Delayed endoscopy as a risk factor for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage

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.

Timing of endoscopy in patients with cirrhosis and acute variceal bleeding: a single-center retrospective study

BACKGROUND

The optimal timing of endoscopy in liver cirrhosis with acute variceal bleeding (AVB) remains controversial in current guidelines and studies.

METHODS

Consecutive patients with liver cirrhosis and AVB were screened. The timing of endoscopy was calculated from the last presentation of AVB or the admission to endoscopy. Early endoscopy was defined as the interval < 12 h, < 24 h, or < 48 h. A 1:1 propensity score matching (PSM) analysis was performed. Five-day failure to control bleeding and in-hospital mortality were evaluated.

RESULTS

Overall, 534 patients were included. When the timing of endoscopy was calculated from the last presentation of AVB, PSM analysis demonstrated that the rate of 5-day failure to control bleeding was significantly higher in early endoscopy group defined as < 48 h (9.7% versus 2.4%, P = 0.009), but not < 12 h (8.7% versus 6.5%, P = 1.000) or < 24 h (13.4% versus 6.2%, P = 0.091), and that the in-hospital mortality was not significantly different between early and delayed endoscopy groups (< 12 h: 6.5% versus 4.3%, P = 1.000; <24 h: 4.1% versus 3.1%, P = 1.000; <48 h: 3.0% versus 2.4%, P = 1.000). When the timing of endoscopy was calculated from the admission, PSM analyses did not demonstrate any significant difference in the rate of 5-day failure to control bleeding (< 12 h: 4.8% versus 12.7%, P = 0.205; <24 h: 5.2% versus 7.7%, P = 0.355; <48 h: 4.5% versus 6.0%, P = 0.501) or in-hospital mortality (< 12 h: 4.8% versus 4.8%, P = 1.000; <24 h: 3.9% versus 2.6%, P = 0.750; <48 h: 2.0% versus 2.5%, P = 1.000) between early and delayed endoscopy groups.

CONCLUSION

Our study could not support any significant association of timing of endoscopy with cirrhotic patients with AVB.

The influences of timing of urgent endoscopy in patients with acute variceal bleeding: a cohort study

BACKGROUND

There has always been a debate on the optimal timing of endoscopy in patients with acute variceal bleeding (AVB).

OBJECTIVE

This study aimed to examine the relation between the timing of endoscopy and the short-term outcomes of patients with AVB.

METHODS

Patients with AVB who underwent endoscopy within 24 h after admission at our tertiary care center from 2014 to 2022 were evaluated retrospectively. The primary outcomes were the 6-week mortality and re-bleeding. The secondary outcomes included the total number of blood units transfused, the length of hospital stay, and the need for salvage therapy. We used Cox proportional hazards model to analyze the predictors of 6-week mortality in all patients as well as in those who were at high risk of further bleeding or death.

RESULTS

A total of 312 patients were enrolled. Among them, 170 patients (54.49%) underwent urgent endoscopy (< 6 h), and 142 patients (45.51%) underwent early endoscopy (6-24 h). There were no significant differences between the urgent-endoscopy group and the early-endoscopy group, regarding the 6-week mortality (16.47% vs. 10.56%; P value = 0.132) and 6-week re-bleeding rate (11.2% vs. 16.2%; P value = 0.196). In multivariate analysis, time to endoscopy was independent of 6-week mortality (P value = 0.170), but the time between the beginning of bleeding and endoscopy (within 12 h) was significantly associated with low 6-week mortality (OR: 0.16; 95% CI: 0.06-0.46; P value = 0.001). Time to endoscopy was still not associated with 6-week mortality in patients at high risk for further bleeding or death (Glasgow-Blatchford score ≥ 12, n = 138, P value = 0.902).

CONCLUSIONS

Endoscopy performed within 6 h of admission, rather than within 6 to 24 h, did not improve six-week clinical outcomes in patients in stable condition with AVB and even those who were at high risk of further bleeding and death.

Analysis of the timing of endoscopic treatment for esophagogastric variceal bleeding in cirrhosis

Background

Existing guidelines recommend endoscopic treatment within 12 h or 12–24 h for patients with esophagogastric variceal bleeding (EGVB) in cirrhosis. In addition, research findings on the optimal time for endoscopy are inconsistent.

Aim

The aim of this study was to investigate the relationship between the timing of endoscopy and clinical outcomes in cirrhotic patients with EGVB and to analyze the risk factors for the composite outcomes after endoscopic treatment.

Methods

From January 2019 to June 2020, 456 patients with cirrhotic EGVB who underwent endoscopy were matched by a 1:1 propensity score. Finally, 266 patients were divided into two groups, including 133 patients within 12 h (urgent endoscopy group) of admission and after 12 h (non-urgent endoscopy group). Baseline data and clinical outcomes were compared. Logistic regression model analysis was used to determine risk factors for 30 days rebleeding and mortality.

Results

In 266 patients, the overall 30 days rebleeding rate and mortality were 10.9% (n = 29) and 3.4% (n = 9), respectively. Patients who underwent endoscopic treatment within 12 h had significantly higher 30 days rebleeding outcomes than those who underwent treatment beyond 12 h (15 vs. 6.8%, p = 0.003). However, 30 days mortality did not differ significantly between the two groups (3 vs. 3.8%, p = 0.736). Logistic regression analysis showed that age and shock on admission were independent risk factors for the composite outcome of 30 days rebleeding and mortality in patients with EGVB.

Conclusion

The 30 days rebleeding rate in patients with cirrhotic EGVB treated with urgent endoscopy was significantly higher than that in patients treated with non-urgent endoscopy, but there was no significant difference in 30 days mortality.

Risk factors for emergency endoscopic variceal ligation treatment failure of acute variceal bleeding

OBJECTIVE

To determine the risk factors for emergency endoscopic variceal ligation (EVL) failure in acute variceal bleeding (AVB).

METHODS

Data from 161 cirrhosis patients with oesophageal variceal bleeding who underwent emergency EVL treatment at the Second Hospital of Hebei Medical University from January 2018 to May 2021 were retrospectively analysed. Enrolled patients were divided into a successful treatment group and a failed treatment group. The variables studied were demographic, clinical, imaging, laboratory, and endoscopic data from the enrolled patients.

RESULTS

Of the enrolled patients, 19 patients experienced emergency EVL failure. Of these patients, nine underwent emergency endoscopic treatment again, six patients were treated with a Sengstaken-Blakemore tube for haemostasis and endoscopic treatment, four patients received drug therapy. The presence of portal vein thrombosis (PVT) in the failure group was higher than that in the success group (p < .05). Active bleeding on endoscopy was associated with emergency EVL failure for patients with Child-Pugh class C (p < .05).

CONCLUSIONS

Child-Pugh class C with active bleeding on endoscopy or the presence of PVT could increase the risk of emergency EVL failure. The patient's condition should be fully evaluated before emergency endoscopic treatment to reduce the risk of failure.

Ендоскопічне лікування кровотеч із варикозно розширених вен шлунка

Кровотеча з варикозно розширених вен стравоходу та шлунка є найнебезпечнішим для життя ускладненням цирозу печінки та портальної гіпертензії. Кровотеча з варикозно розширених вен шлунка часто є серйознішою та може призвести до смерті. Для її зупинки спочатку проводиться ендоскопічне лікування. Зараз міжнародні консенсусні рекомендації щодо лікування кровотечі з варикозу шлунка відрізняються залежно від ендоскопічної класифікації. Варикозне розширення вен шлунка має іншу фізіологію та клінічні характеристики порівняно з варикозним розширенням вен стравоходу. Існує мало інформації про способи гемостазу при кровотечі зі шлункових вариксів. Незважаючи на те, що кілька нещодавніх розробок щодо препаратів і методів поліпшили результати при цій патології, консенсус щодо оптимального лікування не досягнутий. У цій статті розглядаються сучасні можливості ендоскопічного втручання при варикозній кровотечі зі шлунка за літературними даними з бази MedLine.

