathy, varices, ascites, spontaneous bacterial peritonitis, epatorenal syndrome, and hepatopulmonary syndrome. Managing patients with acute or chronic liver failure is challenging, and liver failure may have profound effects on other organ systems. Most therapies are directed at managing the complications and bridging patients to liver transplantation. The clinician must be aware of the pathologic presentations and the appropriate management, including pharmacologic and nonpharmacologic therapies, goals and end points of therapy, and monitoring of therapy. This review focuses on the management of the complications directly associated with liver dysfunction (encephalopathy and coagulopathy) and portal hypertension (varices, ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, hepatopulmonary syndrome).
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Affiliation(s)
- Robert MacLaren
- University of Colorado Denver, School of Pharmacy, Aurora, Colorado,
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45
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Ma H, Suo T, Zhang W, Fu D, Liu T, Zhao N. Organic nitrates for prevention of oesophageal varices bleeding and re-bleeding. Hippokratia 2000. [DOI: 10.1002/14651858.cd002149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Huaixing Ma
- Zhongshan Hospital, Fudan University; Department of Medical Oncology; Shanghai China
| | - Tao Suo
- Zhongshan Hospital, Fudan University; Department of General Surgery, Institute of General Surgery; 180 Fenglin Road, Xuhui District Shanghai Shanghai China 200032
| | - Wei Zhang
- Medical Library of Fudan University; Department of Reference; Shanghai China
| | - Daiquan Fu
- Zhongshan Hospital, Fudan University; Department of General Medicine; 180 Fenglin Road Shanghai Shanghai China 200032
| | - Tianshu Liu
- Zhongshan Hospital, Fudan University; Department of Medical Oncology; Shanghai China
| | - Naiqing Zhao
- School of Public Health, Fudan University; Department of Biostatistics; 130 Dong'an Road Shanghai China 200032
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