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Initial Experience With Endoscopic Ultrasound-guided Coil Placement for Pediatric Gastric Variceal Hemostasis. J Pediatr Gastroenterol Nutr 2021; 72:532-537. [PMID: 33394889 DOI: 10.1097/mpg.0000000000003028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Gastric variceal (GV) bleeding is among the most morbid sequelae of portal hypertension, with mortality ranging from 30% to 50%. Pediatric data focused on endoscopic approaches to management are needed. The present study represents the first pediatric case series of endoscopic ultrasound (EUS)-guided coil placement within feeding vessels as monotherapy for management of GV bleeding. METHODS Using our prospectively maintained endoscopy database, we identified patients 18 years and younger who underwent EUS-guided coil placement for management of GV bleeding from 2008 to 2018. Demographics, indication, procedural interventions/findings, and available clinical outcomes data were analyzed. RESULTS Twelve patients (median age 15, range 11-18 years) underwent EUS-guided coil placement for GV bleeding. All had portal hypertension, with EV in 58.3% and prior GV bleeding with attempted endoscopic management in 75%. Coil placement was accomplished using a linear echoendoscope and a 19-gauge needle. A mean of 2.75 (± 0.43) coils were placed in each patient (4, 6, 8, and 10 mm Nester Embolization Coils, Cook Medical, Bloomington, Indiana, USA). Immediate hemostasis was achieved in all patients, and 25% of patients developed recurrent gastric varices at a median of 5.5 months following the initial EUS-guided coil placement (range 4-6 months) over the median 12 month follow-up period. CONCLUSIONS The present study establishes the feasibility and efficacy of EUS-guided coil placement as monotherapy for GV bleeding in children and adolescents. The technique was technically successful, with primary hemostasis achieved in all patients. EUS-guided embolization with coils may represent an alternative to current approaches for management of highly morbid GV bleeding.
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Abstract
Cirrhosis is the fifth leading cause of death in adults. Advanced cirrhosis can cause significant portal hypertension (PH), which is responsible for many of the complications observed in patients with cirrhosis, such as varices. If portal pressure exceeds a certain threshold, the patient is at risk of developing life-threatening bleeding from varices. Variceal bleeding has a high incidence among patients with liver cirrhosis and carries a high risk of mortality and morbidity. The management of variceal bleeding is complex, often requiring a multidisciplinary approach involving pharmacological, endoscopic, and radiologic interventions. In terms of management, three stages can be considered: primary prophylaxis, active bleeding, and secondary prophylaxis. The main goal of primary and secondary prophylaxis is to prevent variceal bleeding. However, active variceal bleeding is a medical emergency that requires swift intervention to stop the bleeding and achieve durable hemostasis. We describe the pathophysiology of cirrhosis and PH to contextualize the formation of gastric and esophageal varices. We also discuss the currently available treatments and compare how they fare in each stage of clinical management, with a special focus on drugs that can prevent bleeding or assist in achieving hemostasis.
