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Itule PW, Mwanga A, Khamisi RH, Byomuganyizi M, Lutege W, Kagaruki TB. Clinical characteristics and management of patient with portal hypertension at tertial level hospital in Tanzania. BMC Cardiovasc Disord 2024; 24:428. [PMID: 39148048 PMCID: PMC11328360 DOI: 10.1186/s12872-024-04072-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 07/23/2024] [Indexed: 08/17/2024] Open
Abstract
BACKGROUND Portal hypertension is a common diagnosis in Sub-Saharan African countries, with the majority of patients presenting late. This study aimed to understand Clinical characteristics, aetiology, the treatment offered in our setting, and factors associated with portal hypertension at a tertiary-level hospital, in Tanzania. METHODOLOGY A prospective cross-sectional observational single hospital-based study was conducted at MNH, from May 2021 to April 2022. A minimum of 152 subjects were required with an error of less than 5% and a study power of 80% at a 95% confidence interval. A structured questionnaire was used to collect data. Ethical clearance was obtained from the MUHAS/MNH IRB. RESULTS A total of 154 eligible participants consented and participated in this study. The mean age of participants was 42 ± 15.8 years (range 2-87). Most of the study participants were males 64.9% with a male-to-female (M: F) ratio of 1.8:1. Vomiting blood was the common symptom among the study participants 51.3%. Schistosomiasis 53.9% and viral infection 26.6% were the common etiologies followed by alcohol abuse 7.8%. Most were medically treated at 89.61% followed by radiological treatment at 8.44% while only 1.95% of patients received surgical treatment. There was a significant association between the grade of oesophagal varices and bleeding consequences (p-value < 0.01). CONCLUSION The majority of patients were medically treated while patients who require surgical care are unable to assess it. We recommend the establishment of a transplant services program to counteract the unmet need and more retrospective research toward policy establishment.
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Affiliation(s)
| | - Ally Mwanga
- Muhimbili University of Health and Allied Sciences, P.O box 65001, Dar es Salaam, Tanzania
| | | | - Moses Byomuganyizi
- Muhimbili University of Health and Allied Sciences, P.O box 65001, Dar es Salaam, Tanzania
| | - William Lutege
- Muhimbili National Hospital, P.O box 65000, Dar es Salaam, Tanzania
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Lee NHC, Kiddle SJ, Chandankhede S, Agrawal S, Bean DM, Hunt PR, Parker VER, Greasley PJ, Ambery P. Evaluating clinical outcomes and prognosis in patients with cirrhosis and portal hypertension: a retrospective observational cohort study. BMJ Open Gastroenterol 2023; 10:e001234. [PMID: 38030407 PMCID: PMC10689413 DOI: 10.1136/bmjgast-2023-001234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023] Open
Abstract
OBJECTIVE Cirrhosis describes the end-stage of chronic liver disease. Irreversible changes in the liver cause portal hypertension, which can progress to serious complications and death. Only a few studies with small sample sizes have investigated the prognosis of cirrhosis with portal hypertension. We used electronic healthcare records to examine liver-related outcomes in patients with diagnosed/suspected portal hypertension. DESIGN This retrospective observational cohort study used secondary health data between 1 January 2017 and 3 December 2020 from the TriNetX Network, a federated electronic healthcare records platform. Three patient groups with cirrhosis and diagnosed/suspected portal hypertension were identified ('most severe', 'moderate severity' and 'least severe'). Outcomes studied individually and as a composite were variceal haemorrhage, hepatic encephalopathy, complications of ascites and recorded mortality up to 24 months. RESULTS There were 13 444, 23 299, and 23 836 patients in the most severe, moderate severity and least severe groups, respectively. Mean age was similar across groups; most participants were white. The most common individual outcomes at 24 months were variceal haemorrhage in the most severe group, recorded mortality and hepatic encephalopathy in the moderate severity group, and recorded mortality in the least severe group. Recorded mortality rate was similar across groups. For the composite outcome, cumulative incidence was 59% in the most severe group at 6 months. Alcohol-associated liver disease and metabolic-associated steatohepatitis were significantly associated with the composite outcome across groups. CONCLUSION Our analysis of a large dataset from electronic healthcare records illustrates the poor prognosis of patients with diagnosed/suspected portal hypertension.
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Affiliation(s)
| | - Steven J Kiddle
- Data Science & Advanced Analytics, Data Science & Artificial Intelligence, R&D, AstraZeneca, Cambridge, UK
| | | | - Shubh Agrawal
- Real World Evidence, ZS Associates, Bangalore, India
| | - Daniel M Bean
- Data Science & Advanced Analytics, Data Science & Artificial Intelligence, R&D, AstraZeneca, Cambridge, UK
| | - Phillip R Hunt
- Medical Affairs, Cardiovascular, Renal and Metabolism, AstraZeneca, Gaithersburg, Maryland, USA
| | - Victoria E R Parker
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Peter J Greasley
- Early Clinical Development, Research and Early Development, Cardiovascular Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Philip Ambery
- Clinical Late Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
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Almenara S, Lozano-Ruiz B, Herrera I, Gimenez P, Miralles C, Bellot P, Rodriguez M, Palazon JM, Tarín F, Sarmiento H, Francés R, Gonzalez-Navajas JM, Pascual S, Zapater P. Immune changes over time and survival in patients with cirrhosis treated with non-selective beta-blockers: A prospective longitudinal study. Biomed Pharmacother 2023; 163:114885. [PMID: 37201262 DOI: 10.1016/j.biopha.2023.114885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/03/2023] [Accepted: 05/12/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND Treatment with non-selective beta-blockers (NSBB) has been associated with anti-inflammatory and anti-cancer effects in patients with cirrhosis. This study aims to analyze the impact of chronic NSBB treatment on immune activation and disease progression in stable outpatients with cirrhosis. METHODS In this prospective follow-up of 150 patients with cirrhosis, 39 received treatment with NSBB. Blood samples were taken every 6-9 months, and immune and adrenergic variables were measured. Mixed linear models were used to assess the effect of NSBB on these variables over time. Multivariate Cox regression was used to study associations with adverse clinical events (hepatocellular carcinoma, death, or liver transplant). RESULTS Median follow-up was 1635 days. NSBB treatment was associated with significantly lower levels of IL-6 (β - 4.7; 95% confidence interval [CI] -6.9, -2.6) throughout the study. During follow-up, 11 patients developed hepatocellular carcinoma, 32 died, and 4 underwent liver transplant. Patients with higher concentrations of IL-10, IL-6 and IFN-γ developed more clinical events. Event-free survival was significantly better in patients treated with NSBB (hazard ratio 0.36, 95% CI 0.18, 0.71) in a multivariate Cox regression adjusted for Child-Pugh-Score, esophageal varices, and platelets. CONCLUSION Chronic treatment with NSBB in patients with stable cirrhosis gives rise to a different state of immune activation, characterized by lower concentrations of IL-6 over time, and it is associated with a reduced risk of adverse event (death, hepatocellular carcinoma, or transplant), after controlling for disease severity.
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Affiliation(s)
- Susana Almenara
- CIBERehd, Health Institute Carlos III, Madrid, Spain; Clinical Pharmacology Unit. Alicante General University Hospital, Alicante, Spain; Institute of Research, Development, and Innovation in Healthcare Biotechnology of Elche (IDiBE), University Miguel Hernández de Elche, Spain; Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Beatriz Lozano-Ruiz
- CIBERehd, Health Institute Carlos III, Madrid, Spain; Institute of Research, Development, and Innovation in Healthcare Biotechnology of Elche (IDiBE), University Miguel Hernández de Elche, Spain
| | - Ivan Herrera
- Liver Unit. Alicante General University Hospital, Alicante, Spain
| | - Paula Gimenez
- CIBERehd, Health Institute Carlos III, Madrid, Spain
| | | | - Pablo Bellot
- Liver Unit. Alicante General University Hospital, Alicante, Spain
| | - Maria Rodriguez
- Liver Unit. Alicante General University Hospital, Alicante, Spain
| | - Jose M Palazon
- Liver Unit. Alicante General University Hospital, Alicante, Spain
| | - Fabián Tarín
- Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain; Hematology Department. Alicante General University Hospital, Alicante, Spain
| | - Héctor Sarmiento
- Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain; Hematology Department. Alicante General University Hospital, Alicante, Spain
| | - Rubén Francés
- CIBERehd, Health Institute Carlos III, Madrid, Spain; Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain; Clinical Medicine Department, University Miguel Hernández de Elche, Alicante, Spain
| | - Jose Manuel Gonzalez-Navajas
- CIBERehd, Health Institute Carlos III, Madrid, Spain; Institute of Research, Development, and Innovation in Healthcare Biotechnology of Elche (IDiBE), University Miguel Hernández de Elche, Spain; Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Sonia Pascual
- CIBERehd, Health Institute Carlos III, Madrid, Spain; Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain; Liver Unit. Alicante General University Hospital, Alicante, Spain
| | - Pedro Zapater
- CIBERehd, Health Institute Carlos III, Madrid, Spain; Clinical Pharmacology Unit. Alicante General University Hospital, Alicante, Spain; Institute of Research, Development, and Innovation in Healthcare Biotechnology of Elche (IDiBE), University Miguel Hernández de Elche, Spain; Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain.
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Nomogram model for predicting esophsagogastric varices in hepatocellular carcinoma with cirrhosis. Eur J Gastroenterol Hepatol 2023; 35:342-348. [PMID: 36708306 DOI: 10.1097/meg.0000000000002496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND/AIMS The prognosis for hepatocellular carcinoma (HCC) with cirrhosis is poor. The risk of death also increases in patients with esophagogastric varices (EGV). Based on routine clinical features and related noninvasive parameters, a nomogram prediction model was developed in this study to facilitate the early identification of EGV in HCC patients. METHODS A retrospective cohort analysis of patients with HCC in the Renmin Hospital of Wuhan University from 2020 to 2021 was performed. Clinical and noninvasive parameters closely related to EGV risk were screened by univariate and multivariate logistic regression analysis and integrated into a nomogram. The nomogram was validated internally and externally by calibration, receiver operating characteristic curve and decision curve analysis (DCA). RESULTS A total of 165 patients with HCC-related cirrhosis were recruited. In the raining cohort, multivariate logistic regression analysis identified platelet (PLT) [odds ratio (OR), 0.950; 95% confidence interval (CI), 0.925-0.977; P < 0.001], D-dimer (OR. 3.341; 95% CI, 1.751-6.376, P < 0.001), spleen diameter (SD) (OR, 2.585; 95% CI, 1.547-4.318; P < 0.001) as independent indicators for EGV. The nomogram for predicting EGV risk was well calibrated with a favorable discriminative ability and an area under curve of 0.961. In addition, the nomogram showed better net benefits in the DCA. The results were validated in the validation cohort. CONCLUSIONS The proposed nomogram model based on three indicators (PLT, D-dimer and SD) showed an excellent predictive effect, leading to the avoidance of unnecessary esophagogastroduodenoscopy.
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Thabut D, Weil D, Bouzbib C, Rudler M, Cassinotto C, Castéra L, Serste T, Oberti F, Ganne-Carrié N, de Lédinghen V, Bourlière M, Bureau C. Non-invasive diagnosis and follow-up of portal hypertension. Clin Res Hepatol Gastroenterol 2022; 46:101767. [PMID: 34332128 DOI: 10.1016/j.clinre.2021.101767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 07/23/2021] [Indexed: 02/04/2023]
Abstract
Compensated advanced chronic liver disease (cACLD) describes the spectrum of advanced fibrosis/cirrhosis in asymptomatic patients at risk of developing clinically significant portal hypertension (CSPH, defined by a hepatic venous pressure gradient (HVPG) ≥10 mmHg). Patients with cACLD are at high risk of liver-related morbidity and mortality. In patients at risk of chronic liver disease, cACLD is strongly suggested by a liver stiffness (LSM) value >15 kPa or clinical/biological/radiological signs of portal hypertension, and ruled out by LSM <10 kPa, or Fibrotest® ≤0.58, or Fibrometer® ≤0.786. Patients with chronic liver disease (excluding vascular diseases) with a LSM <10 kPa are at low risk of developing portal hypertension complications. The presence of CSPH can be strongly suspected when LSM is ≥20 kPa. In a patient without clinical, endoscopic or radiological features of portal hypertension, measurement of the HVPG is recommended before major liver or intra-abdominal surgery, before extra-hepatic transplantation and in patients with unexplained ascites. Endoscopic screening for oesophageal varices can be avoided in patients with LSM <20 kPa and a platelet count >150 G/L (favourable Baveno VI criteria) at the time of diagnosis. There is no non-invasive method alternative for oeso-gastroduodenal endoscopy in patients with unfavourable Baveno criteria (liver stiffness ≥20 kPa or platelet count ≤50 G/l). Platelet count and liver stiffness measurements must be performed once a year in patients with cACLD with favourable Baveno VI criteria at the time of diagnosis. A screening oeso-gastroduodenal endoscopy is recommended if Baveno VI criteria become unfavourable.