Timing of endoscopic intervention in patients with cirrhosis with acute variceal haemorrhage (TEACH trial): protocol for a randomised clinical trial (RCT)

INTRODUCTION

Acute variceal haemorrhage (AVH) in patients with cirrhosis remains a topic of great interest. Although several guidelines recommend endoscopy within 24 hours after AVH, there is no consensus on the most appropriate time to perform this intervention. The purpose of this study is to identify whether urgent endoscopy (within 6 hours after gastroenterological consultation) is superior to non-urgent endoscopy (between 6 hours and 24 hours after gastroenterological consultation) in reducing the rebleeding rate of these patients.

METHODS AND ANALYSIS

This is a single-centred, prospective, randomised clinical trial. Between March 2021 and December 2023, an estimated 400 patients will be randomised in a 1:1 ratio to receive endoscopic intervention either within 6 hours or between 6 and 24 hours after gastroenterological consultation. Randomisation will be conducted by permuted block randomisation, with stratification by age, systolic blood pressure and pulse rate. The primary efficacy endpoint is rebleeding within 42 days after control of AVH. The secondary efficacy endpoints mainly include all-cause mortality within 42 days after randomisation, persistent bleeding, length of hospitalisation, etc. ETHICS AND DISSEMINATION: The study protocol was approved by the Ethical Committees of Jinling Hospital (authorised ethics no. DZQH-KYLL-21-01). This trial will provide valuable insights into the timing of endoscopic intervention for AVH in patients with cirrhosis. Furthermore, the trial results and conclusions could provide high-quality evidence to guide clinical research and treatment.

TRIAL REGISTRATION NUMBER

NCT04786743.

Treatment Strategies in Emergency Endoscopy for Acute Esophageal Variceal Bleeding (CHESS1905): A Nationwide Cohort Study

Background and Aims

Emergency endoscopy is recommended for patients with acute esophageal variceal bleeding (EVB) and their prognosis has improved markedly over past decades due to the increased specialization of endoscopic practice. The study aimed to compare outcomes following emergency endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL) in cirrhotic patients with acute EVB.

Methods

Cirrhotic patients with acute EVB who underwent emergency endoscopy were retrospectively enrolled from 2013 to 2020 across 34 university hospitals from 30 cities. The primary outcome was the incidence of 5-day rebleeding after emergency endoscopy. Subgroup analysis was stratified by Child-Pugh class and bleeding history. A 1:1 propensity score matching (PSM) analysis was performed.

Results

A total of 1,017 and 382 patients were included in EIS group and EVL group, respectively. The 5-day rebleeding incidence was similar between EIS group and EVL group (4% vs. 5%, P = 0.45). The result remained the same after PSM (P = 1.00). Among Child-Pugh class A, B and C patients, there were no differences in the 5-day rebleeding incidence between the two groups after PSM (P = 0.25, 0.82, and 0.21, respectively). As for the patients with or without bleeding history, the differences between EIS group and EVL group were not significant after PSM (P = 1.00 and 0.26, respectively).

Conclusion

The nationwide cohort study indicates that EIS and EVL are both efficient emergency endoscopic treatment strategies for acute EVB. EIS should not be dismissed as an economical and effective emergency endoscopic treatment strategy of acute EVB. ClincialTrials.gov number NCT04307264.

Acute upper gastrointestinal bleeding due to portal hypertension in children: What is the best timing of endoscopy?

OBJECTIVE

To compare initial clinical/laboratory parameters and outcomes of mortality/rebleeding of endoscopy performed <12 h(early UGIE) versus endoscopy performed after 12-24h(late UGIE) of ED admission in children with acute upper gastrointestinal bleeding(AUGIB) due to portal hypertension.

METHODS

This is a retrospective cohort study. From January 2010 to July 2017, medical records of all children admitted to a tertiary care hospital with AUGIB due to portal hypertension were reviewed until 60 days after ED admission.

RESULTS

A total of 98 ED admissions occurred from 73 patients. Rebleeding was identified in 8/98(8%) episodes, and 9 deaths were observed. UGIE was performed in 92(94%) episodes, and 53(58%) of them occurred within 12 h of ED admission. Episodes with early UGIE and late UGIE were similar in terms of history/complaints/laboratory data at admission, chronic liver disease associated, AUGIB duration, and initial management. No statistically significant associations were found between early UGIE and the outcomes of death/rebleeding and prevalence of endoscopic hemostatic treatment (band ligation or sclerotherapy) compared to late UGIE. In the multivariable logistic regression model, the endoscopic hemostatic treatment showed a negative association with early UGIE(OR=0.33;95%CI=0.1-0.9;p = 0.04).

CONCLUSIONS

This study suggests that in pediatric patients with AUGIB and portal hypertension, UGIE may be performed after 12-24 h without harm to the patient, facilitating better initial clinical stabilization/treatment and optimization of resources.

Outcomes of early versus delayed endoscopy in cirrhotic patients with acute variceal bleeding: a systematic review with meta-analysis

OBJECTIVES

Endoscopy is the mainstay treatment option for acute variceal bleeding (AVB) in liver cirrhosis. However, the optimal timing of endoscopy in such patients remains unclear.

METHODS

PubMed, EMBASE and Cochrane Library databases were searched. We compared the mortality, incidence of rebleeding, length of stay, endoscopic hemostasis, need for salvage and units of transfusion between cirrhotic patients with AVB who underwent early and delayed endoscopy. Meta-analyses were performed by using a random-effect model. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Subgroup analysis was performed in studies where early endoscopy was defined as <12 h.

RESULTS

Nine retrospective studies involving 2824 patients were included. The early endoscopy group had a significantly lower overall mortality than the delayed endoscopy group in overall analysis (OR = 0.56, 95% CI, 0.33-0.95, P = 0.03), but the difference between them was NS in subgroup analysis (OR = 0.72, 95% CI, 0.38-1.38, P = 0.33). In-hospital (OR = 0.77, 95% CI, 0.26-2.32, P = 0.65) and 6-week (OR = 0.78, 95% CI, 0.42-1.47, P = 0.45) mortality were not significantly different between them. Overall rebleeding was not significantly different between early and delayed endoscopy groups in both overall (OR = 0.88, 95% CI, 0.51-1.51, P = 0.63) and subgroup (OR = 1.04, 95% CI, 0.55-1.95, P = 0.90) analyses. In-hospital (OR = 1.41, 95% CI, 0.67-2.96, P = 0.37) and 6-week (OR = 0.93, 95% CI, 0.40-2.17, P = 0.86) rebleeding remained not significantly different between them. Additionally, the length of stay, endoscopic hemostasis, need for salvage and units of transfusion were not significantly different between them.

CONCLUSIONS

Early endoscopy may improve the survival of cirrhotic patients with AVB, but has no remarkable benefit on the prevention of rebleeding. These findings should be further validated by high-quality studies.

Clinical algorithms for the prevention of variceal bleeding and rebleeding in patients with liver cirrhosis

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.

The Role of Interventional Endoscopic Ultrasound in Liver Diseases: What Have We Learnt?