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Liu Z, Dou X, Guo J, Zhao Y, Zhang J, Ren W, Tang S, Zhang Y, Zhang X, Huang L, Lin L. Utility of Transabdominal Ultrasonography Enhanced by Oral Cellulose-Based Contrast Agent in Depicting Varices at Cardia and Fundus. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:1428-1434. [PMID: 32217027 DOI: 10.1016/j.ultrasmedbio.2020.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/24/2020] [Accepted: 02/18/2020] [Indexed: 06/10/2023]
Abstract
The use of transabdominal color Doppler ultrasound after oral administration of an oral cellulose-based contrast agent (TUS-OCCA) in depicting varices at the cardia and fundus was explored. Both gastroscopy and transabdominal color Doppler ultrasound (TUS) were performed for this purpose, with gastroscopy serving as the gold standard. Patients were assigned by TUS protocol to one of three groups: TUS + empty stomach (TUS-ES); TUS + oral water intake (TUS-OW); and TUS-OCCA. TUS-based grading of varices reflected venous diameters and blood flow velocities, designated as follows: Ux = difficulty discerning gastric fundus and cardia or delineating varices; U0 = no detectable varices; U1 = diameter <5 mm, flow rate <10 cm/s; U2 = diameter <5 mm, flow rate ≥10 cm/s; U3 = diameter 5-10 mm, flow rate <10 cm/s; U4 = diameter 5-10 mm, flow rate ≥10 cm/s; and U5 = diameter >10 mm, any flow rate. Between August 2016 and August 2019, 239 patients with cirrhosis were enrolled prospectively, including bleeding (n = 71) and non-bleeding (n = 168) groups. Varices were directly observed in 10.5% (25/239) of TUS-ES group members, compared with 59.2% (58/98) of the TUS-OW group and 89.6% (104/116) of the TUS-OCCA group; all detection rates differed significantly (TUS-OCCA > TUS-OW > TUS-ES, p < 0.05). TUS-based grading (as defined) revealed the following patient distribution: Ux, n = 34; U0, n = 18; U1, n = 50; U2, n = 41; U3, n = 16; U4, n = 46; U5, n = 34. In grading by variceal diameter, overall correspondence between TUS and gastroscopy was 93% (174/187). TUS-OCCA greatly improved rates of detection of varices at the cardia and fundus, offering a new method by which diagnosis and quantitative grading may be achieved and affording an excellent, non-invasive approach to dynamic follow-up.
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Affiliation(s)
- Zhijun Liu
- Ultrasound Department, Shengjing Hospital of China Medical University, Liaoning Province, People's Republic of China
| | - Xiaoguang Dou
- Infection Diseases Department, Shengjing Hospital of China Medical University, Liaoning Province, People's Republic of China
| | - Jintao Guo
- Gastroenterology Department, Shengjing Hospital of China Medical University, Liaoning Province, People's Republic of China
| | - Ying Zhao
- Gastroenterology Surgery Department, Shengjing Hospital of China Medical University, Liaoning Province, People's Republic of China
| | - Jing Zhang
- Ultrasound Department, Shengjing Hospital of China Medical University, Liaoning Province, People's Republic of China
| | - Weidong Ren
- Ultrasound Department, Shengjing Hospital of China Medical University, Liaoning Province, People's Republic of China
| | - Shaoshan Tang
- Ultrasound Department, Shengjing Hospital of China Medical University, Liaoning Province, People's Republic of China
| | - Yan Zhang
- Ultrasound Department, Shengjing Hospital of China Medical University, Liaoning Province, People's Republic of China
| | - Xiaoyue Zhang
- Ultrasound Department, Shengjing Hospital of China Medical University, Liaoning Province, People's Republic of China
| | - Liping Huang
- Ultrasound Department, Shengjing Hospital of China Medical University, Liaoning Province, People's Republic of China
| | - Lianjie Lin
- Gastroenterology Department, Shengjing Hospital of China Medical University, Liaoning Province, People's Republic of China.
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Xie W, Chen FX, Zhu LY, Wen CC, Zhang X. Risk assessment of first upper gastrointestinal bleeding using computerized tomoscanning in esophageal varices patients with cirrhosis and portal hypertension. Medicine (Baltimore) 2020; 99:e18923. [PMID: 32000404 PMCID: PMC7004787 DOI: 10.1097/md.0000000000018923] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
To evaluate the risk of first upper gastrointestinal bleeding by computerized tomoscanning (CT) for esophageal varices patients with cirrhotic portal hypertension.One hundred thirty two esophageal varices patients with cirrhotic portal hypertension who are also complicated with gastrointestinal bleeding were recruited as bleeding group, while another 132 patients without bleeding as non-bleeding group. The diameter of esophageal varices, number of vascular sections, and total area of blood vessels were measured by CT scanning. The sensitivity and specificity of these indicators were calculated, and Youden index was adjusted with the critical point.The diameter of esophageal varices was 7.83 ± 2.76 mm in bleeding group, and 6.57 ± 3.42 mm in non-bleeding group. The Youden index was 0.32 with the critical point 5.55 mm. The area under the receiver operating characteristics (AUROC) was 0.72. The number of venous vessels was 4.5 ± 2 in bleeding group, whereas being 4 ± 2 in non-bleeding group. The Youden index was 0.35 with a critical point 4, and the area under the curve (AUC) was 0.68. The blood vessel area was 1.73 ± 1.15 cm in bleeding group, and 1.12 ± 0.89 cm in non-bleeding group. The Youden index was 0.48 with the critical point being 1.03 cm, and corresponding AUC was 0.82.Among all 3 indicators of the total area, diameter, and number of sections of the esophageal varices, the total area of esophageal varices showed more accuracy as a potential and novel indicator for bleeding prediction.
