Management of variceal and nonvariceal upper gastrointestinal bleeding in patients with cirrhosis

Does depressurization of the portal vein before liver transplantation affect the recurrence of HCC? A nested case-control study

BACKGROUND

Portal hypertension (PHT) has been proven to be closely related to the development of hepatocellular carcinoma (HCC). Whether PHT before liver transplantation (LT) will affect the recurrence of HCC is not clear.

METHODS

110 patients with depressurization of the portal vein (DPV) operations (Transjugular Intrahepatic Portosystemic Shunt-TIPS, surgical portosystemic shunt or/and splenectomy) before LT from a HCC LT cohort, matched with 330 preoperative non-DPV patients; this constituted a nested case-control study. Subgroup analysis was based on the order of DPV before or after the occurrence of HCC.

RESULTS

The incidence of acute kidney injury and intra-abdominal bleeding after LT in the DPV group was significantly higher than that in non-DPV group. The 5-year survival rates in the DPV and non-DPV group were 83.4% and 82.7% respectively (P = 0.930). In subgroup analysis, patients in the DPV prior to HCC subgroup may have a lower recurrence rate (4.7% vs.16.8%, P = 0.045) and a higher tumor free survival rate (88.9% vs.74.4%, P = 0.044) after LT under the up-to-date TNMI-II stage, while in TNM III stage, there was no difference for DPV prior to HCC subgroup compared with the DPV after HCC subgroup or the non-DPV group.

CONCLUSION

Compared with DPV after HCC, DPV treatment before HCC can reduce the recurrence rate of HCC after early transplantation (TNM I-II). DPV before LT can reduce the recurrence of early HCC.

Esophageal Stent in Acute Refractory Variceal Bleeding: A Systematic Review and a Meta-Analysis

Background: Acute esophageal variceal bleeding accounts for up to 70% of upper-gastrointestinal bleeding in cirrhotic patients. About 10-20% of patients with acute variceal bleeding have refractory bleeding that is not controlled by medical or endoscopic therapy, and this condition can be life-threatening. Balloon tamponade is a long-standing therapy which is only effective temporarily and has several complications, while transjugular intrahepatic portosystemic shunt (TIPS) and liver transplantation may not be readily available at some centers. The use of self-expandable metal stents (SEMSs) in refractory esophageal variceal bleeding has been studied for effectiveness and adverse events and has been recommended for use as a bridge to a more definitive treatment. Aim: To investigate the effectiveness and safety of SEMSs in managing refractory variceal bleeding. Methods: A systematic search of the MEDLINE, EMBASE, and Cochrane library databases was performed from inception to October 2022 using the following terms: "esophageal stent", "self-expandable metal stents", "endoscopic hemostasis", "refractory esophageal varices", and "esophageal variceal bleeding". Studies were included in the meta-analysis if they met the following criteria: (1) patients' age older than 18 and (2) a study (or case series) that has at least 10 patients in the study. Exclusion criteria included (1) non-English publications, (2) in case of overlapping cohorts, data from the most recent and/or most appropriate comprehensive report were collected. DerSimonian-Laird random-effects meta-analysis was performed using the meta package in R statistical software(version 4.2.2). Results: Twelve studies involving 225 patients with 228 stents were included in the analyses. The mean age and/or median age ranged from 49.4 to 69 years, with a male-to-female ratio of 4.4 to 1. The median follow-up period was 42 days. The mean SEMS dwell time was 9.4 days. The most common cause of acute refractory variceal bleeding in chronic liver disease patients included alcohol use followed by viral hepatitis. The pooled rate of immediate bleeding control was 91% (95% CI 82-95%, I2 = 0). The pooled rate of rebleeding was 17% (95% CI 8-32%, I2 = 69). The pooled rate of stent ulceration was 7% (95% CI 3-13%, I2 = 0), and the pooled rate of stent migration was 18% (95% CI 9-32%, I2 = 38). The pooled rate of all-cause mortality was 38% (95% CI 30-47%, I2 = 34). Conclusions: SEMSs should be primarily considered as salvage therapy when endoscopic band ligation and sclerotherapy fail and can be used as a bridge to emergent TIPS or definitive therapy, such as liver transplantation.

The prognostic evaluation of ALBI score in endoscopic treatment of esophagogastric varices hemorrhage in liver cirrhosis

To analyze the independent risk factors for recurrent bleeding and death within 1 year after endoscopic treatment of esophagogastric varices hemorrhage (EGVB) in patients with liver cirrhosis, and to validate the predictive value of ALBI score for recurrent bleeding and death within 1 year after endoscopic treatment of EGVB in patients with liver cirrhosis. A total of 338 patients with EGVB who received endoscopic treatment for the first time in the Department of Gastroenterology, First Affiliated Hospital of Nanchang University from January 1, 2016 to March 1, 2020 were selected. A database was established to analyze the patients' demographic data, surgical variables and postoperative outcomes. All patients were contacted and followed up to verify the predictive value of ALBI score for recurrent bleeding and mortality. 130 patients had rebleeding within 1 year after surgery (38.5%). 66 patients died within 1 year after surgery (19.5%). Patients with ALBI grade 3 had significantly higher rebleeding and mortality rates than those with grades 1 and 2. The AUC was used to compare the predictive value of the four scores for rebleeding and mortality within one year after endoscopic surgery. Both ALBI scores had the largest AUC. The ALBI score has certain predictive value for rebleeding and mortality within 1 year after endoscopic therapy in patients with cirrhotic EGVB.