Chronic liver disease (CLD) is still a major problem, where the disease progression will lead to liver cirrhosis (LC) or hepatocellular carcinoma (HCC). Portal hypertension (PH) management and loco-regional therapy for HCC have become the cornerstones in advanced liver disease management. Recently, there are studies looking at the potential role of interventional endoscopic ultrasound (EUS) in liver diseases. EUS may be useful in vascular changes of the digestive wall evaluation, performing dynamic assessment of hemodynamic changes, predicting variceal bleeding and rebleeding risk, and assessing the pharmacological effects. In PH management, EUS-guided vascular therapy-which revolves around glue injection, endovascular coil placement/embolization, and combination of both-has shown promising results. As a diagnostic modality for liver cancer, the implementation of EUS in liver diseases is currently not only limited to liver biopsy (EUS-LB) but also in shear-wave elastography (SWE) and portal pressure gradient measurement, as well as portal vein sampling. The application of EUS-guided radiofrequency ablation (EUS-RFA) and tumor injection can also overcome the limitations shown by both modalities without EUS. Nevertheless, establishing EUS as a firm diagnostic and therapeutic modality is still challenging since the performance of interventional EUS requires high expertise and adequate facilities.

Endoscopic management of acute oesophageal variceal bleeding within 12 hours of admission is superior to 12-24 hours

Background: Acute oesophageal variceal haemorrhage (AOVH) is a medical emergency. The American Association for the Study of Liver Diseases recommends endoscopy management as soon as possible and not more than 12 hours after presentation. The United Kingdom guidelines recommended endoscopy for unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation and within 24 hours of admission. We aimed to evaluate the outcome of endoscopic management of AOVH in less than 12 hours compared to 12-24 hours post admission.Methods: 297 patients with AOVH were divided into groups depending on the timing of the endoscopic management: 180 within 12 h of admission and 117 patients at 12-24 hours of admission. Routine clinical and laboratory data were collected.Results: Compared to patients with endoscopic management at 12-24 hours (mean 16 hours), patients with endoscopic management within 12 hours (mean 8.3 hours) of admission had fewer hospital stay days (P = 0.001), significant reduction of ammonia levels (P < 0.0001) and significant improvement in associated hepatic encephalopathy grade 25 (p = 0.048). There were no major clinical events in the 12-hour group, but 8 events in the 12-24 hour group (p < 0.01).Conclusion: Endoscopic management of acute variceal bleeding within 12 hours of admission is superior to endoscopic management at 12-24 hours of admission regarding reduction of hospital stay, ammonia levels, correction of hepatic encephalopathy, re-bleeding and mortality rate, hence, reducing the cost of treatment benefiting patient satisfaction and improving hospital bed availability.

Variceal bleeding is aggravated by portal venous invasion of hepatocellular carcinoma: a matched nested case-control study

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.

Validation of a decision rule to predict patients at low risk of variceal upper gastrointestinal hemorrhage

BACKGROUND

Determining the likelihood of a variceal versus nonvariceal source of upper gastrointestinal bleeding (UGIB) guides ED therapy, but can be difficult to determine on clinical grounds. A simple decision rule, using only platelet and international normalized ratio (INR) values, was previously derived in a single center and had high sensitivity (97%). We sought to validate this decision rule using multi-center data.

MATERIALS AND METHODS

We performed this decision rule validation using data collected from 21 Canadian hospitals, comprising 2020 patients. The parent study enrolled patients aged ≥18 years at participating hospitals with nonvariceal or variceal UGIB from January 2004 through May 2005. To validate the existing decision rule, we computed the test characteristics of the rule on this study population. The existing decision rule, in order to predict patients at low risk for variceal hemorrhage, is designed to be highly sensitive for variceal UGIB. In the previously derived rule, patients are not low risk if either is present: INR ≥1.3 or platelet count ≤200 × 10⁹/L. We additionally added a third common-sense criterion to the decision rule in a separate analysis: whether the patient has previously had variceal hemorrhage.

RESULTS

2001 patients were eligible for analysis, including 214 (10.7%) with a variceal source of gastrointestinal hemorrhage. Median age was 69 (IQR 55-79), and 764 (38%) were women. The two-step rule correctly identified 204 of the 214 (95.3%) patients with variceal hemorrhage; adding prior variceal hemorrhage as a variable identified 5 more patients (209/214 [97.7%]). Of the 2001 patients, 953 (47%) would have been classified as low risk for variceal hemorrhage; of these patients, 5 (0.5%) experienced variceal hemorrhage. The sensitivity of the rule in this validation cohort was 95.3% (95% CI 91.6-97.7%), with a negative likelihood ratio of 0.09 (95% CI 0.05-0.16). Adding prior variceal hemorrhage increased sensitivity to 97.7% (95% CI 94.6-99.2%), with a negative likelihood ratio of 0.04 (95% CI 0.02-0.11).

CONCLUSION

We have validated a simple decision rule to identify patients at low risk for variceal UGIB. This two-step (three-step if prior history of variceal hemorrhage is known) rule is simple to use, and may enable safe deferment of unnecessary or harmful therapies.

Emergent Transjugular Intrahepatic Portosystemic Shunt Creation in Acute Variceal Bleeding

Emergent transjugular intrahepatic portosystemic shunt (TIPS) creation is most commonly employed in the setting of acute variceal hemorrhage. Given a propensity for decompensation, these patients often require a multidisciplinary, multimodal approach involving prompt diagnosis, pharmacologic therapy, and endoscopic intervention. While successful in the majority of cases, failure to medically control initial bleeding can prompt interventional radiology consultation for emergent portal decompression via TIPS creation. This article discusses TIPS creation in emergent, acute variceal hemorrhage, reviewing the natural history of gastroesophageal varices, presentation and diagnosis of acute variceal hemorrhage, pharmacologic therapy, endoscopic approaches, patient selection and risk stratification for TIPS, technical considerations for TIPS creation, adjunctive embolotherapy, and the role of salvage TIPS versus early TIPS in acute variceal hemorrhage.

Optimal endoscopy timing in patients with acute variceal bleeding: A systematic review and meta-analysis

Although current guidelines recommend performing endoscopy within 12 hours for acute variceal bleeding (AVB), the optimal timing remains controversial. This study aimed to assess the effect of endoscopy timing on the mortality and rebleeding rates in AVB through a systematic review and meta-analysis of all eligible studies. PubMed, Cochrane Library, and Embase were searched for relevant publications up to January 2019. Overall mortality, rebleeding rate, and other clinical outcomes were determined. For the non-randomized studies, the risk of bias assessment tool was used to assess the methodological quality of the included publications. The Mantel-Haenszel random-effects model of the RevMan software (Cochrane) and the inverse variance method were used to analyse binary end points and continuous outcomes, respectively. This meta-analysis included five studies with 854 and 453 participants who underwent urgent (≤12 hours) and non-urgent endoscopies (>12 hours), respectively. All the included studies were retrospective in nature, because of obvious ethical issues. No significant differences in the severity indexes were found between the urgent and non-urgent groups. Three studies showed 6-week mortality and the others in-hospital mortality as main outcomes. No significant difference in overall mortality rate was found between the groups (odds ratio [OR]: 0.72, 95% confidence interval [CI]: 0.36–1.45, p = 0.36). The rebleeding rate was similar between the two groups (OR: 1.21, 95% CI: 0.76–1.93, p = 0.41). Other outcomes such as successful haemostasis, need for salvage therapy, length of hospital stay, and number of blood transfusions were also similar between the groups. We demonstrated that endoscopy timing does not affect the mortality or rebleeding rate of patients with AVB. Therefore, an appropriate timing of endoscopy would be more important than an urgent endoscopy depending on each patient’s condition.