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Affiliation(s)
- Dominique Thabut
- Service d'hépato-gastroentérologie, Hôpital Pitié- Salpêtrière, Sorbonne Université, APHP, 47-83 boulevard de l'Hôpital, 75013 Paris, France.
| | - Delphine Weil
- Service d'hépatologie, CHRU Besançon, Besançon, France
| | - Charlotte Bouzbib
- Service d'hépato-gastroentérologie, Hôpital Pitié- Salpêtrière, Sorbonne Université, APHP, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Marika Rudler
- Service d'hépato-gastroentérologie, Hôpital Pitié- Salpêtrière, Sorbonne Université, APHP, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Christophe Cassinotto
- Radiologie diagnostique et interventionnelle Saint Eloi, CHU Montpellier, Montpellier, France
| | - Laurent Castéra
- Service d'Hépatologie, Hôpital Beaujon, Université de Paris, APHP, Paris, France
| | - Thomas Serste
- Service d'hépato-gastroentérologie, CHU Saint-Pierre, Bruxelles, France
| | - Frédéric Oberti
- Service d'hépato-gastroentérologie et oncologie digestive, CHU Angers, Angers, France
| | - Nathalie Ganne-Carrié
- Service d'hépatologie, Hôpital Avicenne, APHP, Université Sorbonne Paris Nord, Bobigny & INSERM UMR 1138, Centre de Recherche des Cordeliers, Université de Paris, France
| | - Victor de Lédinghen
- Service d'hépato-gastroentérologie et d'oncologie digestive, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac & INSERM U1053, Université de Bordeaux, Bordeaux, France
| | - Marc Bourlière
- Service d'hépato-gastroentérologie, Hôpital Saint Joseph & INSERM UMR 1252 IRD SESSTIM Aix Marseille Université, Marseille, France
| | - Christophe Bureau
- Service d'hépatologie, Hôpital Rangueil, CHU Toulouse, Toulouse, France
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Zhan PC, Li Z, Li X, Lv PJ, Zhang YY, Yu P, Ji K, Shi Y, Ye SW, Xie BC, Gao JB, Zhou PL, Wu G. A Nomogram to Predict the Risk of Stent Dysfunction After TIPS in Patients with Hepatitis B Cirrhosis. Acad Radiol 2022; 29:1532-1540. [PMID: 35216866 DOI: 10.1016/j.acra.2022.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 01/13/2022] [Accepted: 01/23/2022] [Indexed: 12/14/2022]
Abstract
RATIONALE AND OBJECTIVES To develop and validate a nomogram for the prediction of stent dysfunction after transjugular intrahepatic portosystemic shunt (TIPS) placement in patients with hepatitis B cirrhosis. MATERIALS AND METHODS From 2012 to 2020, 355 patients with hepatitis B cirrhosis who underwent TIPS placements were enrolled in this study. A multivariable logistic regression analysis was applied to determine independent risk factors for the nomogram construction. Discrimination, calibration, and clinical usefulness of the prediction model were assessed by using receiver operating characteristic curves, calibration scatter plots, and a decision curve analysis (DCA). RESULTS Independent factors for TIPS stent dysfunction included diabetes, previous splenectomy, the shunting branch of the portal vein, and stent position, which were used to construct the nomogram. The AUC values in the training and validation cohorts were 0.817 (95% CI: 0.731-0.903) and 0.804 (95% CI: 0.673-0.935), respectively, which suggested a good predictive ability. The calibration curves in both cohorts revealed good agreement between the predictions and actual observations. The DCA curve indicated that when the threshold probability ranged from 2% to 88%, the nomogram could provide clinical usefulness and a net benefit. CONCLUSION The nomogram that we developed could be conveniently used to predict TIPS stent dysfunction in patients with hepatitis B cirrhosis.
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Affiliation(s)
- Peng-Chao Zhan
- Department of Radiology, Zhengzhou University First Affiliated Hospital, Zhengzhou, China
| | - Zhen Li
- Department of Interventional Radiology, Zhengzhou University First Affiliated Hospital, No.1 Jianshe Road, Zhengzhou 450052, China.
| | - Xin Li
- Department of Interventional Radiology, Zhengzhou University First Affiliated Hospital, No.1 Jianshe Road, Zhengzhou 450052, China
| | - Pei-Jie Lv
- Department of Radiology, Zhengzhou University First Affiliated Hospital, Zhengzhou, China
| | - Yu-Yuan Zhang
- Department of Interventional Radiology, Zhengzhou University First Affiliated Hospital, No.1 Jianshe Road, Zhengzhou 450052, China
| | - Peng Yu
- Department of Interventional Radiology, Zhengzhou University First Affiliated Hospital, No.1 Jianshe Road, Zhengzhou 450052, China
| | - Kun Ji
- Department of Interventional Radiology, The First Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Yang Shi
- Department of Radiology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shu-Wen Ye
- Department of Interventional Radiology, Zhengzhou University First Affiliated Hospital, No.1 Jianshe Road, Zhengzhou 450052, China
| | - Bing-Can Xie
- Department of Interventional Radiology, Zhengzhou University First Affiliated Hospital, No.1 Jianshe Road, Zhengzhou 450052, China
| | - Jian-Bo Gao
- Department of Radiology, Zhengzhou University First Affiliated Hospital, Zhengzhou, China
| | - Peng-Li Zhou
- Department of Interventional Radiology, Zhengzhou University First Affiliated Hospital, No.1 Jianshe Road, Zhengzhou 450052, China
| | - Gang Wu
- Department of Interventional Radiology, Zhengzhou University First Affiliated Hospital, No.1 Jianshe Road, Zhengzhou 450052, China
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5-year mortality of alcohol-related cirrhosis: patients die just as much but not in the same manner. Acta Gastroenterol Belg 2022; 85:447-451. [DOI: 10.51821/85.3.9644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background and study aim: Patients with alcohol-related cirrhosis have a poor short-term prognosis. We aimed to determine whether the 5-year mortality of alcohol-related cirrhosis has changed over the past two decades in our institution.
Patients and methods: From January 1995 to December 2014, 932 cirrhotic patients who attended the hepatology outpatient’s clinics of our institution were consecutively listed in a registry. From this registry, 565 patients had alcohol-related cirrhosis and were the subject of this study. 16 patients were excluded because they were loss to follow-up and 114 patients were excluded because the diagnosis of cirrhosis was made more than 2 years before the inclusion in the registry. We separated the 435 remaining patients into two cohorts collected during two similar period of 10-year duration, but 10 years apart: the cohort 1, patients included in the registry from 1995 to 2004 (n = 206) and the cohort 2, patients included from 2005 to 2014 (n = 229). The 5-year mortality was assessed in both cohorts and the precipitating events leading to death were compared.
Results: From the 206 patients in the cohort 1, 80 died within 5 years after the diagnosis of cirrhosis (Group A) compared to 83 patients from the 229 patients in the cohort 2 (Group B) (Cohort 1: 39 % vs Cohort 2: 36 %, p = 0.6). Patients in Group A died more often from gastrointestinal bleeding than patients in Group B (Group A: 30 % vs Group B: 9 %, p = 0.003). Patients in Group A died less by sepsis than patients in Group B (Group A: 1.5 % vs Group B: 14 %, p = 0.009).
Conclusions: The 5-year mortality rate in patients with alcoholrelated cirrhosis has not changed however, the circumstances of death have changed.
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Sallout D, Tatro E, Adler DG. Managing gastric varices. Frontline Gastroenterol 2022; 13:535-542. [PMID: 36250174 PMCID: PMC9559633 DOI: 10.1136/flgastro-2021-101834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/11/2022] [Indexed: 02/04/2023] Open
Abstract
Gastric varices (GV) are a type of ectopic varix, which is a natural portosystemic shunt occurring in response to an increase in intrahepatic vascular resistance, mostly commonly from portal hypertension. GV are present in up to 20% of patients with portal hypertension. Although oesophageal varices are more common than GV, and oesophageal variceal bleeding (EVB) happens more often than gastric variceal bleeding (GVB), GVB tends to be more severe, to have higher associated hospital costs, length of stay, higher rebleeding rates and have higher mortality. Mortality rates associated with variceal bleeding range from 6% in EVB to 20%-55% in GVB. Risk factors for GV haemorrhage include location, size, severity of liver failure, presence of variceal red spots, and presence of HCC (hepatocellular carcinoma). This manuscript will review endoscopic and non-endoscopic treatment of GV.
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Affiliation(s)
- Deema Sallout
- The University of Utah Department of Internal Medicine, Salt Lake City, Utah, USA
| | - Eric Tatro
- The University of Utah Department of Internal Medicine, Salt Lake City, Utah, USA
| | - Douglas G Adler
- Endoscopy, Center for Advanced Therapeutic Endoscopy, Denver, Colorado, USA
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Wang R, Huang X, Zhou T, Li Y, Ding M, Xu H, Gao Y. Safety and Feasibility of Early Oral Nutrition after Endoscopic Treatment for Patients with Liver Cirrhosis: A Historical-prospective, Comparative-Effectiveness Study. JPEN J Parenter Enteral Nutr 2022; 46:1660-1670. [PMID: 35040175 DOI: 10.1002/jpen.2328] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/02/2021] [Accepted: 01/03/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND This study aimed to evaluate the safety and efficacy of early oral nutrition (EON) after endoscopic treatment compared with parenteral nutrition (PN) for patients with gastroesophageal variceal bleeding varices as cirrhotic complications. METHODS This historical-prospective study enrolled patients from Qilu Hospital of Shandong University in China with gastroesophageal varices as cirrhotic complications and undergoing endoscopic therapy. A total of 197 patients who fasted for 4 h after treatment were prospectively enrolled as the oral nutrition group whereas those who fasted for more than 48 h were retrospectively matched in a ratio of 1:1 as the parenteral nutrition group. The primary endpoint was variceal re-bleeding, whereas the secondary endpoints were mortality and adverse events during the 42-day follow-up. Hospitalisation duration and expenses, levels of inflammatory factors, defecation time, and the satisfaction of patients were evaluated. RESULTS During the 42-day follow-up, no significant difference was observed in the rate of variceal re-bleeding (P = 0.586) and morality (P = 1.000) between the oral nutrition group and the parenteral nutrition group. However, the average days of hospitalisation (P < 0.001) and expenses (P < 0.001) were significantly decreased in the oral nutrition group. Furthermore, C-reactive protein lever (P = 0.002) and defecation time (P < 0.001) were lower, whereas the satisfaction rate was higher (P < 0.001) in the oral nutrition group than those in the parenteral nutrition group. Linear regression analysis showed that tissue adhesive dosage was related to diet time (P = 0.038, 95% CI: 0,135-4.516). CONCLUSIONS EON was proven to be safe, feasible, and hence, recommended after endoscopic treatment in patients with cirrhosis. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Renren Wang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan City, Shandong Province, People's Republic of China
| | - Xiaoli Huang
- Department of Nutrition, Qilu Hospital of Shandong University, Jinan City, Shandong Province, People's Republic of China
| | - Tao Zhou
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan City, Shandong Province, People's Republic of China
| | - Yueyue Li
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan City, Shandong Province, People's Republic of China
| | - Mengmeng Ding
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan City, Shandong Province, People's Republic of China
| | - Huawei Xu
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan City, Shandong Province, People's Republic of China
| | - Yanjing Gao
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan City, Shandong Province, People's Republic of China
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Long-term outcomes of hemostatic therapy for variceal bleeding and the challenge pending in the post-direct-acting antivirals era. Acta Gastroenterol Belg 2022; 85:7-14. [PMID: 35304988 DOI: 10.51821/85.1.9276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background and study aims This study evaluated the longterm outcomes of mainly endoscopic hemostatic therapy for gastrointestinal variceal bleeding and of the transition of hemostatic therapy. Patients and methods Among 1,163 patients treated for gastrointestinal varices between April 2006 and June 2020, a total of 125 patients who underwent emergency hemostatic therapy were enrolled. Survival rates and secondary evaluation points were analyzed. Additionally, patients were classified into two groups: the previous and latter term. Patients' background, therapeutic method, and treatment results were compared between the groups. Results 94.4% had cirrhosis. The average Child-Pugh score was 8.90. Successful primary hemostasis rate was 98.4%, and 5.6% died within 2 weeks, all with a Child-Pugh score ≥9. The respective 1- and 5-year survival rates for Child-Pugh grade A/B were 81.3% and 55.4%, while those for Child-Pugh grade C were 58.1% and 17.8%. Child-Pugh grade C or hepatocellular carcinoma was significantly associated with poor prognosis. In total, 21.6% experienced variceal re-bleeding; 62.9% of these cases were triggered by continued alcohol consumption. There was no significant difference in survival between patients with and without variceal re-bleeding and in post-treatment survival between the previous and latter terms. In the latter term, the number of cases caused by continued alcohol consumption significantly increased. Conclusions Multidisciplinary treatment and continuation of proper management after hemostatic therapy for variceal bleeding are crucial. Continued alcohol consumption leads to variceal bleeding and re-bleeding; its proper management, including alcohol abstinence, is one of the major challenges left in the post-directacting antivirals era.
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Kim JH, Choe WH, Lee SY, Kwon SY, Sung IK, Park HS. Comparative study for predictability of type 1 gastric variceal rebleeding after endoscopic variceal ligation: High-frequency intraluminal ultrasound study. World J Clin Cases 2021; 9:10566-10575. [PMID: 35004988 PMCID: PMC8686123 DOI: 10.12998/wjcc.v9.i34.10566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/31/2021] [Accepted: 10/15/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The efficacy of endoscopic ultrasonography for the follow-up of gastric varices treated with endoscopic variceal ligation (EVL) has not been established.