Hepatic Impairment as a Risk Factor for Drug Safety: Suitability and Comparison of Four Liver Scores as Screening Tools

Hepatic impairment (HI) influences the pharmacokinetics and pharmacodynamics of drugs and represents an important risk factor for drug safety. A reliable screening tool for HI identification at hospital admission by pharmacists would be desirable but is currently lacking. Therefore, we tested four liver scores as potential screening instruments. We retrospectively recorded liver/bile diagnoses, symptoms and abnormalities (summarized as hepatic findings) of 200 surgical patients followed by an assessment of the relevance of these findings for drug therapy (rating). The agreement between the Model of Endstage Liver Disease (MELD), Non-alcoholic fatty liver disease fibrosis score (NFS), Fibrosis 4 index (FIB-4), and aspartate-aminotransferase to platelet ratio index (APRI) and the rating was quantified by Cohen's Kappa. The performance of the scores in this setting was further evaluated by their sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Of 200 patients, 18 (9%) had hepatic findings relevant for drug therapy. Fair agreement was found for FIB-4 and MELD and slight agreement for APRI and NFS compared to the rating. The highest values for sensitivity, specificity, PPV, and NPV were 41.2% (MELD), 99.3% (APRI), 66.7% (APRI), and 93.6% (MELD), respectively. Due to low performance, none of the scores can be recommended for clinical use as a single screening tool for HI at hospital admission.

Gastro‑oesophageal reflux disease in liver cirrhosis: Possible pathogenesis and clinical intervention (Review)

Oesophageal variceal bleeding is a common complication of decompensated liver cirrhosis (LC). Some studies have reported that reflux oesophagitis (RE) is a risk factor for upper gastrointestinal bleeding, and greatly impacts the quality of life. However, the frequency and mechanism of gastro-oesophageal reflux disease (GERD) in LC remain unclear. The present review explored the possible pathogenesis, and analysed the advantages and disadvantages of the interventional measures and the need for implementation of these measures. By combining the comprehensive terms associated with LC, GERD and RE, EMBASE, Medline/PubMed and the Cochrane Library were systematically searched. The underlying pathological mechanism of GERD in LC was summarized: Transient relaxation of the lower oesophageal sphincter, delayed gastric emptying, increased intra-abdominal pressure, increased intragastric pressure and excessive nitric oxide production destroyed the 'anti-reflux barrier', causing gastric content reflux. Proton pump inhibitors (PPIs) have been widely used empirically to lower the risk of oesophageal venous rupture and bleeding. However, long-term use of acid inhibitors in patients with LC may induce complications, such as spontaneous bacterial peritonitis. The metabolic half-life of PPIs is prolonged in patients with severe liver function impairment. Therefore, the indications for using acid inhibitors lack clarity. However, after endoscopic oesophageal variceal eradication, additional benefits may be gained from the long-term use of PPIs in small doses.

The Clinical and Endoscopic Profiles of Patients With Upper Gastrointestinal Bleeding (UGIB) and the Role of the Rockall Scoring System in Predicting Adverse Outcomes

INTRODUCTION

Upper gastrointestinal bleeding (UGIB) is one of the common emergencies seen by physicians. Upper gastrointestinal (UGI) endoscopy remains a crucial tool in the identification of UGIB.

OBJECTIVE

The aim of the present study was to determine the clinical and endoscopic profiles of UGIB in an adult population.

METHODS

This prospective, cross-sectional study was conducted in Dayanand Medical College and Hospital (DMCH), Ludhiana, where 75 patients aged 18 years and above admitted to the hospital with a history of UGIB from July 1 to December 31, 2018, were enrolled in the study. After obtaining the demographic data, all patients underwent clinical examination, laboratory investigations, and video endoscopy. The Rockall scoring system was used to assess their prognosis.

RESULTS

The mean age of the study population was 52.19±6.65 years. The majority (33%) were in the age group of 51-60 years. Of the study population, 82.7% were male and 17.3% were female. Chronic alcohol intake was found to be the most common risk factor, followed by drug intake. On upper gastrointestinal endoscopy, esophageal varices (65.3%) were the most common finding, followed by peptic ulcer disease (25.2%), gastric erosions (2.6%), gastroduodenitis (1.3%), Mallory-Weiss tear (1.3%), carcinoma stomach (1.3%), Camron's lesion (1.3%), and Dieulafoy's lesion (1.3%). Mortality attributed to UGIB was found to be 8%.

CONCLUSION

The present study reported portal hypertension as the most common cause of UGIB, while the most common endoscopic lesions reported were esophageal varices. The factors associated with poor prognosis were age >60 years, shock, respiratory failure, low hemoglobin, low platelet count, deranged international normalized ratio (INR), variceal bleed, renal failure, rebleed, Rockall score ≥ 8, and late endoscopy (>24 hours of admission). Urgent appropriate hospital management definitely helps to reduce morbidity and mortality in patients with UGIB.

Uncommon, overlooked and underreported causes of upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGB) is a potentially fatal consequence of digestive disorders. There is a wide range of rare causes for UGB that can lead to misdiagnosis and occasionally catastrophic outcomes. The lifestyles of those who are afflicted are mostly responsible for the underlying conditions that result in the hemorrhagic cases. The development of a novel approach targeted at raising public awareness of the issue and educating the public about it could significantly contribute to the elimination of gastrointestinal bleeding with no associated risks and to a nearly zero mortality rate. There are reports of UGB related to Sarcina ventriculi, gastric amyloidosis, jejunal lipoma, gastric schwannoma, hemobilia, esophageal varices, esophageal necrosis, aortoenteric fistula, homosuccus pancreaticus, and gastric trichbezoar in the literature. The common feature of these rare causes of UGB is that the diagnosis is difficult to establish before surgery. Fortunately, UGB with a clear lesion in the stomach itself is a clear sign for surgical intervention, and the diagnosis can only be verified by pathological examination with the help of immunohistochemical detection of a particular antigen for a specific condition. The clinical traits, diagnostic techniques, and the therapeutic, or surgical options of unusual causes of UGB reported in the literature are compiled in this review.