Endoscopic Therapy and Radiologic Intervention of Acute Gastroesophageal Variceal Bleeding

Acute gastroesophageal variceal hemorrhage is a dreaded complication in patients with liver cirrhosis. Endoscopic therapy and radiologic intervention for gastroesophageal bleeding have rapidly developed in the recent decades. Endoscopic treatment is initially performed to stop variceal hemorrhage. For the treatment of esophageal variceal bleeding, endoscopic variceal ligation (EVL) is considered the endoscopic treatment of choice. In cases of gastric variceal hemorrhage, the type of gastric varices (GVs) is important in deciding the strategy of endoscopic treatment. Endoscopic variceal obturation (EVO) is recommended for fundal variceal bleeding. For the management of gastroesophageal varix type 1 bleeding, both EVO and EVL are available treatment options; however, EVO is preferred over EVL. If endoscopic management fails to control variceal hemorrhage, radiologic interventional modalities could be considered. Transjugular intrahepatic portosystemic shunt is a good option for rescue treatment in refractory variceal bleeding. In cases of refractory hemorrhage of GVs in patients with a gastrorenal shunt, balloon-occluded retrograde transvenous obliteration could be considered as a salvage treatment.

Optimal endoscopy timing according to the severity of underlying liver disease in patients with acute variceal bleeding

BACKGROUND

Current guidelines recommend endoscopic therapy to be performed within 12 h for acute variceal bleeding (AVB). However, the optimal timing of endoscopic therapy for AVB remains unclear.

AIMS

To examine the relationship between the endoscopy timing and clinical outcomes in AVB, with emphasis on liver function and endoscopy timing.

METHODS

From January 2010 to June 2017, cirrhotic patients with AVB confirmed by endoscopy were evaluated. The primary outcome was a composite of 6-week rebleeding and mortality. We stratified patients according to the MELD score.

RESULTS

In 411 patients, the overall composite outcome rate was 30.9% (n = 127) at 6 week. Patients who underwent urgent endoscopy (≤12 h) had a significantly higher composite outcome than patients who underwent non-urgent endoscopy (>12 h) (34.4% vs. 19.1%; P = 0.005). Low-risk patients who underwent urgent endoscopy were more likely to reach the composite outcome (adjusted OR, 0.84 per 4 h; 95% CI, 0.73-0.98; P = 0.027). These findings persisted even after adjustment for baseline characteristics between the urgent and non-urgent groups.

CONCLUSIONS

Urgent endoscopy is significantly associated with a poorer outcome in patients with AVB, especially in low-risk patients. Our result provides a treatment strategy according to the severity of underlying liver disease in patients with AVB.

Management of acute variceal hemorrhage

Gastrointestinal bleeding is one of the major causes of death in patients with cirrhosis, and gastroesophageal varices represent the main source of hemorrhage. Even though in the last decades survival has been improved because of the widespread adoption of effective treatments and optimization of general medical care, mortality is still significantly high, and decompensated patients pose a complex challenge requiring a multidisciplinary approach that is crucial to improve survival. The aims of this commentary are to review the most recent advances in the management of esophageal variceal bleeding and to highlight useful information to aid hepatologists in clinical practice.

Timing of upper gastrointestinal endoscopy does not influence short-term outcomes in patients with acute variceal bleeding

AIM

To examine the association between the timing of endoscopy and the short-term outcomes of acute variceal bleeding in cirrhotic patients.

METHODS

This retrospective study included 274 consecutive patients admitted with acute esophageal variceal bleeding of two tertiary hospitals in Korea. We adjusted confounding factors using the Cox proportional hazards model and the inverse probability weighting (IPW) method. The primary outcome was the mortality of patients within 6 wk.

RESULTS

A total of 173 patients received urgent endoscopy (i.e., ≤ 12 h after admission), and 101 patients received non-urgent endoscopy (> 12 h after admission). The 6-wk mortality rate was 22.5% in the urgent endoscopy group and 29.7% in the non-urgent endoscopy group, and there was no significant difference between the two groups before (P = 0.266) and after IPW (P = 0.639). The length of hospital stay was statistically different between the urgent group and non-urgent group (P = 0.033); however, there was no significant difference in the in-hospital mortality rate between the two groups (8.1% vs 7.9%, P = 0.960). In multivariate analyses, timing of endoscopy was not associated with 6-wk mortality (hazard ratio, 1.297; 95% confidence interval, 0.806-2.089; P = 0.284).

CONCLUSION

In cirrhotic patients with acute variceal bleeding, the timing of endoscopy may be independent of short-term mortality.

Evaluation and management of variceal bleeding

Acute variceal bleeding is one of the most fatal complications of cirrhosis and is responsible for about one-third of cirrhosis-related deaths. Therefore, every effort should be made to emergently resuscitate the patients, start pharmacotherapy as soon as possible and do endoscopic therapy in a timely manner. Despite the recent advances in treatment, mortality rate is still high. We provide a comprehensive review of evaluation and management of variceal bleeding.

Prevention and management of gastroesophageal varices

Bleeding from gastroesophageal varices is a serious complication in patients with liver cirrhosis and portal hypertension. Although there has been significance improvement in the prognosis of variceal bleeding with advancement in diagnostic and therapeutic modalities for its management, mortality rate still remains high. Therefore, appropriate prevention and rapid, effective management of bleeding from gastroesophageal varices is very important. Recently, various studies about management of gastoesophageal varices, including prevention of development and aggravation of varices, prevention of first variceal bleeding, management of acute variceal bleeding, and prevention of variceal rebleeding, have been published. The present article reviews published articles and practice guidelines to present the most optimal management of patients with gastroesophageal varices.

Endoscopic treatments for portal hypertension

Acute esophageal variceal hemorrhage is a dreaded complication of portal hypertension. Its management has evolved rapidly in recent years. Endoscopic therapy is often employed to arrest bleeding varices as well as to prevent early rebleeding. The combination of vasoconstrictor and endoscopic therapy is superior to vasoconstrictor or endoscopic therapy alone for control of acute esophageal variceal hemorrhage. After control of acute variceal bleeding, combination of banding ligation and beta-blockers is generally recommended to prevent variceal rebleeding. To prevent the catastrophic event of acute variceal bleeding, endoscopic banding ligation is an important tool in the prophylaxis of first bleeding. Endoscopic obturation with cyanoacrylate is usually utilized to arrest acute gastric variceal hemorrhage as well as to prevent rebleeding. It can be concluded that endoscopic therapies play a pivotal role in management of portal hypertensive bleeding.

Suboptimal Implementation of Evidence-based Therapy for Acute Variceal Hemorrhage: A Systematic Review of Observational Studies

BACKGROUND & AIMS

Gastroenterologists should strive to improve the outcomes associated with acute variceal hemorrhage (AVH) by optimizing care delivery and clinician preparedness through training. Unfortunately, data regarding contemporary outcomes and management of AVH are limited.

METHODS

We performed a systematic review of cohort studies examining outcomes and management of AVH from January 1990 to September 2016. We pooled data on mortality and utilization of medical therapy, endoscopic interventions, balloon tamponade (BT), and salvage procedures (portal decompressive surgery or transjugular portosystemic shunt).