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Affiliation(s)
- Wei Xie
- Department of Radiology, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Fa-xiang Chen
- Department of Radiology, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Li-Yao Zhu
- Department of Hepatology, The Fourth People's Hospital of Huai’an, Jiangsu
| | - Cheng-Cai Wen
- Department of Rehabilitation, The Second People's Hospital of Huai’an and The Affiliated Huai’an Hospital of Xuzhou Medical University, Huai’an
| | - Xin Zhang
- Department of Radiology, The Fourth People's Hospital of Huai’an, Jiangsu, P.R. China
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Jogo A, Nishida N, Yamamoto A, Kageyama K, Nakano M, Sohgawa E, Hamamoto S, Hamuro M, Miki Y. Selective Balloon-occluded Retrograde Transvenous Obliteration for Gastric Varices. Intern Med 2019; 58:2291-2297. [PMID: 31118379 PMCID: PMC6746652 DOI: 10.2169/internalmedicine.2356-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective Balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices (GV) is associated with drawbacks including a postoperative increase in portal pressure and the risk of subsequent worsening of esophageal varices (EV). Selective B-RTO that embolizes only the varices may have the potential to minimize such risks. The aim of this study is to retrospectively compare the postoperative course of patients after selective B-RTO (Group S) and conventional B-RTO (Group B). Methods One hundred four patients treated from January 2007 to April 2012 were classified into Groups S (n=5) and B (n=99). In the univariate analysis, the volume of 5% ethanolamine oleate iopamiodol (EOI) administered at baseline and the GV blood flow on endoscopic ultrasound after B-RTO were considered as covariates. The rates of GV recurrence and EV aggravation was also compared between Groups B and S. Results In Group S, the volume of 5% EOI was significantly lower (Group S vs. Group B: 14.6±5.5 vs. 28.5±16.4 mL; p=0.0012) and the rate of EV aggravation was lower in comparison to Group B (p=0.045). However, in Group S, the rate of complete eradication of GV blood flow was significantly lower (Group S vs. Group B: 0% vs. 89.9%; p<0.001) and the rate of re-treatment for GV was higher in comparison to Group B (Group S vs. Group B: 60% vs. 1.0%; p<0.001). Conclusion Selective B-RTO for GV could minimize the risk of a worsening of EV or reduce the amount of sclerosants; however, the rate of recurrence was high in comparison to conventional B-RTO.
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Affiliation(s)
- Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Japan
| | - Norifumi Nishida
- Department of Radiology, Osaka Saiseikai Nakatsu Hospital, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Japan
| | - Mariko Nakano
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Japan
| | - Shinichi Hamamoto
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Japan
| | - Masao Hamuro
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Japan
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Tseng Y, Ma L, Luo T, Zeng X, Li F, Li N, Wei Y, Chen S. Patient Response to Endoscopic Therapy for Gastroesophageal Varices Based on Endoscopic Ultrasound Findings. Gut Liver 2019; 12:562-570. [PMID: 29699062 PMCID: PMC6143452 DOI: 10.5009/gnl17471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 12/11/2017] [Accepted: 12/21/2017] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Gastroesophageal variceal hemorrhage is a common complication of portal hypertension. Endoscopic therapy is currently recommended for preventing gastroesophageal variceal rebleed. However, the rate of variceal rebleed and its associated mortality remain concerning. This study is aimed at differentiating patient response to endoscopic therapy based on endoscopic ultrasound (EUS) findings. Methods One-hundred seventy patients previously treated with repeat endoscopic therapy for secondary prophylaxis were enrolled and classified into two groups based on treatment response. Prior to consolidation therapy, all patients received an EUS examination to observe for extraluminal phenomena. All available follow-up endoscopic examination records were retrieved to validate study results. Results Of the 170 subjects, 106 were poor responders, while 64 were good responders. The presence of para-gastric, gastric perforating, and esophageal perforating veins was associated with poor patient response (p<0.001). The odds ratio for para-gastric veins was 5.374. Follow-up endoscopic findings for poor responders with incomplete variceal obliteration was closely correlated with the presence of para-gastric veins (p=0.002). Conclusions The presence of para-gastric veins is a characteristic of poor response to endoscopic therapy for treating gastroesophageal varices. Early identification of this subgroup necessitates a change in course of treatment to improve overall patient outcome.