AIM To evaluate the diagnostic correlation of esophagogastroduodenoscopy (EGD) and high-frequency intraluminal ultrasound (HFIUS) for type 1 gastric varices (GOV1) after EVL and to identify the predictability for rebleeding of EGD and HFIUS.
METHODS In liver cirrhosis patients with GOV1, we performed endoscopic follow-up using EGD and HFIUS synchronously after EVL for hemorrhage from GOV1. Endoscopic grading and red color signs were analyzed using EGD, and the largest variceal cross-sectional areas were measured using HFIUS. In addition, 1-year follow-up was performed. Variceal rebleeding was defined as the presence of hematemesis, hematochezia, or melena without other evidence of bleeding on endoscopic follow-up.
RESULTS In 26 patients with GOV1, variceal cross-sectional areas on HFIUS of GOV1 was poorly correlated with EGD grading of GOV1 (r = 0.36). In 17 patients who completed the 1-year follow-up, variceal cross-sectional areas on HFIUS was a good predictor of subsequent rebleeding, whereas EGD grading was not a predictor of subsequent rebleeding.
CONCLUSION HFIUS measurement is more predictive of GOV1 rebleeding than EGD grading, so HFIUS measurement may be necessary for endoscopic follow-up after EVL in patients with GOV1.
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Affiliation(s)
- Jeong Hwan Kim
- Department of Internal Medicine, Konkuk University School of Medicine, Konkuk University Medical Center, Seoul 05030, South Korea
| | - Won Hyeok Choe
- Department of Internal Medicine, Konkuk University School of Medicine, Konkuk University Medical Center, Seoul 05030, South Korea
| | - Sun-Young Lee
- Department of Internal Medicine, Konkuk University Medical Center, Seoul 143729, South Korea
| | - So Young Kwon
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul 05030, South Korea
| | - In-Kyung Sung
- Department of Internal Medicine, Konkuk University School of Medicine, Konkuk University Medical Center, Seoul 05030, South Korea
| | - Hyung Seok Park
- Department of Internal Medicine, Digestive Disease Center, Konkuk University School of Medicine, Seoul 05030, South Korea
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12
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Yao Q, Chen W, Yan C, Yu J, Jiang T, Cao H. Efficacy and Safety of Treatments for Patients With Portal Hypertension and Cirrhosis: A Systematic Review and Bayesian Network Meta-Analysis. Front Med (Lausanne) 2021; 8:712918. [PMID: 34540867 PMCID: PMC8446274 DOI: 10.3389/fmed.2021.712918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/12/2021] [Indexed: 12/19/2022] Open
Abstract
Background and Aims: Viral hepatitis are one of the main causes of liver cirrhosis. The treatment of portal hypertension caused by liver cirrhosis is difficult and diverse, and the therapeutic effect is unknown. Bayesian network meta-analysis was performed to compare the efficacy and safety of treatments for patients with portal hypertension and cirrhosis, including a transjugular intrahepatic portosystemic shunt (TIPS), endoscopic therapy, surgical therapy and medications. Methods: Eligible articles were searched for in PubMed, Embase, Cochrane Library and Web of Science databases from their inception until June 2020. Using the "gemtc-0.8.4" package in R v.3.6.3 software and the Just Another Gibbs Sampler v.4.2.0 program, network meta-analysis was performed using a random effects model within a Bayesian framework. The odds ratios for all-cause rebleeding, bleeding-related mortality, overall survival (OS), treatment failure and hepatic encephalopathy were determined within the Bayesian framework. Results: Forty randomized controlled trials were identified, including 4,006 adult patients and nine treatment strategies. Our results showed that distal splenorenal shunt and TIPS provided the best control of hemorrhage. Endoscopic variceal ligation with medication resulted in the highest OS rate. Medication alone resulted in poor OS and treatment failure. Conclusions: We performed a systematic comparison of diverse treatments for cirrhotic patients with portal hypertension. Our meta-analysis indicated that a TIPS and distal splenorenal shunt resulted in lower rates of rebleeding than did other therapies. Furthermore, drugs are more suitable for combination therapy than monotherapy.
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Affiliation(s)
- Qigu Yao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Clinical Research Center for Infectious Diseases, Hangzhou, China
| | - Wenyi Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Clinical Research Center for Infectious Diseases, Hangzhou, China
| | - Cuilin Yan
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiong Yu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Clinical Research Center for Infectious Diseases, Hangzhou, China
| | - Tian'an Jiang
- National Clinical Research Center for Infectious Diseases, Hangzhou, China.,Department of Ultrasound, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hongcui Cao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Clinical Research Center for Infectious Diseases, Hangzhou, China.,Zhejiang Provincial Key Laboratory for Diagnosis and Treatment of Aging and Physic-Chemical Injury Diseases, Hangzhou, China
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13
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Pfisterer N, Unger LW, Reiberger T. Clinical algorithms for the prevention of variceal bleeding and rebleeding in patients with liver cirrhosis. World J Hepatol 2021; 13:731-746. [PMID: 34367495 PMCID: PMC8326161 DOI: 10.4254/wjh.v13.i7.731] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/14/2021] [Accepted: 07/07/2021] [Indexed: 02/06/2023] Open
Abstract
Portal hypertension (PH), a common complication of liver cirrhosis, results in development of esophageal varices. When esophageal varices rupture, they cause significant upper gastrointestinal bleeding with mortality rates up to 20% despite state-of-the-art treatment. Thus, prophylactic measures are of utmost importance to improve outcomes of patients with PH. Several high-quality studies have demonstrated that non-selective beta blockers (NSBBs) or endoscopic band ligation (EBL) are effective for primary prophylaxis of variceal bleeding. In secondary prophylaxis, a combination of NSBB + EBL should be routinely used. Once esophageal varices develop and variceal bleeding occurs, standardized treatment algorithms should be followed to minimize bleeding-associated mortality. Special attention should be paid to avoidance of overtransfusion, early initiation of vasoconstrictive therapy, prophylactic antibiotics and early endoscopic therapy. Pre-emptive transjugular intrahepatic portosystemic shunt should be used in all Child C10-C13 patients experiencing variceal bleeding, and potentially in Child B patients with active bleeding at endoscopy. The use of carvedilol, safety of NSBBs in advanced cirrhosis (i.e. with refractory ascites) and assessment of hepatic venous pressure gradient response to NSBB is discussed. In the present review, we give an overview on the rationale behind the latest guidelines and summarize key papers that have led to significant advances in the field.
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Affiliation(s)
- Nikolaus Pfisterer
- Medizinische Abteilung für Gastroenterologie und Hepatologie, Klinik Landstraße/Krankenanstalt Rudolfstiftung, Vienna 1030, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna 1090, Austria
| | - Lukas W Unger
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna 1090, Austria
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, University of Cambridge, Cambridge CB2 0AW, United Kingdom.
| | - Thomas Reiberger
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna 1090, Austria
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna 1090, Austria
- Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna 1090, Austria
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14
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Afaa TJ, Amegan-Aho KH, Richardson E, Goka B. Diagnosis and management of extrahepatic oesophageal variceal bleed in children in a low resourced setting. Ghana Med J 2021; 54:274-278. [PMID: 33883777 PMCID: PMC8042811 DOI: 10.4314/gmj.v54i4.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Extrahepatic portal vein obstruction (EHPVO) is a major cause of portal hypertension (PH) in children. Portal vein thrombosis (PVT) is the most common cause accounting for up to 75% of cases in developing countries. Upper gastrointestinal bleeding is the most dreaded and commonest presentation of portal hypertension. Successful treatment of paediatric PH, though challenging is performed in resource constraint countries.
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Affiliation(s)
- Taiba J Afaa
- Department of Child Health, University of Ghana Medical School, College of Health Sciences, University of Ghana, Accra.,Department of Child Health, Korle Bu Teaching Hospital, Accra
| | - Kokou H Amegan-Aho
- Department of Child Health, Korle Bu Teaching Hospital, Accra.,Department of Paediatrics and Child Health, School of Medicine, University of Health and Allied Sciences, Ho, Ghana
| | | | - Bamenla Goka
- Department of Child Health, University of Ghana Medical School, College of Health Sciences, University of Ghana, Accra.,Department of Child Health, Korle Bu Teaching Hospital, Accra
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15
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Yoon KT, Liu H, Lee SS. β-blockers in advanced cirrhosis: More friend than enemy. Clin Mol Hepatol 2021; 27:425-436. [PMID: 33317244 PMCID: PMC8273637 DOI: 10.3350/cmh.2020.0234] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/10/2020] [Accepted: 11/18/2020] [Indexed: 12/16/2022] Open
Abstract
Nonselective beta-adrenergic blocker (NSBB) therapy for the prevention of initial and recurrent gastrointestinal bleeding in cirrhotic patients with gastroesophageal varices has been used for the past four decades. NSBB therapy is considered the cornerstone of treatment for varices, and has become the standard of care. However, a 2010 study from the group that pioneered β-blocker therapy suggested a detrimental effect of NSBBs in decompensated cirrhosis, especially in patients with refractory ascites. Since then, numerous additional studies have incompletely resolved whether NSBBs are deleterious, although more recent evidence weighs against a harmful effect. The possibility of a "therapeutic window" has also been raised. We aimed to review the literature to analyze the pros and cons of using NSBBs in patients with cirrhosis, not only with respect to bleeding or mortality but also to other potential benefits and risks. β-blockers are highly effective in preventing first bleeding and recurrent bleeding. Furthermore, NSBBs improve congestion/ischemia of the gut mucosa, decrease intestinal permeability, and therefore indirectly alleviate systemic inflammation. β-blockers shorten the electrocardiographic prolonged QTc interval and may also decrease the incidence of hepatocellular carcinoma. On the other hand, the possibility of deleterious effects in cirrhosis has not been completely eliminated. NSBBs may be associated with an increased risk of portal vein thrombosis, although this could be correlational artifact. Overall, we conclude that β-blockers in cirrhosis are much more of a friend than enemy.
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Affiliation(s)
- Ki Tae Yoon
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Hongqun Liu
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Samuel S. Lee
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, Canada
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16
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Tsurugai Y, Takeda A, Eriguchi T, Sanuki N, Aoki Y. Hypofractionated radiotherapy for hepatocellular carcinomas adjacent to the gastrointestinal tract. Hepatol Res 2021; 51:294-302. [PMID: 33201542 DOI: 10.1111/hepr.13590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/21/2020] [Accepted: 11/09/2020] [Indexed: 12/16/2022]
Abstract
AIM Decisions regarding therapeutic plans for inoperable patients with hepatocellular carcinoma (HCC) adjacent to the gastrointestinal (GI) tract are challenging because radiofrequency ablation has the potential risk of thermal injury. Moreover, the response rate of transcatheter arterial chemoembolization is relatively low and stereotactic body radiotherapy (SBRT) is believed to be too toxic. We have applied hypofractionated radiotherapy (HFRT) for such lesions. This study investigated the outcomes and toxicities of this treatment. METHODS Among consecutive HCC patients treated with radiotherapy with curative intent at our institution between 2015 and 2019, we retrospectively extracted those outside of the indication for SBRT due to exceeding the constraint of the GI tract and who were treated using HFRT with a prescription dose of 42 Gy in 14 fractions and prophylactic proton pump inhibitor administration for 6 months. The oncological outcomes and toxicities were investigated. RESULTS A total of 66 patients with 73 lesions were eligible. The median follow-up period was 24.0 months. The local recurrence, intrahepatic recurrence, liver-related death, and overall survival rates at 2 years were 11.3%, 50.6%, 15.9%, and 60.4%, respectively. Six (9.1%) patients experienced Child-Pugh score deterioration ≥2 within 6 months following treatment. Two and one patient developed grades 2 and 3 gastroduodenal bleeding, respectively. CONCLUSIONS HFRT can achieve good local control in patients with HCC adjacent to the GI tract, with low GI toxicity incidence. Our study demonstrated that HFRT can be a potentially curative treatment option for lesions.