RESULTS

The pooled 6-week mortality rate after AVH was 17.7% (95% confidence interval [CI], 14.4%-21.7%). Sclerotherapy was used in 18.7% of cases (95% CI, 9.2%-34.3%), and no endoscopic intervention was provided in 14.3% of patients (95% CI, 9.7%-20.6%). The overall rate of BT use was 10.8% (95% CI, 8.2%-14.1%). Salvage procedures were used in 5.7% (95% CI, 3.7%-8.6%), falling to 1.7% (95% CI, 0.7%-3.8%) among patients treated after 2000. Although pooled rates of timely endoscopy and vasoactive medication use were high (85.8% and 83.0%, respectively), only half of patients received prophylactic antibiotics (52.8%; 95% CI, 40.0%-66.2%). In studies that enrolled patients exclusively after 2000, 13.8% of patients (95% CI, 7.0%-25.4%) received sclerotherapy, salvage transjugular portosystemic shunt fell to 1.7% (95% CI, 0.7%-3.8%), BT use fell slightly to 8.7% (95% CI, 6.4%-11.6%), and vasoactive medication and prophylactic antibiotic use rose to 91.4% (95% CI, 86.0%-94.9%) and 62.7% (95% CI, 48.9%-74.9%), respectively.

CONCLUSIONS

AVH is associated with high mortality rates and suboptimal implementation of evidence-based therapies including prophylactic antibiotics and endoscopic interventions, suggesting a need for quality improvement. In addition, the frequent need for BT and sclerotherapy suggests that specific attention to these procedures in gastroenterology training curricula may be warranted.

Recurrence and prognosis of patients emergently hospitalized for acute esophageal variceal bleeding: A long-term cohort study

AIM

To elucidate the rates of recurrence and mortality in acute esophageal variceal bleeding and the associated risk factors.

METHODS

A cohort of 174 patients emergently hospitalized for esophageal variceal bleeding was analyzed. All patients underwent endoscopic variceal ligation within 3 h of arrival. Comorbidities, vital signs, drug use, laboratory data, etiology, endoscopic findings, transfusion requirement, and follow-up endoscopy were assessed. Cox's proportional hazards model was used to estimate hazard ratios (HR).

RESULTS

Rebleeding was identified in 49 patients with a mean follow-up of 18 months. The cumulative rebleeding rate at 1 month, 1 year, and 5 years was 10.2%, 30.0%, and 51.0%, respectively. In multivariate analysis, independent risk factors for rebleeding were child-Pugh class C (HR 1.94; P = 0.027), alcoholic liver cirrhosis (HR 2.32; P = 0.01), and no follow-up endoscopy (HR 13.3; P < 0.001). During the overall mean follow-up of 22 months, 69 patients died (17 due to bleeding), and the cumulative mortality rate at 1 month, 1 year, and 5 years was 12.2%, 26.6%, and 63.0%, respectively. In multivariate analysis, independent risk factors for mortality were child-Pugh class C (HR 2.91; P < 0.001), coexistence of hepatocellular carcinoma (HR 1.92; P = 0.013), and no follow-up endoscopy (HR 23.6; P < 0.001).

CONCLUSION

This study revealed more than 50% cumulative rebleeding and mortality in the 5-year period after endoscopic variceal ligation for esophageal variceal bleeding in an emergency setting. Child-Pugh C, alcoholic liver cirrhosis, and no follow-up endoscopy increased the risk of rebleeding; Child-Pugh C, coexistence of hepatocellular carcinoma, and no follow-up endoscopy increased the risk of mortality.

Building Effective Quality Improvement Programs for Liver Disease: A Systematic Review of Quality Improvement Initiatives

BACKGROUND & AIMS

Quality indicators are the measurable components of clinical standards. Data are limited about the design and impact of interventions to improve quality indicators for patients with chronic liver disease.

METHODS

A systematic review of PubMed, Web of Science, and conference proceedings was performed to find reports of quality improvement (QI) interventions. Data regarding the several indicators were collected. The search focused on vaccination against hepatitis A or hepatitis B virus, management of spontaneous bacterial peritonitis, screening for varices, management of acute variceal hemorrhage, hepatocellular carcinoma screening, and 30-day readmissions.

RESULTS

Fifteen studies reported on the results of QI interventions. Ten focused on specific quality indicators (1 specific to vaccination, 2 spontaneous bacterial peritonitis, 3 gastrointestinal bleeding, and 4 hepatocellular carcinoma screening); 5 focused on clinical outcomes. Most studies used a pre-post study design. Interventions included checklists, educational conferences, electronic decision supports, nurse coordinators, and systematic changes to facilitate specialist co-management. Successful interventions optimized clinical workflow, closed knowledge gaps among frontline providers, created forced functions in the electronic ordering system, added dedicated staff to manage specific indicators, and provided viable alternatives to hospitalization to reduce readmission. Unsuccessful interventions included case management, phone calls, and home visits to reduce readmissions, checklists, and educational programs.

CONCLUSIONS

Past experience with QI provides generalizable rules for successful future interventions aimed at improved quality indicator adherence and patient outcomes.

PROPOSAL OF A CLINICAL CARE PATHWAY FOR THE MANAGEMENT OF ACUTE UPPER GASTROINTESTINAL BLEEDING

BACKGROUND

Upper gastrointestinal bleeding implies significant clinical and economic repercussions. The correct establishment of the latest therapies for the upper gastrointestinal bleeding is associated with reduced in-hospital mortality. The use of clinical pathways for the upper gastrointestinal bleeding is associated with shorter hospital stay and lower hospital costs.

OBJECTIVE

The primary objective is the development of a clinical care pathway for the management of patients with upper gastrointestinal bleeding, to be used in tertiary hospital.

METHODS

It was conducted an extensive literature review on the management of upper gastrointestinal bleeding, contained in the primary and secondary information sources.

RESULTS

The result is a clinical care pathway for the upper gastrointestinal bleeding in patients with evidence of recent bleeding, diagnosed by melena or hematemesis in the last 12 hours, who are admitted in the emergency rooms and intensive care units of tertiary hospitals. In this compact and understandable pathway, it is well demonstrated the management since the admission, with definition of the inclusion and exclusion criteria, passing through the initial clinical treatment, posterior guidance for endoscopic therapy, and referral to rescue therapies in cases of persistent or rebleeding. It was also included the care that must be taken before hospital discharge for all patients who recover from an episode of bleeding.

CONCLUSION

The introduction of a clinical care pathway for patients with upper gastrointestinal bleeding may contribute to standardization of medical practices, decrease in waiting time for medications and services, length of hospital stay and costs.

Endoscopic capacity in West Africa

BACKGROUND

Levels of endoscopic demand and capacity in West Africa are unclear.

OBJECTIVES

This paper aims to: 1. describe the current labor and endoscopic capacity, 2. quantify the impact of a mixed-methods endoscopy course on healthcare professionals in West Africa, and 3. quantify the types of diagnoses encountered.

METHODS

In a three-day course, healthcare professionals were surveyed on endoscopic resources and capacity and were taught through active observation of live cases, case discussion, simulator experience and didactics. Before and after didactics, multiple-choice exams as well as questionnaires were administered to assess for course efficacy. Also, a case series of 23 patients needing upper GI endoscopy was done.

RESULTS

In surveying physicians, less than half had resources to perform an EGD and none could perform an ERCP, while waiting time for emergency endoscopy in urban populations was at least one day. In assessing improvement in medical knowledge among participants after didactics, objective data paired with subjective responses was more useful than either alone. Of 23 patients who received endoscopy, 7 required endoscopic intervention with 6 having gastric or esophageal varices. Currently the endoscopic capacity in West Africa is not sufficient. A formal GI course with simulation and didactics improves gastrointestinal knowledge amongst participants.