Predictive value of hepatic venous pressure gradient and efficacy and significance of early PTVE for gastrointestinal bleeding after TACE for liver cancer

Aims

To investigate the predictive value of hepatic venous pressure gradient (HVPG) and the efficacy and significance of early percutaneous transhepatic varices embolization (PTVE) for gastrointestinal bleeding after transcatheter arterial chemoembolization (TACE) for liver cancer.

Methods and Materials

This retrospective study enrolled 60 patients diagnosed with stage B or stage C liver cancer, according to the Barcelona Clinic Liver Cancer (BCLC) staging system, between December 2019 and October 2021. TACE and HVPG measurement (>16 mmHg or >20 mmHg) were performed on all 60 patients, who were randomized into control and experimental (PTVE) groups. All patients were followed up for 12 months.

Statistical Analysis Used

SPSS 20.0 software was used for data analysis. The two groups were compared with respect to the initial occurrence time of hemorrhage after TACE, recurrence time of hemorrhage, liver function, TACE frequency, TACE type, and tumor control.

Results

The initial hemorrhage rates at one, three, six, and 12 months after TACE were 3.2%, 12.9%, 22.6%, and 48.4%, respectively, in the control group (n = 31) and 0%, 0%, 3.4%, and 10.3%, respectively, in the PTVE group (n = 29). Differences between the groups in terms of initial hemorrhage rate at six and 12 months postoperatively were significant (P < 0.05). The recurrence rates of hemorrhage at one, three, six, and 12 months after TACE were 11.1%, 22.2%, 22.2%, and 33.3%, respectively, in 27 patients in the control group. In eight patients in the PTVE group, the corresponding rates were 0%, 0%, 0%, and 25.0%. The differences between the groups in the recurrence rate of hemorrhage at the four time points were significant (P < 0.05). At six months postoperatively, liver function recovery and remission were noted in eight (25.8%) and 18 (66.7%) patients, respectively, in the control group; these events were noted in 10 (34.5%) and 19 patients (65.5%), respectively, in the PTVE group, and the difference between the groups was not significant (P > 0.05). In the control group, TACE was performed for a total of 94 times on 31 patients within 12 months, including conventional transcatheter arterial chemoembolization (C-TACE, 75.5%) and the drug-eluting bead TACE (DEB-TACE, 24.5%); the objective response rate (ORR) was 39.3%. In the PTVE group, TACE was performed for a total of 151 times on 29 patients within 12 months, with an average of 5.21 times on each patient, including the C-TACE (57.6%) and DEB-TACE (42.4%); the ORR was 60.1%. Differences in TACE frequency, proportion of C-TACE/DEB-TACE, and ORR were significant between the two groups (P < 0.05).

Conclusion

HVPG can accurately evaluate gastrointestinal bleeding after TACE in patients with liver cancer. Early PTVE can significantly lower the risk of gastrointestinal bleeding and help TACE control tumor progression in patients with an HVPG >16 mmHg or >20 mmHg.

PPI efficacy in the reduction of variceal bleeding incidence and mortality, a meta-analysis

Objective

To review the efficacy and safety of proton pump inhibitors (PPIs) in gastroesophageal varices (GEVs).

Methods

We searched PubMed MEDLINE, Scopus, and Web of Science for studies that measured the effect of PPI for prophylaxis and treatment of post-band ligation ulcers up to July 20, 2021. We included studies that measured the effect of PPI as treatment or prophylaxis for post-band ligation ulcers; articles that were published in peer-reviewed international journals and had enough data for qualitative and quantitative analysis were included with no language restriction. Heterogeneity was evaluated using the inconsistency (I2) and chi-squared (χ2) test. I2 > 50% was considered substantial heterogeneity in the studies, and a P value less than 0.05 was considered statistically significant. The data was continuous, and we used the standardized mean difference (MD) and risk ratio (RR) with a 95% confidence interval to assess the estimated effect measure.

Results

A total of 7 studies with 2030 patients were included in our study of which 1480 participants were males (72%) and 550 females (18%). Mean age was 59.7 years old. Rebleeding post-band ligation was compared between PPI and placebo with significant favor for PPI (p = 0.00001). The pooled risk ratio was 0.53 (95% CI of 0.41, 0.68); furthermore, bleeding-related death at a 1-month period was compared between PPI and placebo with significant favor for PPI (p = 0.00001). The pooled risk ratio was significant at 0.33 (95% CI of 0.20, 0.53). The length of hospital stay postoperative was compared between PPI and placebo with cumulative mean difference of 0.13 (95% CI of −1.13, 1.39), yet without significance.

Conclusions

The study suggests a twofold reduction in the risk of bleeding and a threefold reduction in the risk of bleeding-related death with the use of PPI following EVL.