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Affiliation(s)
- Yujen Tseng
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lili Ma
- Department of Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tiancheng Luo
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoqing Zeng
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Feng Li
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Na Li
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yichao Wei
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shiyao Chen
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China.,Department of Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China.,Department of Evidence-Based Medicine Center, Zhongshan Hospital, Fudan University, Shanghai, China
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Abstract
Acute variceal bleeding is one of the most fatal complications of cirrhosis and is responsible for about one-third of cirrhosis-related deaths. Therefore, every effort should be made to emergently resuscitate the patients, start pharmacotherapy as soon as possible and do endoscopic therapy in a timely manner. Despite the recent advances in treatment, mortality rate is still high. We provide a comprehensive review of evaluation and management of variceal bleeding.
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Affiliation(s)
- Obada Tayyem
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Mohammad Bilal
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX.
| | - Ronald Samuel
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Sheharyar K Merwat
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX
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Seiberlich E, Sanches MD, Morais BS, Maciel JF. Influência do propranolol pré‐operatório no índice cardíaco durante a fase anepática do transplante hepático. Rev Bras Anestesiol 2015; 65:170-6. [DOI: 10.1016/j.bjan.2014.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 02/05/2014] [Indexed: 11/29/2022] Open
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Seiberlich E, Sanches MD, Morais BS, Maciel JF. Influence of preoperative propranolol on cardiac index during the anhepatic phase of liver transplantation. Braz J Anesthesiol 2015; 65:170-6. [PMID: 25925027 DOI: 10.1016/j.bjane.2014.02.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 02/05/2014] [Indexed: 10/24/2022] Open
Abstract
INTRODUCTION Liver transplantation is the best therapeutic option for end-stage liver disease. Non-selective beta-blocker medications such as propranolol act directly on the cardiovascular system and are often used in the prevention of gastrointestinal bleeding resulting from HP. The effects of propranolol on cardiovascular system of cirrhotic patients during liver transplantation are not known. OBJECTIVE Evaluate the influence of propranolol used preoperatively on cardiac index during the anhepatic phase of liver transplantation. METHOD 101 adult patients (73 male [72.2%]) who underwent cadaveric donor orthotopic liver transplantation by piggyback technique with preservation of the retrohepatic inferior vena cava performed at Hospital das Clinicas, Federal University of Minas Gerais were evaluated. There was no difference in severity between groups by the MELD system, p=0.70. The preoperative use of propranolol and the cardiac index outcome were compared during the anhepatic phase of liver transplantation in 5 groups (I: increased cardiac index, II: cardiac index reduction lower than 16%, III: cardiac index reduction equal to or greater than 16% and less than 31%, IV: cardiac index reduction equal to or greater than 31% and less than 46%, V: cardiac index reduction equal to or greater than 46%). RESULTS Patients in group I (46.4%) who received propranolol preoperatively were statistically similar to groups II (60%), III (72.7%), IV (50%) and V (30.8%), p=0.57. CONCLUSION The use of propranolol before transplantation as prophylaxis for gastrointestinal bleeding may be considered safe, as it was not associated with worsening of cardiac index in anhepatic phase of liver transplantation.