Current approaches to the management of patients with liver cirrhosis who have acute esophageal variceal bleeding

OBJECTIVE

Esophageal variceal bleeding is the most dangerous complication in patients with liver cirrhosis, and it is accompanied by high mortality. Their treatment can be complex, and requires a multidisciplinary approach. This review examines current approaches to the management of patients with liver cirrhosis who have acute esophageal variceal bleeding.

METHODS

PubMed, Google Scholar, and Cochrane Systematic Reviews were searched for articles published between 1987 and 2015. Relevant articles were identified using the following terms: 'esophageal variceal bleeding', 'portal hypertension' and 'complications of liver cirrhosis'. The reference lists of articles identified were also searched for other relevant publications. Inclusion criteria were restricted to the management of patients with liver cirrhosis who have acute esophageal variceal bleeding.

RESULTS

It is currently recommended to combine vasoactive drugs (preferable somatostatin or terlipressin) and endoscopic therapies (endoscopic band ligation as first choice, sclerotherapy if endoscopic band ligation not feasible) for the initial treatment of acute variceal bleeding. Antibiotic prophylaxis must be regarded as an integral part of the treatment. The use of a Sengstaken-Blakemore tube is appropriate only in cases of refractory bleeding if the above methods cannot be used. An alternative to balloon tamponade may be the installation of self-expandable metal stents. The transjugular intrahepatic portosystemic shunt is an extremely useful technique for the treatment of acute bleeding from esophageal varices. Although most current clinical guidelines classify it as second-line therapy, the Baveno VI workshop recommends early transjugular intrahepatic portosystemic shunt with expanded polytetrafluoroethylene-covered stents within 72 h (ideally <24 h) in patients with esophageal variceal bleeding at high risk of treatment failure (e.g. Child-Turcotte-Pugh class C < 14 points or Child-Turcotte-Pugh class B with active bleeding) after initial pharmacological and endoscopic therapy. Urgent surgical intervention is rarely performed and can be considered only in case of failure of conservative and/or endoscopic therapy and being unable to use a transjugular intrahepatic portosystemic shunt. Among surgical operations described in the literature are a variety of portocaval anastomosis and azygoportal disconnection procedures.

CONCLUSIONS

To improve the results of treatment for patients with liver cirrhosis who develop acute esophageal variceal bleeding, it is important to stratify patients into risk groups, which will allow one to tailor therapeutic approaches to the expected results.

A Clinical Decision Rule Based on the AST-to-Platelet Ratio Index Improves Adherence to Published Guidelines on the Management of Acute Variceal Bleeding

BACKGROUND

Optimal management of acute upper gastrointestinal bleeding (UGIB) depends on identifying a variceal versus nonvariceal etiology. An objective measure predicting etiology could guide early management pending endoscopy. The AST-to-platelet ratio index (APRI) score has been studied as a marker of cirrhosis and portal hypertension, but has not been evaluated in the setting of acute UGIB.

METHODS

In this single-center retrospective cohort study, we reviewed endoscopy reports and other data for patients with acute UGIB, and classified episodes as variceal bleeds or other. We assessed the diagnostic utility of the APRI score relative to other objective measures by Area Under the Receiver Operating Characteristic (AUROC) curve analysis. We constructed a clinical decision rule based on the APRI score, and assessed how it would have changed management.

RESULTS

The APRI score performed well in predicting a variceal etiology of acute UGIB, with AUROC 0.89. We developed a clinical decision rule using an APRI score of 0.4 to guide early management of acute UGIB patients. Retroactively applying this to our cohort, adherence to published guidelines for administration of octreotide and antibiotics would have increased from 56% to 91%.

CONCLUSIONS

The APRI score is an objective metric that helps predict a variceal etiology of acute UGIB. Using our proposed decision rule could improve adherence to guidelines on management of acute variceal bleeding. Although we were unable to demonstrate a survival benefit, improved adherence to evidence-based guidelines serves as a metric related to this most important outcome measure. Prospective study to validate these findings is indicated.

Management of acute variceal bleeding using hemostatic powder

BACKGROUND AND OBJECTIVES

This study aimed to test the safety and efficacy of Hemospray® for emergency control of acute variceal bleeding (AVB) due to portal hypertension in cirrhotic patients.

PATIENTS AND METHODS

This single-arm, prospective trial, conducted at two hospitals in Belgium and Egypt, included patients admitted to the emergency room with hematemesis and/or melena and known or suspected liver cirrhosis. All patients received urgent hemodynamic stabilization, octreotide (50 mcg bolus then 25 mcg/hour for 24 hours) and intravenous ceftriaxone (1 g/hour). Endoscopy to confirm AVB and Hemospray® application (if indicated) was performed within six hours of admission. Patients were kept under observation for 24 hours and underwent second endoscopy and definitive therapy (band ligation and/or cyanoacrylate injection in cases of gastric varices) the next day.

RESULTS

Thirty-eight patients were admitted for suspected AVB, and 30 of these had confirmed AVB (70% male; mean age 59.5 years (range, 32.0-73 years)). Child-Pugh class C liver disease was present in 53.4%. Esophageal varices were observed in 83.4% of patients, gastric varices in 10%, and duodenal varices in 6.6%. Spurting bleeding at the time of endoscopy was observed in 43.4%. One patient developed hematemesis six hours after Hemospray® application and underwent emergency endoscopic band ligation. No major adverse events or mortalities were observed during 15-day follow-up.

CONCLUSION

Hemospray® application was safe and effective at short-term follow-up for emergency treatment of AVB in cirrhotic patients.

Self-Expandable Metal Stents for Persisting Esophageal Variceal Bleeding after Band Ligation or Injection-Therapy: A Retrospective Study

BACKGROUND AND STUDY AIMS

Despite a pronounced reduction of lethality rates due to upper gastrointestinal bleeding, esophageal variceal bleeding remains a challenge for the endoscopist and still accounts for a mortality rate of up to 40% within the first 6 weeks. A relevant proportion of patients with esophageal variceal bleeding remains refractory to standard therapy, thus making a call for additional tools to achieve hemostasis. Self-expandable metal stents (SEMS) incorporate such a tool.

METHODS

We evaluated a total number of 582 patients admitted to our endoscopy unit with the diagnosis "gastrointestinal bleeding" according to our documentation software between 2011 and 2014. 82 patients suffered from esophageal variceal bleeding, out of which 11 cases were refractory to standard therapy leading to SEMS application. Patients with esophageal malignancy, fistula, or stricture and a non-esophageal variceal bleeding source were excluded from the analysis. A retrospective analysis reporting a series of clinically relevant parameters in combination with bleeding control rates and adverse events was performed.

RESULTS

The initial bleeding control rate after SEMS application was 100%. Despite this success, we observed a 27% mortality rate within the first 42 days. All of these patients died due to non-directly hemorrhage-associated reasons. The majority of patients exhibited an extensive demand of medical care with prolonged hospital stay. Common complications were hepatic decompensation, pulmonary infection and decline of renal function. Interestingly, we found in 7 out of 11 patients (63.6%) stent dislocation at time of control endoscopy 24 h after hemostasis or at time of stent removal. The presence of hiatal hernia did not affect obviously stent dislocation rates. Refractory patients had significantly longer hospitalization times compared to non-refractory patients.

CONCLUSIONS

Self-expandable metal stents for esophageal variceal bleeding seem to be safe and efficient after failed standard therapy. Stent migration appeared to be a common incident that did not lead to reactivation of bleeding in any of our patients. SEMS should be considered a reasonable treatment option for refractory esophageal variceal bleeding after treatment failure of ligature and sclerotherapy and non-availability of or contraindication for other measures (e.g. TIPS).

