Endoscopic therapy for bleeding esophageal varices improves the outcome of Child C cirrhotic patients

General anesthesia in patients with hepatic encephalopathy and acute variceal bleeding undergoing endoscopic treatment: A retrospective study

The management of cirrhotic patient with encephalopathy and acute variceal bleeding (AVB) remains a clinical challenge with a high mortality. Early endoscopic therapies are frequently applied in patients with AVB. However, the application of general anesthesia in endoscopic surgery for patients with hepatic encephalopathy (HE) is pretty challenging. The present study aimed to evaluate the possible effect of general anesthesia with tracheal intubation on patient complicated with encephalopathy and AVB during endoscopic procedure. Thirty-six cirrhotic patients with encephalopathy and AVB were retrospectively studied, 14 patients underwent endoscopic treatment under general anesthesia with tracheal intubation, and 22 patients received pharmacological treatment, or and endoscopic therapy without general anesthesia served as the control group. Routine clinical and laboratory data were collected. The total mortality rate was 13.9% (5/36), 2 (14.3%) in the anesthesia group, 3 (13.6%) in the control group. The child-Pugh class of death cases were all grade C, 3 (60%) of them were in the stage IV of HE. The stage of HE was all improved in the 2 groups, 12 (85.8 %) patients were totally recovered from consciousness disturbance in the anesthesia group and 16 (72.7 %) in the control group respectively, the difference between the 2 groups was not significant (P>0.05). Except the death cases, there were still 3 patients in the control group had impaired consciousness at discharge. Child-Pugh score, Child-Pugh class and the stage of HE in the anesthesia group were significantly improved at discharge compared with those before operation. General anesthesia does not aggravate the severity of encephalopathy, and endoscopic treatment under general anesthesia with tracheal intubation is effective for HE patients complicated with AVB.

A Practical Model for Predicting Esophageal Variceal Rebleeding in Patients with Hepatitis B-Associated Cirrhosis

Background

Variceal rebleeding is a significant and potentially life-threatening complication of cirrhosis. Unfortunately, currently, there is no reliable method for stratifying high-risk patients. Liver stiffness measurements (LSM) have been shown to have a predictive value in identifying complications associated with portal hypertension, including first-time bleeding. However, there is a lack of evidence to confirm that LSM is reliable in predicting variceal rebleeding. The objective of our study was to evaluate the ability of generating a extreme gradient boosting (XGBoost) algorithm model to improve the prediction of variceal rebleeding.

Methods

This retrospective analysis examined a cohort of 284 patients with hepatitis B-related cirrhosis. XGBoost models were developed using laboratory data, LSM, and imaging data to predict the risk of rebleeding in the patients. In addition, we compared the XGBoost models with traditional logistic regression (LR) models. We evaluated and compared the two models using the area under the receiver operating characteristic curve (AUROC) and other model performance parameters. Lastly, we validated the models using nomograms and decision curve analysis (DCA).

Results

During a median follow-up of 66.6 weeks, 72 patients experienced rebleeding, including 21 (7.39%) and 61 (21.48%) patients who rebleed within 6 weeks and 1 year, respectively. In brief, the AUC of the LR models in predicting rebleeding at 6 weeks and 1 year was 0.828 (0.759-0.897) and 0.799 (0.738-0.860), respectively. In contrast, the accuracy of the XGBoost model in predicting rebleeding at 6 weeks and 1 year was 0.985 (0.907-0.731) and 0.931 (0.806-0.935), respectively. LSM and high-density lipoprotein (HDL) levels differed significantly between the rebleeding and nonrebleeding groups, with LSM being a reliable predictor in those models. The XGBoost models outperformed the LR models in predicting rebleeding within 6 weeks and 1 year, as demonstrated by the ROC and DCA curves.

Conclusion

The XGBoost algorithm model can achieve higher accuracy than the LR model in predicting rebleeding, making it a clinically beneficial tool. This implies that the XGBoost model is better suited for predicting the risk of esophageal variceal rebleeding in patients.