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Affiliation(s)
- Yuichiro Tsurugai
- Radiation Oncology Center, Ofuna Chuo Hospital, Kamakura, Kanagawa, Japan
| | - Atsuya Takeda
- Radiation Oncology Center, Ofuna Chuo Hospital, Kamakura, Kanagawa, Japan
| | - Takahisa Eriguchi
- Radiation Oncology Center, Ofuna Chuo Hospital, Kamakura, Kanagawa, Japan
| | - Naosko Sanuki
- Radiation Oncology Center, Ofuna Chuo Hospital, Kamakura, Kanagawa, Japan
| | - Yousuke Aoki
- Radiation Oncology Center, Ofuna Chuo Hospital, Kamakura, Kanagawa, Japan
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17
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Sun X, Zhang A, Zhou T, Wang M, Chen Y, Zhou T, Chen X, Xiu A, Peng Z, Cheng B, Liu X, Gao Y. Partial splenic embolization combined with endoscopic therapies and NSBB decreases the variceal rebleeding rate in cirrhosis patients with hypersplenism: a multicenter randomized controlled trial. Hepatol Int 2021; 15:741-752. [PMID: 33638769 PMCID: PMC8286949 DOI: 10.1007/s12072-021-10155-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/30/2021] [Indexed: 12/12/2022]
Abstract
Background Global research on endoscopic therapies in combination with partial splenic embolization (PSE) for variceal hemorrhage (VH) is limited. Therefore, we aimed to evaluate the efficacy and safety of endoscopy plus PSE (EP) treatment in comparison to endoscopic (E) treatment for the secondary prophylaxis of VH in cirrhosis patients with hypersplenism. Methods Cirrhosis patients with hypersplenism (platelet count < 100, 000/µL) and those who had recovered from an episode of VH were enrolled in a multicenter randomized controlled trial. The participants were randomly assigned into EP and E groups in a 1:1 ratio. The primary endpoint was variceal rebleeding, and the secondary endpoints were severe variceal recurrence and mortality during the 2-year follow-up. Hematological indices, serum biochemical parameters, and the Child–Pugh score were measured at each time point. Results From June 2016 to December 2019, 108 patients were enrolled in the study, among which 102 patients completed the protocol (51 in EP and 51 in E group). The rebleeding rate of the varices was significantly reduced in the EP group compared to that in the E group during the 2 years (16% vs. 31%, p < 0.001). The EP group showed a significantly lower variceal recurrence rate than the E group (22% vs. 67%, p < 0.001). The COX proportional hazard models revealed that grouping was an independent predictor for variceal rebleeding (H = 0.122, 95% CI 0.055–0.270, p < 0.001) and variceal recurrence (hazard ratio, H = 0.160, 95% CI 0.077–0.332, p < 0.001). The peripheral blood cell count, Child–Pugh class/score, albumin concentration, and coagulation function in the EP group improved significantly compared to the values observed in the E group at any time point (p < 0.05). Conclusions The EP treatment was more effective in preventing variceal rebleeding and variceal recurrence than the conventional E treatment during the secondary prophylaxis of VH in cirrhosis patients with hypersplenism. Furthermore, the EP treatment could significantly increase the peripheral blood cell count and albumin concentration and also improved the coagulation function and the Child–Pugh score. Clinical trials registration Trial registration number ClincialTrials.gov: NCT02778425. The URL of the clinical trial: https://clinicaltrials.gov/ Supplementary Information The online version contains supplementary material available at 10.1007/s12072-021-10155-0.
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Affiliation(s)
- Xin Sun
- Department of Gastroenterology, Qilu Hospital of Shandong University, Wenhua Xi Road, 107, Jinan City, 250012, Shandong Province, People's Republic of China
| | - Anzhong Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan City, 250021, Shandong Province, China
| | - Tao Zhou
- Department of Gastroenterology, Qilu Hospital of Shandong University, Wenhua Xi Road, 107, Jinan City, 250012, Shandong Province, People's Republic of China
| | - Minghui Wang
- Department of Gastroenterology, The 960th Hospital of the PLA Joint Logistics Support Force, Shifan Road, 25, Jinan City, 250031, Shandong Province, People's Republic of China
| | - Yong Chen
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan City, 250021, Shandong Province, China
| | - Ting Zhou
- Department of Gastroenterology, Qilu Hospital of Shandong University, Wenhua Xi Road, 107, Jinan City, 250012, Shandong Province, People's Republic of China
| | - Xiaoning Chen
- Department of Gastroenterology, Qilu Hospital of Shandong University, Wenhua Xi Road, 107, Jinan City, 250012, Shandong Province, People's Republic of China
| | - Aiyuan Xiu
- Department of Gastroenterology, Qilu Hospital of Shandong University, Wenhua Xi Road, 107, Jinan City, 250012, Shandong Province, People's Republic of China
| | - Zhi Peng
- Department of Gastroenterology, Qilu Hospital of Shandong University, Wenhua Xi Road, 107, Jinan City, 250012, Shandong Province, People's Republic of China
| | - Baoquan Cheng
- Department of Gastroenterology, Qilu Hospital of Shandong University, Wenhua Xi Road, 107, Jinan City, 250012, Shandong Province, People's Republic of China
| | - Xiaofeng Liu
- Department of Gastroenterology, The 960th Hospital of the PLA Joint Logistics Support Force, Shifan Road, 25, Jinan City, 250031, Shandong Province, People's Republic of China.
| | - Yanjing Gao
- Department of Gastroenterology, Qilu Hospital of Shandong University, Wenhua Xi Road, 107, Jinan City, 250012, Shandong Province, People's Republic of China.
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19
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Selective Esophagogastric Devascularization in the Modified Sugiura Procedure for Patients with Cirrhotic Hemorrhagic Portal Hypertension: A Randomized Controlled Trial. Can J Gastroenterol Hepatol 2020; 2020:8839098. [PMID: 33354559 PMCID: PMC7735826 DOI: 10.1155/2020/8839098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 10/26/2020] [Accepted: 11/24/2020] [Indexed: 12/20/2022] Open
Abstract
AIM Portal hypertension is a series of syndrome commonly seen with advanced cirrhosis, which seriously affects patient's quality of life and survival. This study was designed to access the efficacy and safety of selective esophagogastric devascularization in the modified Sugiura procedure for patients with cirrhotic hemorrhagic portal hypertension. METHODS Sixty patients with hepatitis B cirrhotic hemorrhagic portal hypertension and meeting the inclusion criteria were selected and randomly divided by using computer into the selective modified Sugiura group (sMSP group, n = 30) and the modified Sugiura group (MSP group, n = 30). The primary endpoint measurement is the postoperative rebleeding rate. Secondary endpoint measurements included free portal venous pressure, liver Child-Pugh score, liver volume, portal vein width and blood flow velocity, survival rate, quality of life, and dysphagia as well as other complications one year postoperatively. This trial is registered with ChiCTR, number ChiCTR2000033468. RESULTS There was no statistically significant difference in rebleeding rates within one year after surgery between patients in the sMSP and MSP groups (χ = 0.11, p=0.73). In comparison with the MSP group, the Child-Pugh score of liver function in the sMSP group significantly increased (χ = 6.4, p=0.04) and the incidence of dysphagia was significantly reduced (χ = 6.23, p=0.01) one year after surgery. There was a statistically significant difference in the quality of life between the two groups. However, there were no statistically significant differences in free portal venous pressure (MD = -3.44, 95% CI: -7.87 to 0.98, p=0.12), postoperative liver volume (3 months: MD = -258.81, 95% CI: -723.21 to 205.57, p=0.24; 1 year: MD = -320.12, 95% CI: -438.43 to 102.78, p=0.16), postoperative portal vein width (3 months: MD = -0.06, p=0.50; 1 year: MD = 0.17, p=0.21), portal vein flow velocity (3 months: MD = 1.64, p=0.21; 1 year: MD = -1.19, p=0.57), 1-year survival rate (χ = 1.01, p=0.31), and other complications between the two groups. CONCLUSIONS Selective esophagogastric devascularization in the modified Sugiura procedure may not lower the incidence of rebleeding in the short term based on our findings. However, it may significantly improve quality of life of patients with cirrhotic hemorrhagic portal hypertension, improve liver function, and reduce postoperative dysphagia.
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20
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Guirola JA, Gil S, Zurera L, Echenegusia M, Blázquez J, Guerrero J, Urbano J, de Gregorio MÁ. Transjugular intrahepatic portosystemic shunt (TIPS) in Spain. Clinical-epidemiological considerations in relation to a multicenter registry. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 113:23-27. [PMID: 33226255 DOI: 10.17235/reed.2020.6783/2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE this study aimed to determine the epidemiological, technical and clinical data of transjugular intrahepatic portosystemic shunt (TIPS) performed by Interventional Radiology departments in Spain. Furthermore, the total number of TIPS carried out in Spain was determined and compared with other countries. MATERIAL AND METHODS a retrospective study was performed with the approval of the Ethical Committee of the Spanish Society of Interventional Radiology (SERVEI). A survey was performed with 31 items (demographic, technical and clinical data) for data acquisition on the current status of TIPS in Spain. The survey was sent to the 49 hospitals that SERVEI included in a previous registry with data of TIPS performed in Spain in 2016. RESULTS of the 49 centers surveyed, 33 (67.35 %) replied to the survey. These centers had completed 265 of the 415 TIPS that year in Spain. The most frequent indication was upper GI bleeding from gastroesophageal varices, which accounted for 144 (54.33 %); 62.26 % of the TIPS were performed urgently and 37.7 % on a scheduled basis. The technical success was 89.16 ± 20.9 %, with a rebleeding rate of 17.9 %. Sixty-nine patients (26.03 %) presented complications, 19.62 % of them minor and 6.41 % major. The 30-day mortality related to the disease was 14.33 %, while mortality at one year was 18.49 %. CONCLUSION notably in our study, the complications of TIPS did not show a clear relationship with the number of procedures performed. With regard to other countries like the United States and France, the number of TIPS in Spain per million inhabitants is currently substantially lower. There were no significant changes compared to the number completed in 2013.
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Affiliation(s)
- José A Guirola
- Radiologia Intervencionista, Hospital Clínico Universitario Lozano Blesa, España
| | - Santiago Gil
- Radiología Intervencionista, Hospital General Universitario Alicante, España
| | - Luis Zurera
- Radiología Intervencionista, Hospital Universitario Reina Sofía, España
| | - Mikel Echenegusia
- Radiología Intervencionista, Hospital Universitario 12 Octubre, España
| | - Javier Blázquez
- Radiología Intervencionista, Hospital Universitario Ramón y Cajal, España
| | - Javier Guerrero
- Radiología Intervencionista, Hospital Clínico Universitario Lozano Blesa, España
| | - José Urbano
- Radiología Intervencionista, Hospital Vithas Pardo de Aravaca, España
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Trebicka J, Gu W, Ibáñez-Samaniego L, Hernández-Gea V, Pitarch C, Garcia E, Procopet B, Giráldez Á, Amitrano L, Villanueva C, Thabut D, Silva-Junior G, Martinez J, Genescà J, Bureau C, Llop E, Laleman W, Palazon JM, Castellote J, Rodrigues S, Gluud L, Ferreira CN, Barcelo R, Cañete N, Rodríguez M, Ferlitsch A, Mundi JL, Gronbaek H, Hernández-Guerra M, Sassatelli R, Dell'Era A, Senzolo M, Abraldes JG, Romero-Gómez M, Zipprich A, Casas M, Masnou H, Primignani M, Weiss E, Catalina MV, Erasmus HP, Uschner FE, Schulz M, Brol MJ, Praktiknjo M, Chang J, Krag A, Nevens F, Calleja JL, Robic MA, Conejo I, Albillos A, Rudler M, Alvarado E, Guardascione MA, Tantau M, Bosch J, Torres F, Pavesi M, Garcia-Pagán JC, Jansen C, Bañares R. Rebleeding and mortality risk are increased by ACLF but reduced by pre-emptive TIPS. J Hepatol 2020; 73:1082-1091. [PMID: 32339602 DOI: 10.1016/j.jhep.2020.04.024] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/07/2020] [Accepted: 04/09/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS The relationship between acute-on-chronic liver failure (ACLF) and acute variceal bleeding (AVB) is poorly understood. Specifically, the prevalence and prognosis of ACLF in the context of AVB is unclear, while the role of transjugular intrahepatic portosystemic shunt (TIPS) in the management in patients with ACLF has not been described to date. METHODS A multicenter, international, observational study was conducted in 2,138 patients from 34 centers between 2011 and 2015. ACLF was defined and graded according to the EASL-CLIF consortium definition. Placement of pre-emptive TIPS (pTIPS) was based on individual center policy. Patients were followed-up for 1 year, until death or liver transplantation. Cox regression and competing risk models (Gray's test) were used to identify independent predictors of rebleeding or mortality. RESULTS At admission, 380/2,138 (17.8%) patients had ACLF according to EASL-CLIF criteria (grade 1: 38.7%; grade 2: 39.2%; grade 3: 22.1%). The 42-day rebleeding (19% vs. 10%; p <0.001) and mortality (47% vs. 10%; p <0.001) rates were higher in patients with ACLF and increased with ACLF grades. Of note, the presence of ACLF was independently associated with rebleeding and mortality. pTIPS placement improved survival in patients with ACLF at 42 days and 1 year. This effect was also observed in propensity score matching analysis of 66 patients with ACLF, of whom 44 received pTIPs and 22 did not. CONCLUSIONS This large multicenter international real-life study identified ACLF at admission as an independent predictor of rebleeding and mortality in patients with AVB. Moreover, pTIPS was associated with improved survival in patients with ACLF and AVB. LAY SUMMARY Acute variceal bleeding is a deadly complication of liver cirrhosis that results from severe portal hypertension. This study demonstrates that the presence of acute-on-chronic liver failure (ACLF) is the strongest predictor of mortality in patients with acute variceal bleeding. Importantly, patients with ACLF and acute variceal (re)bleeding benefit from pre-emptive (early) placement of a transjugular intrahepatic portosystemic shunt.