Prognostic study of acute-on-chronic liver failure patients: Usefulness of the fibrosis-4 index

Acute-on-chronic liver failure (ACLF) is a syndrome characterized by an acute deterioration of liver function in cirrhotic patients. Since treatment of this condition is difficult, its prevention is of paramount importance. The predictors of ACLF are yet to be identified. To determine the prognosis of cirrhotic and ACLF patients, we conducted a retrospective study to analyze each parameter in ACLF patients. Cirrhotic patients with serum total-bilirubin level ≥5.0 mg/dL and prothrombin time (PT) value ≤40% after acute insults were diagnosed with ACLF, whereas patients who met one of the above criteria were diagnosed with extended type of ACLF (EX-ACLF). Overall, in this study, 18 ACLF and 16 EX-ACLF patients retrospectively investigated between 2008 and 2020, and each data was analyzed during and before acute insults. In the analysis during acute insults, renal and coagulation functions showed significant differences between the ACLF and EX-ACLF groups. Furthermore, the mortality rate in the ACLF group was higher than that in the EX-ACLF group. In the analysis before acute insults, aspartate aminotransferase (AST), Fibrosis-4 (FIB-4) index score, and AST to platelet ratio index (APRI) showed significant differences between the two groups. Among these, the FIB-4 index score correlated best with ACLF severity for identifying cirrhotic patients with poor prognosis. The FIB-4 index is the most useful predictor of ACLF severity. Careful management of cirrhotic patients with a high FIB-4 index score is considered beneficial to prevent ACLF occurrence.

Noninvasive diagnostic value of indocyanine green retention test in patients with esophagogastric varices in liver cirrhosis

OBJECTIVE

This study aimed to evaluate the value of the indocyanine green retention test (ICG-R15) as a noninvasive predictor of gastroesophageal varices (GOV) in cirrhosis.

METHODS

A total of 629 patients with cirrhosis who were admitted to Mengchao Hepatobiliary Hospital of Fujian Medical University between June 2016 and September 2020 (450 in the trial group and 179 in the validation group) were selected. The trial group was divided into a GOV group and a non-GOV group based on gastroscopic findings. The two group's ICG results, clinical hematological, biochemical, and ultrasound parameters were compared. A predictive model for the noninvasive diagnosis of GOV was developed by applying binary logistic regression analysis and compared with previous common noninvasive diagnostic methods, followed by model validation in a validation group.

RESULTS

ICG-R15 is positively correlated with the degree of varicose veins. Univariate and multifactorial logistic regression analyses showed that PLT, PT, ICG-R15, splenic length, splenic vein diameter, and the presence of ascites were independent predictors of GOV. Predictive equation 1 for GOV was constructed based on the above factors: Logistic (Y1) = 1.327 × PLT + 0.691 × PT + 1.110 × ICG-R15 + 0.581 × SVD + 0.815 × SD + 1.130 × presence of ascites - 2.133, which predicted GOV in cirrhosis with an AUC of 0.861, sensitivity 84.5%, and specificity 74.1%. As the internal diameter of the splenic vein and the long diameter of the spleen are influenced by subjective factors and data are not easily available, we removed these two factors and constructed the prediction equation logistic (Y2) = 1.516 × PLT + 0.856 × PT + 1.135 × R15 + 1.297 × presence of ascites - 1.513. AUC for predicting GOV was also high at 0.850, with a sensitivity of 75.3% and a specificity of 83.2%. Similar results were obtained in the validation group. However, the previous GOV prediction models ARPI, AAR, FIB-4, Lok, FI, and King had AUCs of 0.731, 0.643, 0.781, 0.763, 0.735, and 0.730, respectively, in our trial group, with only low-to-moderate diagnostic efficacy.

CONCLUSION

ICG-R15 correlates with the severity of GOV in cirrhosis, and the models based on it can further improve the noninvasive diagnostic efficacy of GOV.

Prognostic value of albumin-related ratios in HBV-associated decompensated cirrhosis

Background

Identification of effective and accurate prognostic biomarkers for hepatitis B virus‐associated decompensated cirrhosis (HBV‐DeCi) is challenging. This study was designed to determine and compare the prognostic value of albumin‐related ratios (blood urea nitrogen‐to‐albumin ratio [BAR], C‐reactive protein‐to‐albumin ratio [CAR], prothrombin time‐international normalized ratio‐to‐albumin ratio [PTAR], neutrophil count‐to‐albumin ratio [NAR], and D‐dimer‐to‐albumin ratio [DAR]) in HBV‐DeCi patients.

Methods

We retrospectively recruited 161 HBV‐DeCi patients. Receiver operating characteristic curve, DeLong test, and Cox regression analyses were used to estimate and compare the predictive value of these five albumin‐related ratios and Model for End‐Stage Liver Disease (MELD) score.

Results

A total of 29 (18.0%) patients had died 30 days after admission. The prognostic roles of CAR, DAR, PTAR, NAR, and BAR in HBV‐DeCi were different. CAR, PTAR, NAR, and BAR were significantly higher in non‐survivors compared with survivors. However, DAR did not differ between the two groups. The predictive power of BAR was superior to that of the other four albumin‐related biomarkers and similar to that of MELD score. On multivariate analysis, BAR and MELD score were identified as independent prognostic factors, and the combination of BAR and MELD score may improve the prognostic accuracy in HBV‐DeCi.

Conclusion

The present findings suggest that BAR may be a simple and useful prognostic tool to predict mortality in HBV‐DeCi patients.

Endoscopic findings unrelated to portal hypertension in patients with liver cirrhosis undergoing a varicose vein screening programme

AIM

To determine the prevalence of endoscopic lesions unrelated with portal hypertension in patients with cirrhosis.

PATIENTS AND METHODS

Cross-sectional study including a consecutive cohort of patients with liver cirrhosis enrolled in a screening program of oesophageal varices who underwent an upper gastrointestinal endoscopy from November, 2013, to November, 2018. Clinical predictors of endoscopic lesions unrelated to portal hypertension were analyzed by univariate and multivariate logistic regression.

