Prevention of first variceal bleed: an appraisal of current therapies

The initial experience of safety and efficacy of argon plasma coagulation (APC) in the primary prevention of variceal bleeding

BACKGROUND AND STUDY AIMS

The well-known complications of variceal bleeding together with the high mortality rate mandate effective prophylaxis. Because of the intolerance, failure of response and lack of compliance related to B blockers and because of the high incidence of variceal recurrence after endoscopic variceal ligation (EVL), other alternatives should be investigated. As APC provides coagulation at a shallow depth, it has been considered an ideal procedure to promote mucosal fibrosis for oesophageal varices. This study aims to investigate the safety and effectiveness of APC application to the oesophagus post-variceal obliteration in an attempt to decrease variceal recurrence and bleeding, as compared to EVL.

PATIENTS AND METHODS

This study included 60 patients with chronic liver disease and portal hypertension referred to the Gastrointestinal Endoscopy Unit, Kasr Al-Aini Hospital, Cairo University, during the period from August 2008 till January 2010. Patients had to have large-sized varices (F3), without history of bleeding, portal hypotensive drugs or intervention. Patients were allocated into either group I that included 30 patients for whom EVL was performed and sequentially followed by one session of APC or group II that included 30 patients for whom EVL alone was done. Patients underwent surveillance endoscopy at 3 and 6months to evaluate variceal recurrence (F1 or more).

RESULTS

Both groups were comparable in terms of the demographic features, hepatic functional reserve and endoscopic findings. Post-APC, fever was reported in 6.7%, dysphagia in 3.3%, procedure-related bleeding in 0% and stricture in 3.3%. At 3 and 6months follow-up, both groups were comparable in terms of variceal recurrence and none of the patients in both groups developed variceal bleeding.

CONCLUSION

Although, APC application to the oesophageal mucosa is a safe technique, its additive benefit in terms of variceal recurrence and re-bleeding is comparable to EVL alone. This is encountered when only a single session of APC is applied. A more beneficial effect of multiple sessions of APC awaits further studies.

Practice patterns in screening for varices: an American survey

BACKGROUND AND AIMS

Guidelines recommend screening for gastroesophageal varices. Regional studies suggest screening is underutilized, but information from across the United States is unavailable. We explored practice patterns and adherence to guidelines in a random sample of physicians and sought to define whether differences existed according to practice type, setting and years of practice.

MATERIALS AND METHODS

Surveys were randomly sent to 600 gastroenterologists and hepatologists. Descriptive data is presented as percentage and comparisons were performed by chi-square analysis. Significance was defined at a p value <0.05.

RESULTS

180 completed surveys were returned. Mean age was 48.9+/-10 years and 87% were male. 50% were community-based and 74% had been in practice >10 years. 53% (78% hepatologists versus 45% of gastroenterologists) screened consistently (>75% of the time), (p<0.001). No differences in screening frequency were found according to practice setting or years in practice. 62% screened all cirrhotics whereas 38% screened based on clinical characteristics. In patients without gastroesophageal varices, 60% repeated esophagogastroduodenoscopy in 2-3 years. In those with small gastroesophageal varices, repeat esophagogastroduodenoscopy was recommended in 1-2 years by 73%. In patients with small and large varices, 40% and 54% of physicians respectively, recommended prophylaxis. 6% of physicians recommend prophylaxis regardless of the presence or size of varices.

CONCLUSIONS

Screening for varices is under-implemented. Many screened based on clinical findings that have not been shown to reliably predict high-risk gastroesophageal varices. Continued education and removal of financial barriers to screening are central to increasing screening rates and improving patient outcomes.

Portal hypertension and variceal hemorrhage

Portal hypertension is a progressively debilitating complication of cirrhosis and a principal cause of mortality in patients who have hepatic decompensation. This article describes the classification system and pathophysiology of portal hypertension. It also discusses a practical approach to prevention of first variceal hemorrhage, general management of the acute bleeding episode, and secondary prophylaxis to prevent rebleeding. Pharmacologic, endoscopic, radiologic, and surgical modalities are all described in detail.

Efficacy of absolute alcohol injection compared with band ligation in the eradication of esophageal varices

BACKGROUND

Endoscopic sclerotherapy is an absolute indication for treating esophageal varices. Re-bleeding is common during the treatment period, before all varices become eradicated.

AIM

To compare two techniques of endoscopic esophageal varices eradication: sclerotherapy with absolute alcohol and banding ligation.

PATIENTS AND METHOD

Forty-six patients with liver cirrhosis and esophageal varices were prospectively randomized into two treatment groups: endoscopic sclerotherapy with absolute alcohol and banding ligation. Patients were included if they had large varices with signs of high bleeding risk. Informed writing consent was obtained from every patient and the Ethics Committee of Federal University of São Paulo, SP, Brazil, approved the study. After eradication, all patients were followed up to 1 year to look for re-bleeding episodes and variceal recurrence.

RESULTS

Both groups were similar except that male gender was more common in the sclerotherapy group. There was no statistical difference regarding variceal eradication (78.3% in sclerotherapy group vs 73.9% in the ligation group), recurrence (26.7% vs 42.9%, respectively) and death related to any cause (21.7% vs 13.9%). In the sclerotherapy group more sessions were need to obtain complete variceal eradication. In this group we did observe a high re-bleeding rate (34.8%) and more ulcers associated with retrosternal pain right after the procedure. There was no difference regarding overall morbidity and mortality.

CONCLUSIONS

Banding ligation requires fewer sessions than sclerotherapy with absolute alcohol to eradicate esophageal varices. Both methods are equally efficient regarding variceal eradication and recurrence during a short follow-up period.