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Affiliation(s)
- Jonel Trebicka
- Department of Internal Medicine I, University of Frankfurt, Frankfurt, Germany; Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; European Foundation for the Study of Chronic Liver Failure - EF CLIF, Barcelona, Spain; Institute for Bioengineering of Catalonia, Barcelona, Spain.
| | - Wenyi Gu
- Department of Internal Medicine I, University of Frankfurt, Frankfurt, Germany; European Foundation for the Study of Chronic Liver Failure - EF CLIF, Barcelona, Spain; Department of Gastroenterology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Luis Ibáñez-Samaniego
- Servicio de Medicina de Aparato Digestivo, Hospital General Universitario Gregorio Marañón, liSGM, CIBERehd, Madrid, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi I i Sunyer, IMDIM, University of Barcelona, Barcelona, Spain, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver); Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain
| | - Carla Pitarch
- European Foundation for the Study of Chronic Liver Failure - EF CLIF, Barcelona, Spain
| | - Elisabet Garcia
- European Foundation for the Study of Chronic Liver Failure - EF CLIF, Barcelona, Spain
| | - Bogdan Procopet
- Regional Institute of Gastroenterology and Hepatology "Octavian Fodor", Hepatology Department and "Iuliu Hatieganu" University of Medicine and Pharmacy, 3rd Medical Clinic, Cluj-Napoca, Romania
| | - Álvaro Giráldez
- Clinical Management Unit of Digestive Diseases, University Hospital Virgen del Rocío, Seville, Spain
| | - Lucio Amitrano
- Gastroenterology Unit, Ospedale A Cardarelli, Naples, Italy
| | - Candid Villanueva
- Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain; Servei de Patologia Digestiva, Hospital de la Santa Creu i Sant Pau and CIBERehd, Barcelona, Spain
| | - Dominique Thabut
- Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Paris Sorbonne Université, Paris, France
| | - Gilberto Silva-Junior
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi I i Sunyer, IMDIM, University of Barcelona, Barcelona, Spain, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Javier Martinez
- Department of Gastroenterology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Alcalá, CIBERehd, Madrid, Spain
| | - Joan Genescà
- Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain; Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona and CIBERehd, Barcelona, Spain
| | - Cristophe Bureau
- Department of Hepatology, Rangueil Hospital, CHU Toulouse, University Paul Sabatier of Toulouse, France
| | - Elba Llop
- Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain; Liver Unit, Hospital U, Puerta de Hierro, Universidad Autònoma de Madrid, CIBERehd, Madrid, Spain
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospital KU Leuven, Leuven, Belgium
| | | | - Jose Castellote
- Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, Barcelona, Spain
| | - Susanag Rodrigues
- Gastroenterology and Hepatology Department, Centro Hospitalar São João, Porto, Portugal
| | - Liselotte Gluud
- Gastrounit, Medical Division, University Hospital of Hvidovre, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Carlos Noronha Ferreira
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Rafael Barcelo
- Medical Statistics Core Facility, Institut D'Investigacions Biomédiques August Pi i Sunyer, Hospital Clinic Barcelona, Barcelona, Spain
| | - Nuria Cañete
- Liver Section, Gastroenterology Department, Hospital del Mar, Universitat Autònoma de Barcelona, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Manuel Rodríguez
- Department of Gastroenterology, Hospital Central de Asturias, Oviedo, Spain
| | - Arnulf Ferlitsch
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Jose Luis Mundi
- Department of Gastroenterology, University Hospital San Cecilio, Granada, Spain
| | - Henning Gronbaek
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Manuel Hernández-Guerra
- Gastroenterology Department, University Hospital of the Canary Islands, La Laguna, Tenerife, Spain
| | - Romano Sassatelli
- Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Alessandra Dell'Era
- Gastroenterology Unit, ASST Fatebenefratelli Sacco, Department of Clinical and Biomedical Sciences, University of the Studies of Milan, Milan, Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Juan G Abraldes
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), CEGIIR, University of Alberta, Edmonton, Canada
| | - Manuel Romero-Gómez
- Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain; Unidad de Hepatología, Hospital Universitario de Valme, CIBERehd, Sevilla, Spain
| | - Alexander Zipprich
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Meritxell Casas
- Hepatology Unit, Digestive Disease Department Hospital de Sabadell, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Helena Masnou
- Hospital Universitari Germans Trias i Pujol, Universitat Autònoma Barcelona, Badalona, Spain
| | - Massimo Primignani
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, CRC "A.M.and A.Miglaivacca" Center for Liver Disease, Milan, Italy
| | - Emmanuel Weiss
- European Foundation for the Study of Chronic Liver Failure - EF CLIF, Barcelona, Spain
| | - Maria-Vega Catalina
- Servicio de Medicina de Aparato Digestivo, Hospital General Universitario Gregorio Marañón, liSGM, CIBERehd, Madrid, Spain
| | - Hans-Peter Erasmus
- Department of Internal Medicine I, University of Frankfurt, Frankfurt, Germany
| | | | - Martin Schulz
- Department of Internal Medicine I, University of Frankfurt, Frankfurt, Germany
| | - Maximilian J Brol
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | | | - Johannes Chang
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Frederik Nevens
- Department of Gastroenterology and Hepatology, University Hospital KU Leuven, Leuven, Belgium
| | - Jose Luis Calleja
- Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain; Liver Unit, Hospital U, Puerta de Hierro, Universidad Autònoma de Madrid, CIBERehd, Madrid, Spain
| | - Marie Angèle Robic
- Department of Hepatology, Rangueil Hospital, CHU Toulouse, University Paul Sabatier of Toulouse, France
| | - Irene Conejo
- Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain; Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona and CIBERehd, Barcelona, Spain
| | - Agustin Albillos
- Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain; Department of Gastroenterology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Alcalá, CIBERehd, Madrid, Spain
| | - Marika Rudler
- Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Paris Sorbonne Université, Paris, France
| | - Edilmar Alvarado
- Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain; Servei de Patologia Digestiva, Hospital de la Santa Creu i Sant Pau and CIBERehd, Barcelona, Spain
| | | | - Marcel Tantau
- Regional Institute of Gastroenterology and Hepatology "Octavian Fodor", Hepatology Department and "Iuliu Hatieganu" University of Medicine and Pharmacy, 3rd Medical Clinic, Cluj-Napoca, Romania
| | - Jaime Bosch
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi I i Sunyer, IMDIM, University of Barcelona, Barcelona, Spain, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver); Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain; Swiss Liver Centre, Inselspital, Bern University, Bern, Switzerland
| | - Ferran Torres
- Medical Statistics Core Facility, Institut D'Investigacions Biomédiques August Pi i Sunyer, Hospital Clinic Barcelona, Barcelona, Spain; Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marco Pavesi
- European Foundation for the Study of Chronic Liver Failure - EF CLIF, Barcelona, Spain
| | - Juan Carlos Garcia-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi I i Sunyer, IMDIM, University of Barcelona, Barcelona, Spain, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver); Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain
| | - Christian Jansen
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Rafael Bañares
- Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain; Gregorio Marañón University General Hospital, Gregorio Marañón Sanitary Research Institute, Faculty of Medicine, Complutense University of Madrid, Spain
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Vidal-González J, Quiroga S, Simón-Talero M, Genescà J. Spontaneous portosystemic shunts in liver cirrhosis: new approaches to an old problem. Therap Adv Gastroenterol 2020; 13:1756284820961287. [PMID: 33062057 PMCID: PMC7533929 DOI: 10.1177/1756284820961287] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/02/2020] [Indexed: 02/04/2023] Open
Abstract
Portal hypertension is the main consequence of liver cirrhosis, leading to severe complications such as variceal hemorrhage, ascites or hepatic encephalopathy. As an attempt to decompress the portal venous system, portal flow is derived into the systemic venous system through spontaneous portosystemic shunts (SPSSs), bypassing the liver. In this review, we aim to provide an overview of the published reports in relation to the prevalence and physiopathology behind the appearance of SPSS in liver cirrhosis, as well as the complications derived from its formation and its management. The role of SPSS embolization is specifically discussed, as SPSSs have been assessed as a therapeutic target, mainly for patients with recurrent/persistent hepatic encephalopathy and preserved liver function. Furthermore, different aspects of the role of SPSS in liver transplantation, as well as in candidates for transjugular intrahepatic portosystemic shunt are reviewed. In these settings, SPSS occlusion has been proposed to minimize possible deleterious effects, but results are so far inconclusive.
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Affiliation(s)
- Judit Vidal-González
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sergi Quiroga
- Radiology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | | | - Joan Genescà
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
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23
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Effects of Adjuvant Chinese Patent Medicine Therapy on Prevention of Variceal Rebleeding: A Retrospective Cohort Study. Chin J Integr Med 2020; 27:589-596. [PMID: 32876859 DOI: 10.1007/s11655-020-3272-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess whether adjuvant Chinese patent medicines (CPMs) to standard treatment could reduce recurrent bleeding after variceal bleeding in cirrhotic patients. METHODS This study retrospectively collected 555 consecutive patients who recovered from variceal bleeding. A population-based cohort study was established depending on if adjuvant CPMs were administered to prevent rebleeding. A total of 139 patients who had taken ⩾28 cumulative defined daily doses (cDDDs) of CPMs were included in the CPMs cohort, and 416 patients who used <28 cDDDs of CPMs were enrolled in the non-CPMs cohort. On evaluation of rebleeding incidence, 1:2 propensity score matched was used to estimate for reducing bias. Patients were followed for at least 12 months. The end-point of this study was clinically significant esophagogastric variceal rebleeding. RESULTS Following multivariate analysis, CPMs therapy was an independent factor for variceal rebleeding [adjusted hazard ratio (AHR)=0.657; 95% confidence interval=0.497-0.868; P=0.003]. After the 1:2 propensity score matching, a significant reduction (23.5%) in the incidence of variceal rebleeding in patients was observed, from 58.3% in the non-CPMs cohort to 44.6% in the CPMs cohort (modified log-rank test, P=0.002) within a year. The AHRs for rebleeding were 0.928, 0.553, and 0.105, for 28-90 cDDDs, 91-180 cDDDs, and >180 cDDDs of CPMs, respectively. The median rebleeding interval in the CPMs cohort was significantly larger compared with the non-CPMs cohort (113.5 vs. 93.0 days; P=0.008). CONCLUSION Adjuvant CPMs to standard therapy can significantly reduce the incidence of variceal rebleeding and delay the time to rebleeding.
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24
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Garcovich M, Di Stasio E, Zocco MA, Riccardi L, Ainora ME, Annicchiarico BE, Gibiino G, Santopaolo F, Gasbarrini A, Pompili M. Assessing Baveno VI criteria with liver stiffness measured using a new point-shear wave elastography technique (BAVElastPQ study). Liver Int 2020; 40:1952-1960. [PMID: 32510772 DOI: 10.1111/liv.14558] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 05/21/2020] [Accepted: 05/31/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS To date, no study has explored the potential role of ElastPQ, a novel point-SWE technique, in the assessment of clinically significant portal hypertension. The aim of our study was to determine a liver stiffness (LS) cut-off value measured by ElastPQ and laboratory parameters that could help to identify those patients who can safely avoid screening endoscopy. METHODS Data were collected on 1422 patients who underwent ElastPQ measurement from January 2013 to January 2016 in our Department. Inclusion criteria were a LS value of ≥7 kPa, an upper gastrointestinal endoscopy within 12 months and a diagnosis of compensated chronic liver disease. Exclusion criteria were history of decompensated liver disease, evidence of porto-spleno-mesenteric vein thrombosis and non-cirrhotic portal hypertension. Varices were graded as low-risk varices (grade <2) or varices needing treatment (VNT, grade ≥2). RESULTS The study included 195 patients (120 [61%] HCV, 171 [88%] Child-Pugh A). Varices were present in 35% cases, with 10% prevalence of VNT. According to ROC curve analysis, LS measurement and platelet count were evaluated as predictors of VNT. Overall, 75/195 (38%) met the 'BAVElastPQ' criteria (that is, LS < 12 kPa and platelet count >150 000/μL). Within this group, 11/75 (15%) had any grade of varices and only 1/75 (1%) had VNT. The BAVElastPQ criteria gave sensitivity of 0.95, specificity of 0.42, positive predictive value of 0.15 and negative predictive value of 0.99. CONCLUSIONS The BAVElastPQ criteria correctly identified 99% of patients without VNT. By applying such criteria, we could have potentially avoided 38% of surveillance endoscopies in our cohort.
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Affiliation(s)
- Matteo Garcovich
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Enrico Di Stasio
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Institute of Biochemistry and Clinical Biochemistry, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria A Zocco
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Laura Riccardi
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria E Ainora
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Brigida E Annicchiarico
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giulia Gibiino
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Santopaolo
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maurizio Pompili
- Department of Internal Medicine, Gastroenterology and Liver Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Wang Z, Xie YW, Lu Q, Yan HL, Liu XB, Long Y, Zhang X, Yang JL. The impact of albumin infusion on the risk of rebleeding and in-hospital mortality in cirrhotic patients admitted for acute gastrointestinal bleeding: a retrospective study of a single institute. BMC Gastroenterol 2020; 20:198. [PMID: 32576140 PMCID: PMC7310478 DOI: 10.1186/s12876-020-01337-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 06/08/2020] [Indexed: 02/08/2023] Open
Abstract
Background To investigate the effect of albumin infusion on cirrhotic patients admitted for acute gastrointestinal bleeding. Methods Medical records of cirrhotic patients who admitted due to acute gastrointestinal bleeding through January 2009 to December 2018 were reviewed. Clinical data and the total amount of albumin and red blood cell used during hospitalization were recorded. For patients with rebleeding, the amount of albumin and red blood cell used before rebleeding was also documented. The primary outcome was the occurrence of rebleeding, and the second outcome was in-hospital mortality. Univariate and multivariate logistic analysis was performed to identify risk factors associated with rebleeding and in-hospital mortality. Results A total of 1503 cirrhotic patients were included in the analysis. There were 146 episodes of in-patient rebleeding occurred, while 81 patients died. Overall, more red blood cells and albumin were prescribed to patients who suffered rebleeding. In terms of the amount before rebleeding, the red blood cell was higher in patients with rebleeding, but the albumin infusion was similar. In the multivariate model, the albumin infusion before rebleeding was an independent risk factor associated with rebleeding (adjusted OR for ≤40 g vs 0 g, 0.469 [0.269–0.793], p = 0.006; adjusted OR for > 40 g vs 0 g, 0.272 [0.115–0.576], p = 0.001). In Child-Pugh C class patients, the use of albumin more than 40 g during hospitalization associated with a lower risk of in-patient mortality (adjusted OR for > 40 g vs 0 g, 0.136 [0.019–0.741], p = 0.031). Conclusions Albumin infusion was associated with a lower risk of rebleeding and in-hospital deaths in cirrhosis admitted for acute gastrointestinal bleeding.