RESULTS

A total of 379 patients were included. The most frequent aetiology of liver disease was alcohol consumption (60.4%). The prevalence of endoscopic lesions unrelated with portal hypertension was 39.6% (n=150). Among 96 patients with peptic lesions, urease was obtained in 56.2% of patients (positive in 44.4% of them). The prevalence of endoscopic lesions unrelated to portal hypertension was not associated with age, gender, liver function or ultrasound findings of portal hypertension. The prevalence of endoscopic lesions unrelated to portal hypertension was not associated with age, gender, liver function or ultrasound findings of portal hypertension. Smokers had a trend to increased prevalence of endoscopic lesions unrelated to portal hypertension (43.2% vs. 34.6%; p=0.09), particularly peptic ulcer (6.4% vs. 0.6%; p=0.05) and peptic duodenitis (17.3% vs. 6.3%; p=0.002). Active smoking was the only independent predictor of peptic ulcer or duodenitis (OR=2.56; p=0.017).

CONCLUSION

Active smoking is a risk factor for endoscopic lesions unrelated to portal hypertension. This finding should be further investigated to reassess endoscopic screening programs in cirrhotic smokers.

Proton-pump-inhibitor use associated with lower short-term rebleeding and mortality in patients receiving esophageal variceal band ligation: a retrospective cohort study

BACKGROUND

The impact of proton-pump inhibitor (PPI) therapy on subsequent hemorrhage and mortality after variceal hemorrhage is unclear.

AIM

Evaluate the associations of PPI use with upper gastrointestinal bleeding (UGIB) and death within 30 days of undergoing esophageal variceal band ligation (EBL) separately in inpatient and outpatient settings.

METHODS

Retrospective review of cirrhotic patients with variceal hemorrhage who underwent EBL between 2005 and 2018. Endoscopic findings, PPI use at admission (inpatients only), PPI use at discharge (inpatients and outpatients), and adverse outcomes data (liver transplant, UGIB, transjugular intrahepatic portosystemic shunt, and death within 30 days of discharge or death during hospitalization) were reviewed.

RESULTS

A total of 446 patients (164 inpatients, 282 outpatients) were included. The most commonly observed outcomes were death within 30 days of discharge in inpatients (12.8%), UGIB within 30 days of discharge in inpatients (21.3%), and UGIB within 30 days of discharge in outpatients (8.5%). For inpatients, prescription of PPI at discharge was associated with a lower risk of bleeding within 30 days (odds ratio: 0.30, P = 0.025) and death within 30 days (odds ratio = 0.16, P = 0.002). No other significant associations of PPI with death or UGIB were reported.

CONCLUSION

Post-EBL PPI therapy is associated with reduced risk of bleeding and death within 30 days after variceal hemorrhage in hospitalized patients.

Causes of Upper Gastrointestinal Bleeding Among Pilgrims During the Hajj Period in the Islamic Years 1437-1439 (2016-2018)

Background

Approximately 3.5 million pilgrims perform Hajj every year. Planning for their healthcare requires knowledge of the pattern of diseases and risk factors of pilgrims who require hospitalization during the Hajj period. The aim of the current study was to evaluate common causes and risk factors of upper gastrointestinal bleeding (UGIB) among pilgrims during the Hajj season.

Method

We conducted a retrospective cross-sectional study using a data collection checklist to collect data from medical records. We included all patients who had UGIB and attended the endoscopy department of the King Abdulaziz Hospital, Mecca, in the AL-Hajj season of the Islamic years 1437-1439 (2016-2018).

Results

A total of 93 patients were included in the current study; of those, 65.59% were males. The mean age of the patients was 63.37 ± 12.83 years, and about one-third (29.03%) of them were Indonesian. Overall, melena with or without anemia was the most common presentation (44.09%), followed by hematemesis (34.78%), melena with hematemesis (15.05%), hematemesis with ascites (9.68%), and abdominal/epigastric pain (3.23%). The most common cause of UGIB was the presence of gastric origin (erosive gastritis/gastric ulcer/gastric tumor) with 22.58% of the patients presenting with the same. The most common factors were medications, especially non-steroidal anti-inflammatory drugs (NSAIDs) (37.63%) and blood thinners (22.58%). Hypertension (31.18%), diabetes mellitus (DM) (29.03%), and chronic liver disease/failure (27.96%) were the most common chronic conditions in the studied population.

Conclusion

Medical orientation towards high-risk pilgrims prone to developing UGIB who intend to travel may help reduce the risk of developing the condition, by taking proper measurements of those groups by the medical teams, especially in those with preventable factors.

The Effect of Transjugular Intrahepatic Portosystemic Shunt Plus Partial Splenic Embolization for the Treatment of Patients with Recurrent Variceal Bleeding

RATIONALE AND OBJECTIVES

Transjugular intrahepatic portosystemic shunt (TIPS) and partial splenic embolization (PSE) were two interventional therapies effective for the management of variceal bleeding with cirrhosis. This study aimed to investigate the effect of TIPS plus PSE for the treatment of patients with cirrhosis and recurrent variceal bleeding.

MATERIAL AND METHODS

This is a single-center, nonrandomized and retrospective study that included 32 patients undergoing TIPS alone (the TIPS group) and 16 patients undergoing TIPS plus PSE (the TIPS+PSE group).