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Affiliation(s)
- Emerson Seiberlich
- Department of Surgery, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil.
| | - Marcelo D Sanches
- Department of Surgery, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | | | - Jader F Maciel
- Department of Surgery, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
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Bloom S, Kemp W, Lubel J. Portal hypertension: pathophysiology, diagnosis and management. Intern Med J 2015; 45:16-26. [DOI: 10.1111/imj.12590] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 08/27/2014] [Indexed: 12/19/2022]
Affiliation(s)
- S. Bloom
- Gastroenterology and Hepatology; Eastern Health; Melbourne Victoria Australia
| | - W. Kemp
- Gastroenterology and Hepatology; Alfred Health; Melbourne Victoria Australia
| | - J. Lubel
- Gastroenterology and Hepatology; Eastern Health; Melbourne Victoria Australia
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Factors associated with aggravation of esophageal varices after B-RTO for gastric varices. Cardiovasc Intervent Radiol 2013; 37:1243-50. [PMID: 24322305 PMCID: PMC4156781 DOI: 10.1007/s00270-013-0809-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 11/10/2013] [Indexed: 12/15/2022]
Abstract
PURPOSE To retrospectively evaluate risk factors for aggravation of esophageal varices (EV) within 1 year after balloon-occluded retrograde transvenous obliteration (B-RTO) of gastric varices (GV) and to clarify suitable timing for upper endoscopy to detect EV aggravation after B-RTO. METHODS Participants included 67 patients who underwent B-RTO for GV between January 2006 and December 2010. Whether EV aggravation occurred within 1 year was evaluated, and the time interval from B-RTO to aggravation was calculated. Factors potentially associated with EV aggravation were analyzed. RESULTS B-RTO was successfully performed in all patients. EV aggravation at 1 year after B-RTO was found in 38 patients (56.7 %). Multivariate logistic regression analysis showed that total bilirubin (T-bil) (P = 0.032) and hepatic venous pressure gradient (HVPG) (P = 0.011) were significant independent risk factors for EV aggravation after B-RTO. Cutoff values of T-bil and HVPG yielding maximal combined sensitivity and specificity for EV aggravation were 1.6 mg/dL and 13 mmHg, respectively. The patients with T-bil ≥ 1.6 mg/dL or HVPG ≥ 13 mmHg had a median aggravation time of 5.1 months. All five patients with ruptured EV belonged to this group. In contrast, patients with T-bil < 1.6 mg/dL and HVPG < 13 mmHg had a median aggravation time of 21 months. CONCLUSION T-bil and HVPG were significant independent risk factors for EV aggravation after B-RTO. The patients with T-bil ≥ 1.6 mg/dL or HVPG ≥ 13 mmHg require careful follow-up evaluation, including endoscopy.
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Khamaysi I, Gralnek IM. Acute upper gastrointestinal bleeding (UGIB) - initial evaluation and management. Best Pract Res Clin Gastroenterol 2013; 27:633-8. [PMID: 24160923 DOI: 10.1016/j.bpg.2013.09.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Revised: 09/15/2013] [Accepted: 09/17/2013] [Indexed: 02/07/2023]
Abstract
Acute upper gastrointestinal bleeding (UGIB) is the most common reason that the 'on-call' gastroenterologist is consulted. Despite the diagnostic and therapeutic capabilities of upper endoscopy, there is still significant associated morbidity and mortality in patients experiencing acute UGIB, thus this is a true GI emergency. Acute UGIB is divided into non-variceal and variceal causes. The most common type of acute UGIB is 'non-variceal' and includes diagnoses such as peptic ulcer (gastric and duodenal), gastroduodenal erosions, Mallory-Weiss tears, erosive oesophagitis, arterio-venous malformations, Dieulafoy's lesion, and upper GI tract tumours and malignancies. This article focuses exclusively on initial management strategies for acute upper GI bleeding. We discuss up to date and evidence-based strategies for patient risk stratification, initial patient management prior to endoscopy, potential causes of UGIB, role of proton pump inhibitors, prokinetic agents, prophylactic antibiotics, vasoactive pharmacotherapies, and timing of endoscopy.