Prognosis of endotherapy versus splenectomy and devascularization for variceal bleeding in patients with hepatitis B-related cirrhosis

OBJECTIVE

This study aimed to compare the long-term outcome of endotherapy versus a combination of splenectomy and devascularization for variceal bleeding in patients with hepatitis B-related cirrhosis (HBRC).

MATERIALS AND METHODS

A total of 1074 patients with HBRC and acute variceal bleeding (AVB) treated with endotherapy and 248 patients with HBRC treated with a combination of splenectomy and devascularization surgery were included in the analysis. After one-to-one propensity score matching, 151 paired patients were selected. The primary end-point was death. The secondary outcomes were 3-year survival, 5-year survival, and rebleeding. Complications were recorded.

RESULTS

The median follow-up time was 1165 days in the endoscopic group and 1709 days in the surgical group. Before matching, the 1-year, 3-year, and 5-year survival rates were significantly lower in the endoscopic group than in the surgical group (91.1 vs 96.3%, P = 0.017; 79.6 vs 91.6%, P = 0.001; 65.2 vs 81.3%, P = 0.001). After matching, no significant differences were found between groups (94.5 vs 95.2%, P = 0.767; 87.0 vs 88.9%, P = 0.635; 77.9 vs 77.9%, P = 0.905). The rebleeding rate was lower in the surgical group than in the endoscopic group; the rebleeding-free survival rate was similar in the two groups. No patient died of complications. No statistically significant difference was observed in complications between groups.

CONCLUSIONS

Both endotherapy and a combination of splenectomy and devascularization are good choices for patients with AVB. The rebleeding rate was lower after the surgical procedure, but the long-term prognosis was similar.

Reasons and risk factors for irregular-interval endoscopic variceal sclerotherapy in patients with esophageal variceal bleeding

OBJECTIVE

Endoscopic variceal sclerotherapy (EVS) is usually carried out at weekly intervals in patients with esophageal variceal bleeding (EVB). However, some patients receive sclerotherapy at irregular intervals. In this study we aimed to elucidate the reasons and risk factors for irregular-interval sclerotherapy in patients with EVB, and to evaluate the safety and efficacy of interrupted irregular intervals in these patients.

METHODS

Medical records of patients who were admitted to the Chinese PLA General Hospital from December 2013 to June 2015 for EVS were retrospectively analyzed. EVS sessions were scheduled to be repeated at regular weekly intervals. However, some of these patients received at least one treatment session at irregular intervals (mainly <7 days). This irregular-interval group was further divided into those whose treatment was rescheduled for emergency and elective reasons.

RESULTS

Irregular treatment intervals were mainly caused by early rebleeding, initial emergency treatment, and holidays. However, there were no differences in the rates of complication and variceal eradication between patients treated at weekly and irregular intervals. Multivariate logistic regression analysis identified ascites (P = 0.0009), variceal erosion (P = 0.0003), and maximum injected volume of sclerosing agent per session (P = 0.0008) to be associated with emergency irregular-interval treatment. Only age differed between the elective irregular-treatment and weekly treatment groups.

CONCLUSIONS

Early rebleeding, initial emergency treatment, and treatment over holidays may necessitate irregular sclerotherapy intervals in patients with EVB. Moreover, ascites, variceal erosion, and maximum injected volume of sclerosing agent per session are risk factors for emergency sclerotherapy, whereas elective adjustments to treatment schedules as a result of holidays do not affect the outcomes of patients undergoing EVS for EVB.

Predictive factors for rebleeding and death in alcoholic cirrhotic patients with acute variceal bleeding: a multivariate analysis

BACKGROUND

Bleeding from esophageal varices is a leading cause of death in alcoholic cirrhotic patients. The aim of the present single-center study was to identify risk factors predictive of variceal rebleeding and death within 6 weeks of initial treatment.