RESULTS

The 5-year cumulative rates of variceal rebleeding (20.0% vs. 37.9%, p = 0.027) and shunt stenosis (35.1% vs. 55.9%, p = 0.036) in the TIPS+PSE group were significantly lower than in the TIPS group, whereas the 5-year cumulative rates of shunt blockage (12.5% vs. 25.8%, p = 0.388), and all-cause mortality (37.5% vs. 69.3%, p = 0.414) were not statistically different between the two groups. The 2-year cumulative rate of remaining free of hepatic encephalopathy was also similar between the two groups (75.0% vs. 81.3%, p = 0.704). Cox-regression analyses showed that group and reduction of portal venous pressure before and after TIPS creation were associated with both variceal rebleeding and shunt stenosis, whereas only reduction of portal venous pressure (hazard ratio 0.648, 95% confidence interval: 0.444-0.946, p = 0.025) was associated with shunt blockage. No severe adverse event was observed in the two groups.

CONCLUSION

TIPS+PSE is superior to TIPS alone in control of variceal rebleeding and shunt stenosis. Further prospective studies are warranted to confirm our findings.

Small-cell lung cancer with Mallory-Weiss syndrome as the prominent manifestation

The presence of Mallory-Weiss syndrome (MWS) in patients with small-cell lung cancer (SCLC) is uncommon. MWS is characterized by longitudinal superficial mucosal laceration at the esophagogastric junction and can be caused by a variety of causes, with upper digestive tract hemorrhage as the primary manifestation. SCLC is the most invasive histological subtype of lung cancer, and approximately a quarter of all SCLC patients undergo paraneoplastic syndrome of inappropriate antidiuretic hormone secretion, such as hyponatremia. In this study, we report a case of MWS in a middle-aged patient who was diagnosed with SCLC associated with hyponatremia. Clinicians should be alerted of the presence of MWS in upper gastrointestinal bleeding, such as epigastric pain, hematemesis, or melena, and keep SCLC in mind as a potential cause for underlying disease identification.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Assessment of prognostic performance of Albumin-Bilirubin, Child-Pugh, and Model for End-stage Liver Disease scores in patients with liver cirrhosis complicated with acute upper gastrointestinal bleeding

OBJECTIVE

The Albumin-Bilirubin (ALBI) score was developed recently to assess the severity of liver dysfunction. We aimed to assess its prognostic performance in patients with liver cirrhosis complicated with upper gastrointestinal bleeding (UGIB) while comparing it with Child-Pugh (CP) and Model for End-stage Liver Disease (MELD) scores.

PATIENTS AND METHODS

This was a retrospective unicentric study, including consecutive adult patients with cirrhosis admitted for UGIB between January 2011 and November 2015. Clinical, analytical, and endoscopic variables were assessed and ALBI, CP, and MELD scores at admission were calculated.

RESULTS

This study included 111 patients. During the first 30 days of follow-up, 12 (10.8%) patients died, and during the first year of follow-up, another 10 patients died (first-year mortality of 19.8%).On comparing the three scores, for in-stay and 30-day mortality, only the ALBI score showed statistically significant results, with an area under the curve (AUC) of 0.80 (P<0.01) for both outcomes. For first-year mortality, AUC for ALBI, CP, and MELD scores were 0.71 (P<0.01), 0.64 (P<0.05), and 0.66 (P=0.02), respectively, whereas for global mortality, AUC were 0.75 (P<0.01), 0.72 (P<0.01), and 0.72 (P<0.01), respectively. On comparing the AUC of the three scores, no significant differences were found in first-year mortality and global mortality.

CONCLUSION

In our series, the ALBI score accurately predicted both in-stay and 30-day mortality, whereas CP and MELD scores could not predict these outcomes. All scores showed a fair prognostic prediction performance for first-year and global mortality. These results suggest that the ALBI score is particularly useful in the assessment of short-term outcomes, with a better performance than the most commonly used scores.

Bacteremia in cirrhotic patients with upper gastrointestinal bleeding

BACKGROUND/AIMS

Increased risk of bacterial infection is common in cirrhotic patients with upper gastrointestinal bleeding (UGIB). Our study aimed to explore the association of the bacteremia with in-hospital mortality and risk factors of bacteremia in these patients.

MATERIALS AND METHODS

In our retrospective cohort study, we collected data for cirrhotic patients with UGIB admitted to our hospital between August 2010 and December 2010. The primary outcome was in-hospital mortality. The secondary outcome was bacteremia. A multivariate logistic regression analysis was performed to determine risk factors for mortality and bacteremia.

RESULTS

A total of 202 patients with cirrhosis presenting with UGIB at the emergency department (ED) were enrolled. Bacteremia was associated with a higher mortality rate (adjusted odds ratio [OR]: 9.7; 95% confidence interval [CI]: 1.9-50.6, p=0.007), whereas shock (systolic blood pressure <90 mmHg at ED triage) and bandemia (>0% immature neutrophils of band form) were associated with bacteremia in cirrhotic patients with UGIB (adjusted OR: 5.3; 95% CI: 2.3-12.7, p<0.0001 and adjusted OR: 4.0; 95% CI: 1.6-9.9, p=0.0003, respectively).

CONCLUSION

Bacteremia in cirrhotic patients with UGIB is one of the major risk factors leading to in-hospital mortality. On the basis of our findings, prevention of bacteremia in cirrhotic patients with UGIB, especially in those with shock and bandemia, is important; thus, adequate antibiotic treatment is suggested.

Evaluation and management of variceal bleeding

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

Development of a prognostic nomogram for cirrhotic patients with upper gastrointestinal bleeding

BACKGROUND AND AIM

Upper gastrointestinal bleeding (UGIB) is a complication with a high mortality rate in critically ill patients presenting with cirrhosis. Today, there exist few accurate scoring models specifically designed for mortality risk assessment in critically ill cirrhotic patients with upper gastrointestinal bleeding (CICGIB). Our aim was to develop and evaluate a novel nomogram-based model specific for CICGIB.