Self-Expanding Metal Stent (SEMS): an innovative rescue therapy for refractory acute variceal bleeding

BACKGROUND

Acute variceal bleeding (AVB) is a life-threatening complication of liver cirrhosis or less commonly splenic vein thrombosis. Pharmacological and endoscopic interventions are cornerstones in the management of variceal bleeding but may fail in 10 - 15 % of patients. Rescue therapy with balloon tamponade (BT) or transjugular intrahepatic portosystemic shunt (TIPS) may be required to control refractory acute variceal bleeding effectively but with some limitations. The self-expanding metal stent (SEMS) is a covered, removable tool that can be deployed in the lower esophagus under endoscopic guidance as a rescue therapy to achieve hemostasis for refractory AVB.

AIMS

To evaluate the technical feasibility, efficacy, and safety of SEMS as a rescue therapy for AVB.

METHODS

In this review article, we have performed an extensive literature search summarizing case reports and case series describing SEMS as a rescue therapy for AVB. Indications, features, technique, deployment, success rate, limitations, and complications are discussed.

RESULTS

At present, 103 cases have been described in the literature. Studies have reported 97.08 % technical success rates in deployment of SEMS. Most of the stents were intact for 4 - 14 days with no major complications reported. Stent extraction had a success rate of 100 %. Successful hemostasis was achieved in 96 % of cases with only 3.12 % found to have rebleeding after placement of SEMS. Stent migration, which was the most common complication, was observed in 21 % of patients.

CONCLUSION

SEMS is a safe and effective alternative approach as a rescue therapy for refractory AVB.

Epidemiology, diagnosis and early patient management of esophagogastric hemorrhage

Acute variceal bleeding (AVB) is a potentially life-threatening complication of cirrhosis and portal hypertension. Combination therapy with vasoactive drugs and endoscopic variceal ligation is the first-line treatment in the management of AVB after adequate hemodynamic resuscitation. Short-term antibiotic prophylaxis, early resuscitation, early use of lactulose for prevention of hepatic encephalopathy, targeting of conservative goals for blood transfusion, and application of early transjugular intrahepatic portosystemic shunts in patients with AVB have further improved the prognosis of AVB. This article discusses the epidemiology, diagnosis, and nonendoscopic management of AVB.

A risk scoring system to predict in-hospital mortality in patients with cirrhosis presenting with upper gastrointestinal bleeding

GOALS

We aimed to develop a simple and practical risk scoring system to predict in-hospital mortality in cirrhotics presenting with upper gastrointestinal (GI) bleeding.

STUDY

Extensive clinical data were captured in patients with documented cirrhosis who underwent endoscopic evaluation for upper GI bleeding between January 1, 2003 and June 30, 2011 at Parkland Memorial Hospital. Predictors of mortality were identified by multivariate regression analysis.

RESULTS

A total of 884 patients with cirrhosis admitted for upper GI bleeding were identified; 809 patients survived and 75 died (8.4%). The etiology of bleeding was similar in both groups, with bleeding attributed to esophageal varices in 59% of survivors and 60% of non-survivors (ulcer disease and other etiologies of bleeding accounted for the other causes of bleeding). Mortality was 8.6% and 8.3% in patients with variceal bleeding and nonvariceal bleeding, respectively. While survivors and those who died were similarly matched with regard to gender, age, ethnicity and etiology of cirrhosis, patients who died had lower systolic blood pressures, higher pulse rates and lower mean arterial pressures at admission than patients who survived. Non-survivors were more likely to be Childs C (61% vs. 19%, P<0.001). Multivariate regression analysis identified the following 4 predictors of in-hospital mortality: use of vasoactive pressors, number of packed red blood cells transfused, model for end-stage liver disease (MELD) score, and serum albumin. A receiver operating characteristic curve including these 4 variables yielded an area under the receiver operating characteristic (AUROC) curve of 0.94 (95% confidence interval, 0.91-0.98). Classification and Regression Tree analysis yielded similar results, identifying vasoactive pressors and then MELD>21 as the most important decision nodes for predicting death. By comparison, using the Rockall scoring system in the same patients, the AUROC curve was 0.70 (95% confidence interval, 0.64-0.76 and the comparison of the University of Texas Southwestern model to the Rockall model revealed P<0.0001). A validation set comprised of 150 unique admissions between July 1, 2011 and July 31, 2012, had an AUROC of 0.92, and the outcomes of 97% of the subjects in this set were accurately predicted by the risk score model.

CONCLUSIONS

Use of vasoactive agents, packed red blood cell transfusion, albumin, and MELD score were highly predictive of in-hospital mortality in cirrhotics presenting with upper GI bleeding. These variables were used to formulate a clinical risk scoring system for in-hospital mortality, which is available at: http://medweb.musc.edu/LogisticModelPredictor.

Early Endoscopy Can Shorten the Duration of Hospitalization in Suspected Variceal Hemorrhage

Background. Endoscopic treatment in patients with acute variceal hemorrhage should be performed within 12 hours, but the recommendation is based on the experts’ opinion. Objective. Our study investigated if time to endoscopy was a significant factor that could alter the outcomes of patients with suspected variceal hemorrhage. The primary outcome was the length of hospital stay and the mortality. The secondary outcomes were complications during observation periods. Methods. Patients were included if variceal hemorrhage was suspected in the emergency department. Patients were further divided into early (receiving endoscopy within 12 hours) and delayed groups (receiving endoscopy after 12 hours), and each patient was matched using a standard propensity score greedy-matching algorithm. The primary and secondary outcomes were compared accordingly. Results. 1442 patients met our inclusion criteria and therefore were enrolled for further analysis. In the Cox regression model, log time to endoscopy was not a significant factor. In the propensity score assignment, 566 patients (283 in each group) were further selected into the subcohort (P value = 0.8001). Kaplan-Meier curves showed a discharge benefit favoring the early endoscopy over the control group. The mortality rates and complications were not statistically different between the two groups (P value = 0.0045). Conclusion. Early endoscopy before 12 hours in patients with suspected variceal hemorrhage could result in shorter length of hospitalization without increasing the mortalities and complications. The results would help emergency physicians in decisions making when these patients are encountered.

Management of varices in patients with cirrhosis

Variceal bleeding remains a life-threatening condition with a 6-week mortality rate of ∼20%. Prevention of variceal bleeding can be achieved using nonselective β-blockers (NSBBs) or endoscopic band ligation (EBL), with NSBBs as the first-line treatment. EBL should be reserved for cases of intolerance or contraindications to NSBBs. Although NSBBs cannot be used to prevent varices, if the hepatic venous pressure gradient (HVPG) is ≤10 mmHg, prognosis is excellent. Survival after acute variceal bleeding has improved over the past three decades, but patients with Child-Pugh grade C cirrhosis remain at greatest risk. Vasoactive drugs combined with endoscopic therapy and antibiotics are the best therapeutic strategy for these patients. Transjugular intrahepatic portosystemic shunts (TIPS) should be used in patients with uncontrolled bleeding or those who are likely to have difficult-to-control bleeding. Rebleeding from varices occurs in ∼60% of patients 1-2 years after the initial bleeding episode, with a mortality rate of 30%. Secondary prophylaxis should start at day 6 after initial bleeding using a combination of NSBBs and EBL. TIPS with polytetrafluoroethylene-covered stents are the preferred option in patients who fail combined treatment with NSBBs and EBL. Despite the improvement in patient survival, further studies are needed to direct the management of patients with gastro-oesophageal varices and variceal bleeding.