Primary prophylaxis of variceal hemorrhage

Figure 3 shows an algorithm for the primary prevention of variceal hemorrhage. Pharmacologic therapy is the current standard of treatment for the primary prophylaxis of esophageal variceal bleeding. Patients with medium or large varices should be treated with a nonselective beta-blocker with the dose titrated to achieve a 25% decrement in resting heart rate or a heart rate of 55 to 60 bpm. The development of symptoms will, of course, limit the dose used. As discussed previously, these therapeutic endpoints are not well correlated with decreases in portal pressure. Measurement of the HVPG before therapy and after 3 months of therapy provides a rational approach to drug dosing. If the HVPG decreases by 20% or to less than 12 mm Hg, the medication dose will be effective in preventing hemorrhage. If, however, the HVPG is not appropriately lowered, a long-acting nitrate may be added. Patients with small varices should be observed, with endoscopic examinations every 2 years to assess progression of variceal size. Endoscopic therapy is not indicated for the primary prevention of variceal bleeding.

Review article: current endoscopic therapeutic options in the management of variceal bleeding

Variceal bleeding is a frequent and life-threatening complication of portal hypertension. The first episode of variceal bleeding is not only associated with a high mortality, but also with a high recurrence rate in those who survive. Therefore, many studies and randomized clinical trials have focused on different therapeutic strategies aiming to prevent the first episode of variceal bleeding (primary prophylaxis), to control haemorrhage during the acute bleeding episode (emergency treatment), and to prevent re-bleeding (secondary prophylaxis). These strategies involve pharmacological, endoscopic, surgical, and interventional radiological modalities. This review concentrates on the clinical aspects of the endoscopic modalities used to treat oesophageal variceal haemorrhage, including variceal injection sclerotherapy, variceal band ligation, and the use of tissue adhesives (glue) and their substitutes. We also draw conclusions from the available literature regarding the use of endoscopic modalities in primary prophylaxis, emergency treatment, and secondary prophylaxis of variceal re-bleeding. The management of gastric varices and variceal bleeding during pregnancy is also addressed.

Portal hypertension

Many advances in the management of portal hypertension and variceal hemorrhage have occurred during the last 10 years. Effective therapy for primary prevention of variceal hemorrhage is now available in the form of nonselective beta-blockers. Active bleeding should be managed with terlipressin, somatostatin or its analogues, and endoscopic therapy; TIPS and surgery are reserved as salvage therapy for patients who fail endoscopic treatment. Survivors of a variceal hemorrhage should be evaluated for liver transplantation. Specific treatment may be provided with EVL while these patients await transplantation. Patients who fail endoscopic treatment may be treated by TIPS or surgery.

Endoscopic management of the liver transplant patient

The endoscopic evaluation of the asymptomatic liver transplant patient is essential to risk-stratify the patient for future complications related to portal hypertensive bleeding (i.e., presence of large varices), and to exclude findings (e.g., malignancy) that might preclude the patient from consideration of OLT. Because waiting times for transplant are longer after listing, preventive management becomes imperative to diminish attrition on the waiting list and maintain long-term success. Following OLT, endoscopy may be performed to assess a number of common problems: gastrointestinal blood loss that may be caused by anastomotic lesions; persistent portal hypertensive bleeding; biliary complications, including leaks and strictures; and systemic processes (e.g., infectious diseases or lymphoproliferative disorder (LPD). Clearly, endoscopy plays an integral role in the successful management of the patient before and after OLT.

Comparison of endoscopic ligation and propranolol for the primary prevention of variceal bleeding

BACKGROUND AND METHODS

We compared propranolol therapy and endoscopic ligation for the primary prevention of bleeding from esophageal varices. This prospective, controlled trial included consecutive eligible patients who had large varices (>5 mm in diameter) that were at high risk for bleeding. The patients were assigned to either propranolol therapy, at a dose sufficient to decrease the base-line heart rate by 25 percent, or variceal ligation, to be performed weekly until the varices were obliterated or so reduced in size that it was not possible to continue treatment.

RESULTS

Of the 89 patients, 82 of whom had cirrhosis of the liver, 44 received propranolol and 45 underwent variceal ligation. The mean (+/-SD) duration of follow-up in each group was 14+/-9 and 13+/-10 months, respectively. The mean time required to achieve an adequate reduction in the heart rate was 2.5+/-1.7 days; the mean number of sessions needed to complete variceal ligation was 3.2+/-1.1. After 18 months, the actuarial probability of bleeding was 43 percent in the propranolol group and 15 percent in the ligation group (P=0.04). Twelve patients in the propranolol group and four in the ligation group had bleeding. Three of the four in the ligation group had bleeding before their varices had been obliterated. Nine patients in the ligation group had recurrent varices, a mean of 3.7 months after the initial treatment. Five patients in each group died; bleeding from the varices was the cause of death of four patients in the propranolol group and of three in the ligation group. There were no serious complications of variceal ligation; in the propranolol group, treatment was stopped in two patients because of side effects.

CONCLUSIONS

In patients with high-risk esophageal varices, endoscopic ligation of the varices is safe and more effective than propranolol for the primary prevention of variceal bleeding.

Management of esophageal varices

Of the consequences of portal hypertension, varices carry the most sinister implications. During life, the risk of hemorrhage from varices hangs like a "sword of Damocles" over a cirrhotic's head. Hemorrhage, when it occurs, expedites the patient's demise, or often itself proves to be the terminal event. Compared with other causes of gastrointestinal bleeding, hemorrhage from varices is most severe, and the available therapies, over the long-term, are the least definitive.