PATIENTS AND METHODS

Overall, 540 consecutive CICGIB patients were enrolled. On the basis of Cox regression analyses, the nomogram was constructed to estimate the probability of 30-day, 90-day, 270-day, and 1-year survival. An upper gastrointestinal bleeding-chronic liver failure-sequential organ failure assessment (UGIB-CLIF-SOFA) score was derived from the nomogram. Performance assessment and internal validation of the model were performed using Harrell's concordance index (C-index), calibration plot, and bootstrap sample procedures. UGIB-CLIF-SOFA was also compared with other prognostic models, such as CLIF-SOFA and model for end-stage liver disease, using C-indices.

RESULTS

Eight independent factors derived from Cox analysis (including bilirubin, creatinine, international normalized ratio, sodium, albumin, mean artery pressure, vasopressin used, and hematocrit decrease>10%) were assembled into the nomogram and the UGIB-CLIF-SOFA score. The calibration plots showed optimal agreement between nomogram prediction and actual observation. The C-index of the nomogram using bootstrap (0.729; 95% confidence interval: 0.689-0.766) was higher than that of the other models for predicting survival of CICGIB.

CONCLUSION

We have developed and internally validated a novel nomogram and an easy-to-use scoring system that accurately predicts the mortality probability of CICGIB on the basis of eight easy-to-obtain parameters. External validation is now warranted in future clinical studies.

Noninvasive Clinical Predictors of Portal Hypertensive Gastropathy in Patients with Liver Cirrhosis

BACKGROUND AND OBJECTIVES

Portal hypertensive gastropathy (PHG) is described endoscopically as "mosaic-like appearance" of gastric mucosa with or without the red spots. It can only be diagnosed by upper gastrointestinal (GI) endoscopy. The aim of this study was to determine the diagnostic accuracy of platelet count to spleen diameter ratio (PSR) and right liver lobe diameter to albumin ratio (RLAR) in the detection of PHG using upper GI endoscopy as a gold standard in patients with liver cirrhosis.

MATERIAL AND METHODS

This cross-sectional study was conducted in the Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi. All consecutive patients with ages 18-65 years who were screened using esophagogastroduodenoscopy (EGD) to exclude esophageal varices were enrolled. At the same time, findings related to PHG were noted. After informed consent, all the patients had blood tests including platelet count and albumin and abdominal ultrasound determining spleen diameter and right liver lobe diameter.

RESULTS

Out of 111 patients, 59 (53.15%) were males with a mean age of 44 ± 12.61 years. Rate of PHG was observed in 84.68% (94/111) cases confirmed by EGD. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of PSR were 87.23%, 5.88%, 83.67%, 7.69%, and 74.7%, respectively, and those of RLAR were 28.72%, 70.59%, 84.38%, 15.19%, and 35.14%, respectively.

CONCLUSION

PSR is better predictor of PHG than RLAR but at the expense of relatively lower specificities and NPV likely because of underlying pathophysiology (portal hypertension) which is similar for esophageal varices, PHG, and ascites.

Study of the association between hemorrhage and the position of hemorrhagic stigmata in patients with esophageal varices

The aim of the present study was to investigate the predilection position of hemorrhagic stigmata (HS) in patients with esophageal variceal hemorrhage and provide guidance on endoscopic therapy for esophageal varices. The clinical characteristics, particularly the endoscopic manifestations of HS, in the patients who presented with gastroesophageal variceal hemorrhage and cirrhosis between January 2003 and December 2013 at our hospital were summarized and patients were grouped according to the distance of the lesion site to incisors at 35-40 and ~30 cm. The association between the location of HS and active hemorrhage was assessed. The location of hemorrhage and HS at 35-40 cm from the incisors was more common in esophageal varices patients, followed by the location at ~30 cm from the incisors (P<0.0001). The incidence of HS in esophageal varices patients in the 35-40 cm group was significantly higher than that in the ~30 cm group except for HS at 9:00 position (P<0.0001). The highest incidence of HS in the ~30 cm group was at the 3:00 position, followed by the 12:00, 6:00 and 9:00 position. Among them, there were significant differences between the 3:00 and 6:00 position, the 3:00 and 9:00 position, and the 9:00 and 12:00 position (P<0.05). The order in the 35-40 cm group was similar to that in the ~30 cm group and the incidence of HS at the 9:00 position was lowest (P<0.05). A certain association between the point of location of HS and hemorrhage was identified. HS located at 35-40 cm from the lesion site to incisors was identified to be most likely to bleed, followed by that located at ~30 cm. In addition, the incidence of HS at 9:00 position was found to be lower than that in the other positions. Therefore, HS located at ~30 cm and 35-40 cm from the lesion site to incisors should be paid attention to and the 3:00, 12:00 and 6:00 rather than the 9:00 position should be prioritized during endoscopic treatment, particularly in emergency situations.

Acute gastrointestinal bleeding cases presenting to the emergency department are associated with age, sex and seasonal and circadian factors

BACKGROUND

Gastrointestinal bleeding (GIB) is one of the most common emergencies in gastroenterology. The aim of this study was to investigate the association between the incidence of GIB and seasonal, circadian and meteorological patterns in the emergency department (ED) of a tertiary hospital.

PATIENTS AND METHODS

From January 2007 until December 2012, we retrospectively evaluated patients presenting to the ED with respect to the number and location of GIB, season, time of day and weather.