[Mexican consensus on portal hypertension]

The aim of the Mexican Consensus on Portal Hypertension was to develop documented guidelines to facilitate clinical practice when dealing with key events of the patient presenting with portal hypertension and variceal bleeding. The panel of experts was made up of Mexican gastroenterologists, hepatologists, and endoscopists, all distinguished professionals. The document analyzes themes of interest in the following modules: preprimary and primary prophylaxis, acute variceal hemorrhage, and secondary prophylaxis. The management of variceal bleeding has improved considerably in recent years. Current information indicates that the general management of the cirrhotic patient presenting with variceal bleeding should be carried out by a multidisciplinary team, with such an approach playing a major role in the final outcome. The combination of drug and endoscopic therapies is recommended for initial management; vasoactive drugs should be started as soon as variceal bleeding is suspected and maintained for 5 days. After the patient is stabilized, urgent diagnostic endoscopy should be carried out by a qualified endoscopist, who then performs the corresponding endoscopic variceal treatment. Antibiotic prophylaxis should be regarded as an integral part of treatment, started upon hospital admittance and continued for 5 days. If there is treatment failure, rescue therapies should be carried out immediately, taking into account that interventional radiology therapies are very effective in controlling refractory variceal bleeding. These guidelines have been developed for the purpose of achieving greater clinical efficacy and are based on the best evidence of portal hypertension that is presently available.

Delayed endoscopy increases re-bleeding and mortality in patients with hematemesis and active esophageal variceal bleeding: a cohort study

BACKGROUND & AIMS

Active bleeding is a poor prognostic indicator in patients with acute esophageal variceal bleeding. This study aimed at determining indicators of 6-week re-bleeding and mortality in patients with "active" esophageal variceal bleeding, particularly emphasizing the presenting symptoms and timing of endoscopy to define the treatment strategy.

METHODS

From July 2005 to December 2009, cirrhotic patients with endoscopy-proven active esophageal variceal bleeding were evaluated. Cox proportional hazards regression analysis was used to determine the indicators of 6-week re-bleeding and mortality. Outcome comparisons were performed by Kaplan-Meier method and log rank test.

RESULTS

In 101 patients, the overall 6-week and 3-month re-bleeding rates were 25.7% (n=26) and 29.7% (n=30), respectively. The overall 6-week and 3-month mortality was 31.7% (n=32) and 38.6% (n=39), respectively. Door-to-endoscopy time (hr), MELD score, and portal vein thrombosis were indicators of 6-week re-bleeding, while hematemesis upon arrival, MELD score, and hepatocellular carcinoma were indicators of 6-week mortality. Overall mortality was poorer in hematemesis than in non-hematemesis patients (39.7% vs. 10.7%, p=0.007). In hematemesis patients, 6-week re-bleeding rate (18.9% vs. 38.9%, p=0.028) and mortality (27% vs. 52.8%, p=0.031) were lower in those with early (≤ 12 h) than delayed (>12h) endoscopy. In non-hematemesis patients, early and delayed endoscopy had no difference on 6-week re-bleeding rate (17.6% vs. 18.2%, p=0.944) and mortality (11.8% vs. 9.1%, p=0.861).

CONCLUSIONS

It is likely that early endoscopy (≤ 12 h) is associated with a better outcome in hematemesis patients, but a randomized trial with larger case numbers is required before making a firm conclusion.

Acute variceal hemorrhage in patients with liver cirrhosis: weekend versus weekday admissions

PURPOSE

Little is known about the impact of weekend admission on acute variceal hemorrhage (AVH). Thus, we investigated whether day of admission due to AVH influenced in-hospital mortality.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 294 patients with cirrhosis admitted between January 2005 and February 2009 for the management of AVH. Clinical characteristics were compared between patients with weekend and weekday admission, and independent risk factors for in-hospital mortality were determined by multivariate binary logistic regression analysis.

RESULTS

No demographic differences were observed between patients according to admission day or in the clinical course during hospitalization. Seventeen (23.0%) of 74 patients with weekend admission and 48 (21.8%) of 220 with weekday admission died during hospitalization (p=0.872). Univariate and subsequent multivariate analysis showed that initial presentation with hematochezia [p=0.042; hazard ratio (HR), 2.605; 95% confidence interval (CI), 1.038-6.541], in-patient status at the time of bleeding (p=0.003; HR, 4.084; 95% CI, 1.598-10.435), Child-Pugh score (p<0.001; HR, 1.877; 95% CI, 1.516-2.324), and number of endoscopy sessions for complete hemostasis (p=0.001; HR, 3.864; 95% CI, 1.802-8.288) were independent predictors for in-hospital mortality.

CONCLUSION

Weekend admission did not influence in-hospital mortality in patients with cirrhosis who presented AVH.

Application of endoscopy in improving survival of cirrhotic patients with acute variceal hemorrhage

Playing a central role in the modern multidisciplinary management of acute gastroesophageal variceal hemorrhage, endoscopy is essential to stratify patient at risk, control active hemorrhage, and prevent first as well as recurrent bleeding. Before endoscopic procedure, antibiotic prophylaxis along with vasoactive medication is now routine practice. Intravenous erythromycin effectively cleanses stomach and may improve the quality of endoscopy. The timing of endoscopy should be on an urgent basis as delay for more than 15 hours after presentation is associated with mortality. Active variceal bleeding on endoscopy in a patient with hepatic decompensation heralds poor prognosis and mandates consideration of aggressive strategy with early portosystemic shunting. Band ligation has become the preferred modality to control and prevent bleeding from esophageal varices, although occasionally sclerotherapy may still be used to achieve hemostasis. Addition of pharmacotherapy with nonselective beta blockade to endoscopic ligation has become the current standard of care in the setting of secondary prophylaxis but remains controversial with inconsistent data for the purpose of primary prophylaxis. Gastric varices extending from esophagus may be treated like esophageal varices, whereas variceal obliteration by tissue glue is the endoscopic therapy of choice to control and prevent bleeding from fundic and isolated gastric varices.

Acute esophageal variceal bleeding: Current strategies and new perspectives

Management of acute variceal bleeding has greatly improved over recent years. Available data indicates that general management of the bleeding cirrhotic patient by an experienced multidisciplinary team plays a major role in the final outcome of this complication. It is currently recommended to combine pharmacological and endoscopic therapies for the initial treatment of the acute bleeding. Vasoactive drugs (preferable somatostatin or terlipressin) should be started as soon as a variceal bleeding is suspected (ideally during transfer to hospital) and maintained afterwards for 2-5 d. After stabilizing the patient with cautious fluid and blood support, an emergency diagnostic endoscopy should be done and, as soon as a skilled endoscopist is available, an endoscopic variceal treatment (ligation as first choice, sclerotherapy if endoscopic variceal ligation not feasible) should be performed. Antibiotic prophylaxis must be regarded as an integral part of the treatment of acute variceal bleeding and should be started at admission and maintained for at least 7 d. In case of failure to control the acute bleeding, rescue therapies should be immediately started. Shunt therapies (especially transjugular intrahepatic portosystemic shunt) are very effective at controlling treatment failures after an acute variceal bleeding. Therapeutic developments and increasing knowledge in the prognosis of this complication may allow optimization of the management strategy by adapting the different treatments to the expected risk of complications for each patient in the near future. Theoretically, this approach would allow the initiation of early aggressive treatments in high-risk patients and spare low-risk individuals unnecessary procedures. Current research efforts will hopefully clarify this hypothesis and help to further improve the outcomes of the severe complication of cirrhosis.