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Affiliation(s)
- Zhu Wang
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, 37# Guoxue Lane, Chengdu, 610041, Sichuan, China
| | - Ya-Wen Xie
- West China School of Medicine of Sichuan University, Chengdu, China
| | - Qing Lu
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, 37# Guoxue Lane, Chengdu, 610041, Sichuan, China
| | - Hai-Lin Yan
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, 37# Guoxue Lane, Chengdu, 610041, Sichuan, China
| | - Xin-Bin Liu
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, 37# Guoxue Lane, Chengdu, 610041, Sichuan, China
| | - Yi Long
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, 37# Guoxue Lane, Chengdu, 610041, Sichuan, China
| | - Xian Zhang
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, 37# Guoxue Lane, Chengdu, 610041, Sichuan, China
| | - Jin-Lin Yang
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, 37# Guoxue Lane, Chengdu, 610041, Sichuan, China.
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26
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Kong Y, Shi L. Comparison of the effectiveness of 11 mainstay treatments for secondary prophylaxis of variceal bleeding in patients with cirrhosis: A network meta-analysis. Exp Ther Med 2020; 19:3479-3496. [PMID: 32346409 PMCID: PMC7185170 DOI: 10.3892/etm.2020.8633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 12/05/2019] [Indexed: 01/30/2023] Open
Abstract
The purpose of the present study was to compare the effectiveness of the transjugular intrahepatic portosystemic shunt (TIPS), endoscopic options, medications and mainstay combination therapies for patients with cirrhosis who have had at least one episode of variceal haemorrhage. The PubMed, Embase, Cochrane Library and Web of Science databases, as well as the reference lists of relevant articles, were searched to identify eligible studies. P-scores, that were based solely on the point estimates and standard errors of the network estimates, were performed to rank all treatments, on a scale from 0 (worst) to 1 (best). The odds ratio (OR) was determined to assess effects on mortality, treatment failure and bleeding from gastroesophageal ulcers. A total of 43 randomized controlled trials comprising 3,787 adult patients were included. In total, 26 (61%) trials adopted concealed randomization, while most studies did not specify blinding. The drug combination of nadolol and isosorbide mononitrate (ISMN) ranked first for lowering risks of overall mortality (P-score=0.8162), mortality due to liver failure (P-score=0.7536) and bleeding from gastroesophageal ulcers (P-score=0.7536). This combination was determined to be superior to endoscopic sclerotherapy (ES) alone (OR=0.63, 95% CI: 0.42-0.94) and TIPS alone in reducing overall mortality (OR=0.62, 95% CI: 0.40-0.96). ES was more likely to increase treatment failure compared with TIPS, endoscopic variceal ligation (EVL), ES plus EVL, EVL plus nadolol/propranolol plus ISMN and nadolol/propranolol plus ISMN. In conclusion, the present network meta-analysis suggested that for a decreased mortality due to variceal rebleeding in patients with cirrhosis, nadolol plus ISMN may be a preferable choice, while ES is associated with a higher risk of unfavourable treatment outcomes. Further well-controlled studies are required to further elucidate the appropriate treatment options.
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Affiliation(s)
- Yu Kong
- Second Department of Gastroenterology, Cangzhou Central Hospital, Cangzhou, Hebei 061001, P.R. China
| | - Liang Shi
- Endoscopy Division, Department of General Surgery, Cangzhou Central Hospital, Cangzhou, Hebei 061001, P.R. China
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Chen WC, Hsin IF, Chen PH, Hsu PI, Wang YP, Cheng JS, Lin HS, Hou MC, Lee FY. Addition of Carvedilol to Gastric Variceal Obturation Does Not Decrease Recurrence of Gastric Variceal Bleeding in Patients With Cirrhosis. Clin Gastroenterol Hepatol 2019; 17:2356-2363.e2. [PMID: 30772583 DOI: 10.1016/j.cgh.2019.02.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/24/2019] [Accepted: 02/03/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Gastric variceal bleeding (GVB) frequently recurs after hemostasis by gastric variceal obturation (GVO). We performed a multicenter, randomized controlled trial to determine the efficacy of carvedilol plus GVO in secondary prophylaxis of GVB. METHODS We performed a prospective study of 121 patients with cirrhosis (ages 20-80 years) with GVB proven by endoscopy within 24 hours of bleeding and stable hemodynamics for at least 3 days after initial GVO. Patients were randomly assigned into a group that underwent repeated GVO (n = 61) or a group received repeated GVO plus carvedilol (n = 60). Recurrent GVB, upper gastrointestinal bleeding (UGIB), adverse events, and survival were compared between the groups. RESULTS GVB recurred in 21 patients (34%) in the group that received repeated GVO and 14 patients (23%) in the group that received repeated GVO plus carvedilol (P = .18). Ascites (relative risk [RR], 2.69; 95% CI, 1.33-5.48; P = .006) and hepatoma (RR, 2.10; 95% CI, 1.03-4.28; P = .04) were associated with recurrent GVB. Twenty-nine patients (48%) in the group that received repeated GVO and 17 patients (28%) in the group that received repeated GVO plus carvedilol had recurrent UGIB (P = .03). Carvedilol (RR, 0.44; 95% CI, 0.24-0.80; P = .007) was associated with reduced risk of UGIB recurrence. Ascites (RR, 3.02; 95% CI, 1.59-5.73; P = .001) and hepatoma (RR, 2.07; 95% CI, 1.10-3.88; P = .02) were associated with recurrent UGIB. A higher proportion of patients in the group that received repeated GVO plus carvedilol (53%) had adverse events than the group that received repeated GVO (15%) (P < .001). Mean survival times were 21 ± 18 months in the group that received repeated GVO vs 25 ± 20 months in the group that received repeated GVO plus carvedilol (P = .30). CONCLUSION In a randomized controlled trial, we found that addition of carvedilol to GVO did not decrease recurrence of GVB in patients with cirrhosis but was associated with decreased recurrence of UGIB. However, carvedilol plus GVO produced significantly more adverse events. Mean survival times did not differ significantly between groups. ClinicalTrials.gov no: NCT02504723.
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Affiliation(s)
- Wen-Chi Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - I-Fang Hsin
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ping-Hsien Chen
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ping-I Hsu
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yen-Po Wang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jin-Shiung Cheng
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Huey-Shyan Lin
- Department of Health-Business Administration, Fooying University, Kaohsiung, Taiwan
| | - Ming-Chih Hou
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
| | - Fa-Yauh Lee
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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Vadera S, Yong CWK, Gluud LL, Morgan MY. Band ligation versus no intervention for primary prevention of upper gastrointestinal bleeding in adults with cirrhosis and oesophageal varices. Cochrane Database Syst Rev 2019; 6:CD012673. [PMID: 31220333 PMCID: PMC6586251 DOI: 10.1002/14651858.cd012673.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The presence of oesophageal varices is associated with the risk of upper gastrointestinal bleeding. Endoscopic variceal ligation is used to prevent this occurrence but the ligation procedure may be associated with complications. OBJECTIVES To assess the beneficial and harmful effects of band ligation versus no intervention for primary prevention of upper gastrointestinal bleeding in adults with cirrhosis and oesophageal varices. SEARCH METHODS We combined searches in the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, and Science Citation Index with manual searches. The last search update was 9 February 2019. SELECTION CRITERIA We included randomised clinical trials comparing band ligation verus no intervention regardless of publication status, blinding, or language in the analyses of benefits and harms, and observational studies in the assessment of harms. Included participants had cirrhosis and oesophageal varices with no previous history of variceal bleeding. DATA COLLECTION AND ANALYSIS Three review authors extracted data independently. The primary outcome measures were all-cause mortality, upper gastrointestinal bleeding, and serious adverse events. We undertook meta-analyses and presented results using risk ratios (RRs) with 95% confidence intervals (CIs) and I2 values as a marker of heterogeneity. In addition, we calculated the number needed to treat to benefit (NNTTB) for the primary outcomes . We assessed bias control using the Cochrane Hepato-Biliary domains; determined the certainty of the evidence using GRADE; and conducted sensitivity analyses including Trial Sequential Analysis. MAIN RESULTS Six randomised clinical trials involving 637 participants fulfilled our inclusion criteria. One of the trials included an additional small number of participants (< 10% of the total) with non-cirrhotic portal hypertension/portal vein block. We classified one trial as at low risk of bias for the outcome, mortality and high risk of bias for the remaining outcomes; the five remaining trials were at high risk of bias for all outcomes. We downgraded the evidence to moderate certainty due to the bias risk. We gathered data on all primary outcomes from all trials. Seventy-one of 320 participants allocated to band ligation compared to 129 of 317 participants allocated to no intervention died (RR 0.55, 95% CI 0.43 to 0.70; I2 = 0%; NNTTB = 6 persons). In addition, band ligation was associated with reduced risks of upper gastrointestinal bleeding (RR 0.44, 95% CI 0.28 to 0.72; 6 trials, 637 participants; I2 = 61%; NNTTB = 5 persons), serious adverse events (RR 0.55, 95% CI 0.43 to 0.70; 6 trials, 637 participants; I2 = 44%; NNTTB = 4 persons), and variceal bleeding (RR 0.43, 95% CI 0.27 to 0.69; 6 trials, 637 participants; I² = 56%; NNTTB = 5 persons). The non-serious adverse events reported in association with band ligation included oesophageal ulceration, dysphagia, odynophagia, retrosternal and throat pain, heartburn, and fever, and in the one trial involving participants with either small or large varices, the incidence of non-serious side effects in the banding group was much higher in those with small varices, namely ulcers: small versus large varices 30.5% versus 8.7%; heartburn 39.2% versus 17.4%. No trials reported on health-related quality of life.Two trials did not receive support from pharmaceutical companies; the remaining four trials did not provide information on this issue. AUTHORS' CONCLUSIONS This review found moderate-certainty evidence that, in patients with cirrhosis, band ligation of oesophageal varices reduces mortality, upper gastrointestinal bleeding, variceal bleeding, and serious adverse events compared to no intervention. It is unlikely that further trials of band ligation versus no intervention would be considered ethical.
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Affiliation(s)
- Sonam Vadera
- Division of Medicine, Royal Free Campus, University College LondonUCL Institute for Liver & Digestive HealthRowland Hill StreetHampsteadLondonUKNW3 2PF
| | - Charles Wei Kit Yong
- Division of Medicine, Royal Free Campus, University College LondonUCL Institute for Liver & Digestive HealthRowland Hill StreetHampsteadLondonUKNW3 2PF
| | - Lise Lotte Gluud
- Copenhagen University Hospital HvidovreGastrounit, Medical DivisionKettegaards Alle 30HvidovreDenmark2650
| | - Marsha Y Morgan
- Division of Medicine, Royal Free Campus, University College LondonUCL Institute for Liver & Digestive HealthRowland Hill StreetHampsteadLondonUKNW3 2PF
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Nevens F, Bittencourt PL, Coenraad MJ, Ding H, Hou MC, Laterre PF, Mendizabal M, Ortiz-Olvera NX, Vorobioff JD, Zhang W, Angeli P. Recommendations on the Diagnosis and Initial Management of Acute Variceal Bleeding and Hepatorenal Syndrome in Patients with Cirrhosis. Dig Dis Sci 2019; 64:1419-1431. [PMID: 30684079 DOI: 10.1007/s10620-018-5448-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 12/29/2018] [Indexed: 12/14/2022]
Abstract
Cirrhosis is a serious and life-threatening condition which imposes a significant socioeconomic burden on affected individuals and healthcare systems. Cirrhosis can result in portal hypertension, which may lead to major complications, including acute variceal bleeding and hepatorenal syndrome. Without prompt treatment, these complications may be life-threatening. Over the past 2 decades, new treatment modalities and treatment strategies have been introduced, which have improved patients' prognosis, but the initial management of these severe complications continues to present a challenge. The present recommendations aim to increase clinicians' knowledge on the importance of early diagnosis and treatment, and to provide evidence-based management strategies to potentially, further improve patient outcomes. Special attention was given to the role of terlipressin. A comprehensive non-systematic literature search was undertaken to evaluate the evidence for the diagnosis and initial management of acute variceal bleeding and hepatorenal syndrome in patients with cirrhosis. Recommendations on the diagnosis and initial management of acute variceal bleeding and hepatorenal syndrome in patients with cirrhosis have been developed based on the best available evidence and the expert opinion of the consensus panel following a comprehensive review of the available clinical data. Prompt identification and timely treatment of acute variceal bleeding and hepatorenal syndrome are essential to reduce the burden.