METHODS

Univariate and multivariate analyses were performed on 310 prospectively documented alcoholic cirrhotic patients with acute variceal hemorrhage (AVH) who underwent 786 endoscopic variceal injection treatments between January 1984 and December 2006. All injections were administered during the first 6 weeks after the patients were treated for their first variceal bleed.

RESULTS

Seventy-five (24.2%) patients experienced a rebleed, 38 within 5 days of the initial treatment and 37 within 6 weeks of their initial treatment. Of the 15 variables studied and included in a multivariate analysis using a logistic regression model, a bilirubin level >51 mmol/l and transfusion of >6 units of blood during the initial hospital admission were predictors of variceal rebleeding within the first 6 weeks. Seventy-seven (24.8%) patients died, 29 (9.3%) within 5 days and 48 (15.4%) between 6 and 42 days after the initial treatment. Stepwise multivariate logistic regression analysis showed that six variables were predictors of death within the first 6 weeks: encephalopathy, ascites, bilirubin level >51 mmol/l, international normalized ratio (INR) >2.3, albumin <25 g/l, and the need for balloon tube tamponade.

CONCLUSIONS

Survival was influenced by the severity of liver failure, with most deaths occurring in Child-Pugh grade C patients. Patients with AVH and encephalopathy, ascites, bilirubin levels >51 mmol/l, INR >2.3, albumin <25 g/l and who require balloon tube tamponade are at increased risk of dying within the first 6 weeks. Bilirubin levels >51 mmol/l and transfusion of >6 units of blood were predictors of variceal rebleeding.

Does gastroesophageal reflux have an influence on bleeding from esophageal varices?

BACKGROUND

Mucosal breaks induced by gastroesophageal reflux of gastric contents were more frequently found on the right anterior wall of the lower esophagus. Bleeding from esophageal varices may be also derived from gastroesophageal reflux. The circumferential location of the ruptured esophageal varices was evaluated to elucidate the relationship between gastroesophageal reflux and variceal rupture.

METHODS

Between January 2004 and December 2006, 26 patients who had primary bleeding from esophageal varices and 74 patients without evidence of bleeding with positive red color signs on varices were enrolled in this study retrospectively. Locations of bleeding spots and nonbleeding red color signs of esophageal varices were retrospectively evaluated by endoscopic photographs, and the relationship between the location of red color signs and the risk of bleeding was evaluated. Other possible predictors for bleeding were also investigated by multivariate regression analysis.

RESULTS

Red color signs were frequently found in the right posterior wall of the lower esophagus. However, bleeding spots of esophageal varices were more frequently seen in the right anterior side (64.0%) than in others. The positive predictor for bleeding from esophageal varices was the presence of red color sign in the right anterior wall of the esophagus, and the administration of proton pomp inhibitor was the negative predictor.

CONCLUSIONS

Gastroesophageal acid reflex may be a risk factor of bleeding from esophageal varices. Attention should be paid to the circumferential location of red color signs in endoscopic screening of patients with esophageal varices to predict future bleeding.

Diagnosis and therapy of esophageal vascular disorders

PURPOSE OF REVIEW

The most relevant studies concerning the diagnosis of esophageal varices, primary and secondary prophylaxis and treatment of variceal bleeding published in the last year are reported.

RECENT FINDINGS

The specific areas reviewed are those that refer to studies on the noninvasive or minimally invasive diagnosis of the presence of esophageal varices, the prevention of the formation and of the progression of varices from small to large, the prevention of the first variceal haemorrhage, the treatment of the acute bleeding episode, and the prevention of rebleeding.

SUMMARY

Relevant studies are reviewed regarding the validation of noninvasive indices for the presence of varices, the use of the esophageal videocapsule to diagnose varices, the comparison of methods to prevent the first variceal haemorrhage, the use of the hepatic vein pressure measurement to monitor the haemodynamic response to beta-blockers, the long-term protection from bleeding by beta-blockers, the use of a double dose of somatostatin to control bleeding, the evaluation of the best endoscopic method to treat variceal bleeding in addition to vasoactive drugs, and the identification of prognostic factors for early and late mortality after a variceal bleed.