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Affiliation(s)
- Iyad Khamaysi
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; The Endoscopy Unit of the Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
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Brooks J, Warburton R, Beales ILP. Prevention of upper gastrointestinal haemorrhage: current controversies and clinical guidance. Ther Adv Chronic Dis 2013; 4:206-22. [PMID: 23997925 DOI: 10.1177/2040622313492188] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Acute upper gastrointestinal (GI) bleeding is a common medical emergency and associated with significant morbidly and mortality. The risk of bleeding from peptic ulceration and oesophagogastric varices can be reduced by appropriate primary and secondary preventative strategies. Helicobacter pylori eradication and risk stratification with appropriate gastroprotection strategies when used with antiplatelet drugs and nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in preventing peptic ulcer bleeding, whilst endoscopic screening and either nonselective beta blockade or endoscopic variceal ligation are effective at reducing the risk of variceal haemorrhage. For secondary prevention of variceal haemorrhage, the combination of beta blockade and endoscopic variceal ligation is more effective. Recent data on the possible interactions of aspirin and NSAIDs, clopidogrel and proton pump inhibitors (PPIs), and the increased risk of cardiovascular adverse events associated with all nonaspirin cyclo-oxygenase (COX) inhibitors have increased the complexity of choices for preventing peptic ulcer bleeding. Such choices should consider both the GI and cardiovascular risk profiles. In patients with a moderately increased risk of GI bleeding, a NSAID plus a PPI or a COX-2 selective agent alone appear equivalent but for those at highest risk of bleeding (especially those with previous ulcer or haemorrhage) the COX-2 inhibitor plus PPI combination is superior. However naproxen seems the safest NSAID for those at increased cardiovascular risk. Clopidogrel is associated with a significant risk of GI haemorrhage and the most recent data concerning the potential clinical interaction of clopidogrel and PPIs are reassuring. In clopidogrel-treated patients at highest risk of GI bleeding, some form of GI prevention is indicated.
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Affiliation(s)
- Johanne Brooks
- Department of Gastroenterology, Norfolk and Norwich University Hospital, Norwich, UK
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Wang JG, Kong DR. Efficacy of endoscopic intervention alone versus endoscopic intervention plus propranolol in the prophylaxis of esophageal variceal rebleeding. Shijie Huaren Xiaohua Zazhi 2012; 20:2944-2950. [DOI: 10.11569/wcjd.v20.i30.2944] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compar e the efficacy of endoscopic variceal ligation (EVL) or endoscopic injection sclerotherapy (EIS) alone versus EVL or EIS plus propranolol in the prophylaxis of esophageal variceal rebleeding.
METHODS: Sixty-nine cirrhotic patients were divided randomly into endoscopic intervention group (EIG, n = 40; EVL or EIS) and combination intervention group (CIG, n = 29; EVL or EIS plus propranolol). The mortality, mortality due to rebleeding, and rate of rebleeding were compared between the two groups. All patients were followed for more than one year. In addition, changes in endoscopic characteristics of esophageal varices were evaluated according to the criterion of the Japan Society for Portal Hypertension.
RESULTS: There were no significantly differences in liver function, routine blood parameters, and serum electrolytes between the two groups. After intervention, the diameter of varices decreased significantly in the EIG group (10.92 ± 2.91 vs 8.45 ± 2.26, P < 0.05), but showed no significance in the CIG group (10.14 ± 2.46 vs 8.95 ± 2.21, P > 0.05). The distance from the proximal end of varices to the fore-tooth (22.79 ± 2.83 vs 24.85 ± 3.96, P < 0.05) and the rate of recurrence of red signs in varices (100% vs 76.19%, P < 0.05) decreased significantly after intervention in the CIG group. The morbidity of gastric varices and portal hypertensive gastropathy were both higher after intervention in the CIG group (10.34% vs 28.10%, P < 0.05; 10.34% vs 42.86%, P < 0.05). The appearance of varices in both groups changed from rosary-like to earthworm-like pattern. The rate of rebleeding between two groups displayed no significant difference (50.00% vs 51.71%, P > 0.05). However, the mortality in the CIG group was significantly lower than that in the EIG group (27.50% vs 7.41%, P < 0.05), and the main cause of death in both groups was upper gastrointestinal bleeding.
CONCLUSION: Endoscopic intervention combined with propranolol can decrease the risk of death and reduce endoscopic re-bleeding in the prevention of esophageal variceal re-bleeding.
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