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Affiliation(s)
- Frederik Nevens
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Campus Gasthuisberg, Herestraat 49, 3000, Louvain, Belgium.
| | - Paulo Lisboa Bittencourt
- Unit of Gastroenterology and Hepatology, Portuguese Hospital of Salvador, Rua Prof. Clementino Fraga, 220/1901, Salvador, Bahia, Brazil
| | - Minneke J Coenraad
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2300 ZC, Leiden, The Netherlands
| | - Huiguo Ding
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated with Capital Medical University, No 8, Youan Men Wai Street, Fengtai District, Beijing, 100069, China
| | - Ming-Chih Hou
- Department of Medicine Division of Gastroenterology, Taipei Veterans General Hospital, 201, Sec. II, Shih-Pai Road, Taipei, Taiwan
| | - Pierre-François Laterre
- Medical-surgical Intensive Care Unit, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Avenue Hippocrate 10, Brussels, Belgium
| | - Manuel Mendizabal
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Av. Peron 1500, 1629, Pilar, Provincia de Buenos Aires, Argentina
| | - Nayeli Xochiquetzal Ortiz-Olvera
- Department of Gastroenterology, UMAE, Hospital de Especialidades Dr. Bernardo Sepúlveda, Centro Médico Nacional Siglo XXI, IMSS, Mexico City, Mexico
| | - Julio D Vorobioff
- Department of Gastroenterology and Hepatology, University of Rosario Medical School, Morrison 8750, 2000, Rosario, Argentina
| | - Wenhong Zhang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Rd, Jingan Qu, Shanghai Shi, 200000, China
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine - DIMED, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
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Dwinata M, Putera DD, Adda’i MF, Hidayat PN, Hasan I. Carvedilol vs endoscopic variceal ligation for primary and secondary prevention of variceal bleeding: Systematic review and meta-analysis. World J Hepatol 2019; 11:464-476. [PMID: 31183006 PMCID: PMC6547295 DOI: 10.4254/wjh.v11.i5.464] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/23/2019] [Accepted: 04/28/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Variceal hemorrhage is associated with high mortality and is the cause of death for 20–30% of patients with cirrhosis. Nonselective β blockers (NSBBs) or endoscopic variceal ligation (EVL) are recommended for primary prevention of variceal bleeding in patients with medium to large esophageal varices. Meanwhile, combination of EVL and NSBBs is the recommended approach for the secondary prevention. Carvedilol has greater efficacy than other NSBBs as it decreases intrahepatic resistance. We hypothesized that there was no difference between carvedilol and EVL intervention for primary and secondary prevention of variceal bleeding in cirrhosis patients.
AIM To evaluate the efficacy of carvedilol compared to EVL for primary and secondary prevention of variceal bleeding in cirrhotic patients
METHODS We searched relevant literatures in major journal databases (CENTRAL, MEDLINE, and EMBASE) from March to August 2018. Patients with cirrhosis and portal hypertension, regardless of aetiology and severity, with or without a history of variceal bleeding, and aged ≥ 18 years old were included in this review. Only randomized controlled trials (RCTs) that compared the efficacy of carvedilol and that of EVL for primary and secondary prevention of variceal bleeding and mortality in patients with cirrhosis and portal hypertension were considered, irrespective of publication status, year of publication, and language.
RESULTS Seven RCTs were included. In four trials assessing the primary prevention, no significant difference was found on the events of variceal bleeding (RR: 0.74, 95%CI: 0.37-1.49), all-cause mortality (RR: 1.10, 95%CI: 0.76-1.58), and bleeding-related mortality (RR: 1.02, 95%CI: 0.34-3.10) in patients who were treated with carvedilol compared to EVL. In three trials assessing secondary prevention, there was no difference between two interventions for the incidence of rebleeding (RR: 1.10, 95%CI: 0.75-1.61). The fixed-effect model showed that, compared to EVL, carvedilol decreased all-cause mortality by 49% (RR: 0.51, 95%CI: 0.33-0.79), with little or no evidence of heterogeneity.
CONCLUSION Carvedilol had similar efficacy to EVL in preventing the first variceal bleeding in cirrhosis patients with esophageal varices. It was superior to EVL alone for secondary prevention of variceal bleeding in regard to all-cause mortality reduction.
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Affiliation(s)
- Michael Dwinata
- Department of Internal Medicine, Depati Hamzah General Hospital, Pangkalpinang 33684, Indonesia
| | - David Dwi Putera
- School of Medicine and Public Health, University of Sydney, Sydney 2006, Australia
| | - Muhamad Fajri Adda’i
- Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia
| | - Putra Nur Hidayat
- Hepatobiliary Division, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Jakarta 10430, Indonesia
| | - Irsan Hasan
- Hepatobiliary Division, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Jakarta 10430, Indonesia
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Zhang K, Sun X, Wang G, Zhang M, Wu Z, Tian X, Zhang C. Treatment outcomes of percutaneous transhepatic variceal embolization versus transjugular intrahepatic portosystemic shunt for gastric variceal bleeding. Medicine (Baltimore) 2019; 98:e15464. [PMID: 31045824 PMCID: PMC6504295 DOI: 10.1097/md.0000000000015464] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
There have been few studies comparing percutaneous transhepatic variceal embolization (PTVE) and transjugular intrahepatic portosystemic shunt (TIPS) for the prevention of recurrent gastric variceal bleeding (GVB).Compare the outcomes of these 2 procedures in patients with GVB.A total of 74 cirrhosis patients with GVB who underwent TIPS and modified PTVE were enrolled. The rebleeding and mortality rates, portal vein pressure (PVP) variation, and rates of hepatic encephalopathy (HE) were compared between the 2 groups.A total of 43 PTVE and 31 TIPS patients were enrolled in this study. The difference of rebleeding rate in the 2 groups was not statistically significant (P = .190). The difference of early rebleeding rates and cumulative rebleeding-free rates were all not statistically significant (P = .256, P = .200). The difference of mortality rates in the 2 groups was not statistically significant (χ = 1.206, P = .272). The rate of HE in TIPS group was statistically higher than that in PTVE group (P < .0001).Both PTVE and TIPS were effective for preventing rebleeding of GVs. There were no significant differences in rebleeding and mortality rates. The incidence of HE after TIPS was higher than PTVE.
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Affiliation(s)
- Kai Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Xiaoyan Sun
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Guangchuan Wang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Mingyan Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Zhe Wu
- Department of Gastroenterology, Ningbo Medical Center Lihuili Hospital, Ningbo, China
| | - Xiangguo Tian
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
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Gastrointestinal Bleeding in Left Ventricular Assist Device: Octreotide and Other Treatment Modalities. ASAIO J 2019; 64:433-439. [PMID: 29406356 DOI: 10.1097/mat.0000000000000758] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Left ventricular assist devices (LVADs) offer a therapeutic strategy for patients with end-stage heart failure. Increased device utilization has also increased the incidence of device-related complications including gastrointestinal bleeding (GIB). Multiple mechanisms have been proposed in the pathophysiology of continuous-flow LVAD-associated GIB including physiologic changes associated with high shear and nonpulsatile flow such as gastrointestinal arteriovenous malformations and acquired von Willebrand syndrome. Strategies to minimize the morbidity and mortality of LVAD-associated GIB are needed. Octreotide, a somatostatin analogue, has been described as an adjunct to current therapies and interventions. Factors that contribute to LVAD-associated GIB may be targeted by the pharmacologic effects of octreotide, including improved platelet aggregation, increased vascular resistance, and decreased splanchnic circulation. Octreotide has demonstrated clinical benefit in several case series and clinical trials for the treatment of LVAD-associated GIB. The focus of this article will be to review the pathophysiology of LVAD-associated GIB, discuss pharmacologic and nonpharmacologic treatment modalities, and review available literature on the role of octreotide in the management of LVAD-associated GIB.
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Zheng J, Zhang Y, Li P, Zhang S, Li Y, Li L, Ding H. The endoscopic ultrasound probe findings in prediction of esophageal variceal recurrence after endoscopic variceal eradication therapies in cirrhotic patients: a cohort prospective study. BMC Gastroenterol 2019; 19:32. [PMID: 30782139 PMCID: PMC6380022 DOI: 10.1186/s12876-019-0943-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 01/28/2019] [Indexed: 02/06/2023] Open
Abstract
Background The recurrence of esophageal varices remains high in patients with hepatic portal hypertension after the endoscopic esophageal variceal eradication therapies, including endoscopic variceal band ligation (EVL), injection sclerotherapy (EIS) or EVL plus EIS. The aim of this study was to evaluate the endoscopic ultrasound probe examinations (EUP) findings in the prediction of recurrence following esophageal variceal eradication in a prospective cohort. Methods A total of 206 cirrhotic portal hypertension patients with esophageal variceal eradication, who underwent endoscopic variceal therapy (EVL or EIS or EVL plus EIS) were initially enrolled. All patients were scheduled for a follow-up every 6 months for up to 3 years. EUP was performed to evaluate peri-esophageal collateral veins (peri-ECVs), perforating veins (PFV) and para-esophageal collateral veins (para-ECVs). In addition, computed tomography (CT) were conducted to detect portal vein diameter, portal vein embolus, and major portosystemic collateral shunts. The relationship between esophageal variceal recurrence and EUP findings were analyzed. Results We found that as high as 93.5% of patients developed esophageal variceal recurrence in the 3-year follow-up. The time of esophageal variceal recurrence after variceal eradication was 13.4 months (13.4 ± 9.2 months). Furthermore, the median time of recurrence in patients who were undertaken EVL,EIS and EVL plus EIS was 10, 13 and 12 months, respectively. We identified that the risk factors, including EVL (OR 0.23, 95% CI 0.08–0.71, p < 0.01), Child-Pugh score (OR 3.32,95% CI 1.31–35.35, p < 0.05), large peri-ECVs (OR 4.56, 95% CI 2.17–9.58, p < 0.0001), and existence of PFV (OR 2.14, 95% CI 1.44–3.16, p < 0.001), were significantly associated with the recurrence of esophageal varices. The peri-ECVs and PFV showed better ability to predict esophageal variceal recurrence. When cut-off value of peri-ECVs diameter was 3.5 mm, the specificity of prediction 1-year variceal recurrence was 86% and the sensitivity was 45%. Conclusions The EUP appears to be very effective, convenient and economical examinations to predict esophageal varices recurrence after variceal eradication by endoscopic therapies. The high Child-pugh score, large peri-ECVs, and PFV are independent risk factors related to esophageal varices recurrence.
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Affiliation(s)
- Junfu Zheng
- Department of Gastroenterology and Hepatology, Beijing You An Hospital affiliated to the Capital Medical University, 8 Xi Tou Tiao, Youanmen wai, Beijing, 100069, China
| | - Yuening Zhang
- Department of Gastroenterology and Hepatology, Beijing You An Hospital affiliated to the Capital Medical University, 8 Xi Tou Tiao, Youanmen wai, Beijing, 100069, China
| | - Peng Li
- Department of Gastroenterology and Hepatology, Beijing You An Hospital affiliated to the Capital Medical University, 8 Xi Tou Tiao, Youanmen wai, Beijing, 100069, China
| | - Shibin Zhang
- Department of Gastroenterology and Hepatology, Beijing You An Hospital affiliated to the Capital Medical University, 8 Xi Tou Tiao, Youanmen wai, Beijing, 100069, China
| | - Yue Li
- Department of Gastroenterology and Hepatology, Beijing You An Hospital affiliated to the Capital Medical University, 8 Xi Tou Tiao, Youanmen wai, Beijing, 100069, China
| | - Lei Li
- Department of Gastroenterology and Hepatology, Beijing You An Hospital affiliated to the Capital Medical University, 8 Xi Tou Tiao, Youanmen wai, Beijing, 100069, China.
| | - Huiguo Ding
- Department of Gastroenterology and Hepatology, Beijing You An Hospital affiliated to the Capital Medical University, 8 Xi Tou Tiao, Youanmen wai, Beijing, 100069, China.
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Zacharias AP, Jeyaraj R, Hobolth L, Bendtsen F, Gluud LL, Morgan MY. Carvedilol versus traditional, non-selective beta-blockers for adults with cirrhosis and gastroesophageal varices. Cochrane Database Syst Rev 2018; 10:CD011510. [PMID: 30372514 PMCID: PMC6517039 DOI: 10.1002/14651858.cd011510.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Non-selective beta-blockers are recommended for the prevention of bleeding in people with cirrhosis, portal hypertension and gastroesophageal varices. Carvedilol is a non-selective beta-blocker with additional intrinsic alpha1-blocking effects, which may be superior to traditional, non-selective beta-blockers in reducing portal pressure and, therefore, in reducing the risk of upper gastrointestinal bleeding. OBJECTIVES To assess the beneficial and harmful effects of carvedilol compared with traditional, non-selective beta-blockers for adults with cirrhosis and gastroesophageal varices. SEARCH METHODS We combined searches in the Cochrane Hepato-Biliary's Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, and Science Citation Index with manual searches. The last search update was 08 May 2018. SELECTION CRITERIA We included randomised clinical trials comparing carvedilol versus traditional, non-selective beta-blockers, irrespective of publication status, blinding, or language. We included trials evaluating both primary and secondary prevention of upper gastrointestinal bleeding in adults with cirrhosis and verified gastroesophageal varices. DATA COLLECTION AND ANALYSIS Three review authors (AZ, RJ and LH), independently extracted data. The primary outcome measures were mortality, upper gastrointestinal bleeding and serious adverse events. We undertook meta-analyses and presented results using risk ratios (RR) or mean differences (MD), both with 95% confidence intervals (CIs), and I2 values as a marker of heterogeneity. We assessed bias control using the Cochrane Hepato-Biliary domains and the quality of the evidence with GRADE. MAIN RESULTS Eleven trials fulfilled our inclusion criteria. One trial did not report clinical outcomes. We included the remaining 10 randomised clinical trials, involving 810 participants with cirrhosis and oesophageal varices, in our analyses. The intervention comparisons were carvedilol versus propranolol (nine trials), or nadolol (one trial). Six trials were of short duration (mean 6 (range 1 to 12) weeks), while four were of longer duration (13.5 (6 to 30) months). Three trials evaluated primary prevention; three evaluated secondary prevention; while four evaluated both primary and secondary prevention. We classified all trials as at 'high risk of bias'. We gathered mortality data from seven trials involving 507 participants; no events occurred in four of these. Sixteen of 254 participants receiving carvedilol and 19 of 253 participants receiving propranolol or nadolol died (RR 0.86, 95% CI 0.48 to 1.53; I2 = 0%, low-quality evidence). There appeared to be no differences between carvedilol versus traditional, non-selective beta-blockers and the risks of upper gastrointestinal bleeding (RR 0.77, 95% CI 0.43 to 1.37; 810 participants; 10 trials; I2 = 45%, very low-quality evidence) and serious adverse events (RR 0.97, 95% CI 0.67 to 1.42; 810 participants; 10 trials; I2 = 14%, low-quality evidence). Significantly more deaths, episodes of upper gastrointestinal bleeding and serious adverse events occurred in the long-term trials but there was not enough information to determine whether there were differences between carvedilol and traditional, non-selective beta-blockers, by trial duration. There was also insufficient information to detect differences in the effects of these interventions in trials evaluating primary or secondary prevention. There appeared to be no differences in the risk of non-serious adverse events between carvedilol versus its comparators (RR 0.55, 95% CI 0.23 to 1.29; 596 participants; 6 trials; I2 = 88%; very low-quality evidence). Use of carvedilol was associated with a greater reduction in hepatic venous pressure gradient than traditional, non-selective beta-blockers both in absolute (MD -1.75 mmHg, 95% CI -2.60 to -0.89; 368 participants; 6 trials; I2 = 0%; low-quality evidence) and percentage terms (MD -8.02%, 95% CI -11.49% to -4.55%; 368 participants; 6 trials; I2 = 0%; low-quality evidence). However, we did not observe a concomitant reduction in the number of participants who failed to achieve a sufficient haemodynamic response (RR 0.76, 95% CI 0.57 to 1.02; 368 participants; 6 trials; I2 = 42%; very low-quality evidence) or in clinical outcomes. AUTHORS' CONCLUSIONS We found no clear beneficial or harmful effects of carvedilol versus traditional, non-selective beta-blockers on mortality, upper gastrointestinal bleeding, serious or non-serious adverse events despite the fact that carvedilol was more effective at reducing the hepatic venous pressure gradient. However, the evidence was of low or very low quality, and hence the findings are uncertain. Additional evidence is required from adequately powered, long-term, double-blind, randomised clinical trials, which evaluate both clinical and haemodynamic outcomes.
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Affiliation(s)
- Antony P Zacharias
- Division of Medicine, Royal Free Campus, University College LondonUCL Institute for Liver & Digestive HealthLondonUKNW3 2PF
| | - Rebecca Jeyaraj
- Division of Medicine, Royal Free Campus, University College LondonUCL Institute for Liver & Digestive HealthLondonUKNW3 2PF
| | - Lise Hobolth
- Copenhagen University Hospital HvidovreGastrounit, Medical DivisionKattegaards Alle 30HvidovreDenmark2650
| | - Flemming Bendtsen
- Copenhagen University Hospital HvidovreGastrounit, Medical DivisionKattegaards Alle 30HvidovreDenmark2650
| | - Lise Lotte Gluud
- Copenhagen University Hospital HvidovreGastrounit, Medical DivisionKattegaards Alle 30HvidovreDenmark2650
| | - Marsha Y Morgan
- Division of Medicine, Royal Free Campus, University College LondonUCL Institute for Liver & Digestive HealthLondonUKNW3 2PF
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Flamm SL, Mullen KD, Heimanson Z, Sanyal AJ. Rifaximin has the potential to prevent complications of cirrhosis. Therap Adv Gastroenterol 2018; 11:1756284818800307. [PMID: 30283499 PMCID: PMC6166307 DOI: 10.1177/1756284818800307] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 08/09/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Cirrhosis-related complications are associated with poor prognosis. With our analyses, we examined the potential benefit of rifaximin in reducing the risk of developing cirrhosis-related complications. METHODS Adults with cirrhosis and hepatic encephalopathy (HE) in remission were randomly assigned to receive rifaximin 550 mg twice daily or placebo for 6 months with concomitant lactulose permitted. Post hoc analyses examined time to cirrhosis-related complications (HE, spontaneous bacterial peritonitis (SBP), variceal bleeding, acute kidney injury/hepatorenal syndrome). Subgroup analyses evaluated efficacy for select baseline disease characteristics. RESULTS Of patients receiving rifaximin (n = 140) and placebo (n = 159), 53.6% and 49.1%, respectively, had baseline Model for End-Stage Liver Disease (MELD) score ⩾ 12 and international normalized ratio (INR) ⩾ 1.2. Baseline ascites was observed in 36.4% (rifaximin) and 34.6% (placebo) of patients. In patients with MELD score ⩾ 12 and INR ⩾ 1.2, rifaximin reduced the relative risk (RR) of any first complication experienced during trial by 59% [hazard ratio (HR) = 0.41, 95% confidence interval (CI): 0.25-0.67; p < 0.001] versus placebo. For patients with baseline ascites, rifaximin reduced the RR of any first complication experienced during trial by 42% versus placebo (HR = 0.58, 95% CI: 0.34-1.0; p = 0.045). For some subgroups, there was a decrease in RR of complications of SBP, variceal bleeding, and acute kidney injury/hepatorenal syndrome with rifaximin versus placebo, although there were few events reported in the study. CONCLUSION Rifaximin may reduce the incidence of cirrhosis-related complications and the recurrence of overt HE.[ClinicalTrials.gov identifier: NCT00298038.].
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The Role of Therapeutic Endoscopy in Patients With Cirrhosis-Related Causes of Gastrointestinal Bleeding. Curr Gastroenterol Rep 2018; 20:31. [PMID: 29886513 DOI: 10.1007/s11894-018-0637-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW This article aims to review current therapeutic endoscopic treatments available for the management of gastrointestinal bleeding related to cirrhosis. RECENT FINDINGS Endoscopic band ligation is an effective treatment for primary prophylaxis, acute bleeding, and secondary prophylaxis of esophageal varices as well as for acute bleeding and secondary prophylaxis of select gastric varices. Sclerotherapy is a treatment option for acute bleeding and secondary prophylaxis of esophageal varices when band ligation is technically difficult. Cyanoacrylate glue injection is an effective treatment for acute bleeding of gastric and ectopic varices. Argon plasma coagulation is first-line and radiofrequency ablation is second-line treatment for chronic bleeding secondary to gastric antral vascular ectasia. There are a variety of endoscopic treatment modalities for cirrhosis-related gastrointestinal bleeding, and the appropriate therapy depends on the location of the bleed, history or presence of acute bleeding, and risk factors for intervention-related adverse events.
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Buechter M, Manka P, Theysohn JM, Reinboldt M, Canbay A, Kahraman A. Spleen stiffness is positively correlated with HVPG and decreases significantly after TIPS implantation. Dig Liver Dis 2018; 50:54-60. [PMID: 29102174 DOI: 10.1016/j.dld.2017.09.138] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/11/2017] [Accepted: 09/28/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is indicated in patients with decompensated portal hypertension (PH). Hepatic venous pressure gradient (HVPG) is considered gold standard for assessment of PH. Because HVPG measurement is invasive, non-invasive methods for evaluating severity of PH are warranted. PATIENTS AND METHODS We retrospectively correlated spleen stiffness as measured by FibroScan with HVPG in patients who underwent TIPS. Twenty-four patients with spleen stiffness measurement (SSM) one day before (D-1), one day after (D+1) and 28 days after TIPS (D+28) were included. RESULTS SSM was positively correlated with pre-TIPS HVPG (HVPG <13mmHg, median SSM: 19.7±8.6kPa; HVPG 13-24mmHg, median SSM: 45.0±15.7kPa; HVPG >24mmHg, median SSM: 75.0±6.2kPa; p<0.05]; r2=0.72; p<0.001) and decreased significantly after TIPS implantation (D-1, median SSM: 67.1±17.3kPa; D+1, median SSM: 44.7±18.5kPa; D+28, median SSM: 35.6±17.0kPa; p<0.05), while liver stiffness measurement decrease was not statistically significant. CONCLUSIONS Our study highlights the utility of SSM as non-invasive tool in patients with chronic liver disease in evaluating degree of PH potentially offering a confirmable additional parameter in surveillance of patients undergoing TIPS procedure.
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Affiliation(s)
- Matthias Buechter
- Department of Gastroenterology and Hepatology, University Hospital Essen, Germany
| | - Paul Manka
- Department of Gastroenterology and Hepatology, University Hospital Essen, Germany; Regeneration and Repair, Institute of Hepatology, Division of Transplantation Immunology and Mucosal Biology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jens M Theysohn
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Germany
| | - Marcus Reinboldt
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Germany
| | - Ali Canbay
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany
| | - Alisan Kahraman
- Department of Gastroenterology and Hepatology, University Hospital Essen, Germany.
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Anesthesia for TIPS. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Bittencourt PL, Strauss E, Farias AQ, Mattos AAD, Lopes EP. VARICEAL BLEEDING: UPDATE OF RECOMMENDATIONS FROM THE BRAZILIAN ASSOCIATION OF HEPATOLOGY. ARQUIVOS DE GASTROENTEROLOGIA 2017; 54:349-355. [PMID: 28977116 DOI: 10.1590/s0004-2803.201700000-79] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/11/2017] [Indexed: 12/18/2022]
Abstract
Since the publication of the Brazilian Association of Hepatology recommendations for the prevention and treatment of variceal bleeding in 2010, new evidence-based data were reported in the literature. This has changed our current management for portal hypertension. This review updates the previous recommendations. It takes the new prognostic staging of cirrhosis into account allowing tailored treatment for advanced fibrosis, compensated or decompensated cirrhosis. An organizing panel of five experts reviewed all recommendations according to available data, which were subsequently scrutinized by all members of the Brazilian Association of Hepatology using a web-based approach. The accepted recommendations are presented in this manuscript.
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Affiliation(s)
| | | | - Alberto Queiroz Farias
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
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Tang L, Liu H, Wu Y, Li M, Li W, Jiang M, Hou J, Jiang Y, Xia Z, Meng Q. Sevoflurane may be more beneficial than propofol in patients receiving endoscopic variceal ligation and endoscopic variceal sclerotherapy: A randomized, double-blind study. Exp Ther Med 2017; 14:3145-3152. [PMID: 28966686 DOI: 10.3892/etm.2017.4919] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Accepted: 05/31/2017] [Indexed: 12/25/2022] Open
Abstract
The aim of the present study was to evaluate the safety and efficacy of various general anesthesia regimens during endoscopic variceal ligation (EVL) and endoscopic variceal sclerotherapy (EVS). A total of 123 patients with American Society of Anesthesiologists physical status III and IV, aged 40-70 years, undergoing general anesthesia for EVL and EVS were randomly divided into two groups: Sevoflurane anesthesia (group S; n=60) and propofol anesthesia (group P; n=60). Vital signs, particularly heart rate (HR) and mean arterial pressure (MAP), were monitored. The designated time points were as follows: 5 min before induction (T0), and 1, 5, 10, 15, 20, 25 and 30 min after intubation (T1, T2, T3, T4, T5, T6 and T7, respectively). Time intervals were recorded, including recovery time and extubation time. Following surgery, the observer recorded the Ramsay sedation scale (RSS) score and the visual analogue scale (VAS) score. Adverse reactions were noted. Results demonstrated that there were significant differences in MAP between the two groups at T2, T3, T5, T6 and T7 (P<0.05). There was a significant difference in HR between the two groups at T2, T3 and T4 (P<0.05). Recovery time and extubation time in group P were significantly longer than those in group S (P<0.05; 18.38±2.25 min vs. 14.57±1.04 min and 21.70±2.70 min vs. 15.83±0.88 min, respectively). The rate of ephedrine injected was 58.3% (35/60 patients) in group P vs. 28.3% (17/60 patients) in group S (P<0.05). There was a significant difference in the RSS score between the two groups 5 min after extubation (P<0.05). VRS scores demonstrated that anesthetists and patients were significantly more satisfied with the procedure in group S than in group P (P<0.01). In conclusion, the superiority and special clinical value of inhalational anesthesia has been demonstrated during EVL and EVS attributed to stable hemodynamics and high quality of anesthesia recovery in the present study.
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Affiliation(s)
- Linghua Tang
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Huimin Liu
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Yang Wu
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Mei Li
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Wei Li
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Meng Jiang
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Jiabao Hou
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Ying Jiang
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Zhongyuan Xia
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Qingtao Meng
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
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Affiliation(s)
- Patrick Marcellin
- Service d'hépatologie, INSERM CRI, Université Paris-Diderot, Clichy, France
| | - Emilie Estrabaud
- Service d'hépatologie, INSERM CRI, Université Paris-Diderot, Clichy, France
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