RESULTS

Of 45 458 patients, 578 (1.3%) presented with a GIB. Of these, 62.5% were men compared with 54.7% of all patients in the ED (χ, P=0.0002). Patients with GIB were on average 4.4 years older than those without GIB (95% confidence interval 2.76-5.98, t-test, P<0.001). In addition, 304 (52.6%) patients had upper GIB and 138 (23.9%) had lower GIB. In total, 136 (23.5%) patients required no endoscopy because of initial laboratory and circulatory stability. In univariate analysis, meteorological parameters, including air temperature, cloud cover, relative humidity, vapour pressure, amount of precipitation, sunshine duration and snow height, were each associated with an increased risk of acute GIB (all P-values<0.05). In the 6-year study period, patients with GIB presented to the ED mainly during the winter months. Independent predictors of GIB on multivariate logistic regression were older age, male sex, season and daytime, all P less than 0.005. Emergency admissions during the night were associated with a 54 and 35% higher risk of GIB compared with daytime (8 a.m. to 4 p.m., P=0.0002) and late evening hours (4 p.m. to midnight, P=0.0142), respectively.

CONCLUSION

Presentation of patients with acute GIB in the ED is age and sex specific and shows seasonal and circadian differences in distribution, with an increased incidence in winter months and during night-time. This should be considered when determining possible emergency endoscopic interventions and the availability of emergency endoscopy services.

Spectrum of small-bowel mucosal abnormalities identified by capsule endoscopy in patients with portal hypertension of varied etiology

BACKGROUND

Bleeding from small intestinal ectopic varices and persistent anemia caused by portal hypertensive enteropathy (PHE) can be very challenging. Capsule endoscopy (CE) is one of the best noninvasive modalities in identifying such lesions.

AIM

The aims of this study are to study the prevalence of small-bowel changes related to portal hypertension (PHT) and to correlate them with the observations related to the effects of portal hypertension in the esophagus, stomach, and colon.

METHODS

Thirty-two patients with various etiologies of PHT with either anemia or gastrointestinal bleed were included along with age- and sex-matched controls without PHT. All patients underwent blood tests, gastroscopy, colonoscopy, and CE. The small-bowel findings by CE were categorized as inflammatory-like and vascular lesions. The small-bowel changes were analyzed to find out any association with various demographic, clinical, and endoscopic variables.

RESULTS

Thirty-one out of 32 patients with PHT (96.8%) had PHE identified by CE. Of them, 31 (96.8%) had inflammatory-like appearance, 11 (34.4%) had vascular lesions, and 2 (6.2%) had small-bowel varices. Inflammatory-like appearance was noted in eight (25%) and angiodysplastic lesions in two (6.2%) controls. Findings compatible with PHE were detected in 96.8% of the patients and 25% of the controls (X ² =34.72, p=0.000).The presence of PHE was not associated with any of the above-mentioned variables.

CONCLUSIONS

Small-bowel mucosal changes were seen in significantly higher number of patients with PHT with anemia.

Randomised controlled trial of n-butyl cyanoacrylate glue fixation versus suture fixation of mesh in laparoscopic totally extraperitoneal hernia repair

BACKGROUND:

We present a randomised control trial to compare suture fixation of the mesh with non-mechanical fixation using n-butyl cyanoacrylate (NBCA) glue for laparoscopic totally extraperitoneal (TEP) hernioplasty.

PATIENTS AND METHODS:

After a standard dissection for laparoscopic TEP hernioplasty, the mesh was fixed using sutures or NBCA glue to the Cooper's ligament as per the randomised allocation. The primary endpoints were recurrence at 24 months and chronic groin pain. The secondary endpoints were pain scores, analgesic requirement in the post-operative period and duration of surgery.

RESULTS:

Group A consisting of suture fixation had 127 patients which included a total of 173 hernias while Group B consisting of NBCA had 124 patients including a total of 171 hernias. The patients’ age, sex distribution, body mass indices and co-morbidities were comparable in both groups. No patient suffered any major intra-operative or post-operative complication or mortality. There were no conversions to open surgery in either of the groups. The operating time was similar in both the groups though there was a tendency toward a shorter surgery time in Group B. There was lesser consumption of analgesics in the immediate post-operative period in Group B but this did not reach statistical significance. Using visual analogue scale to measure pain, there was no difference in pain at 48 h; however, Group B patients complained of significantly less pain on day 7 as compared to Group A. Almost 98% of Group A patients and 99.2% of Group B patients completed 24 months of follow-up. There were no recurrences in either groups or was there any significant difference in chronic groin pain, in fact, none of the Group B patients complained of chronic groin pain.

CONCLUSION:

Using NBCA glue to fix the mesh in laparoscopic TEP hernia repair is effective and associated with less pain on day 7 as compared to suture fixation of the mesh.

Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy

AIM

To describe the pathophysiology, clinical presentation, natural history, and therapy of portal hypertensive gastropathy (PHG) based on a systematic literature review.

METHODS

Computerized search of the literature was performed via PubMed using the following medical subject headings or keywords: "portal" and "gastropathy"; or "portal" and "hypertensive"; or "congestive" and "gastropathy"; or "congestive" and "gastroenteropathy". The following criteria were applied for study inclusion: Publication in peer-reviewed journals, and publication since 1980. Articles were independently evaluated by each author and selected for inclusion by consensus after discussion based on the following criteria: Well-designed, prospective trials; recent studies; large study populations; and study emphasis on PHG.

RESULTS

PHG is diagnosed by characteristic endoscopic findings of small polygonal areas of variable erythema surrounded by a pale, reticular border in a mosaic pattern in the gastric fundus/body in a patient with cirrhotic or non-cirrhotic portal hypertension. Histologic findings include capillary and venule dilatation, congestion, and tortuosity, without vascular fibrin thrombi or inflammatory cells in gastric submucosa. PHG is differentiated from gastric antral vascular ectasia by a different endoscopic appearance. The etiology of PHG is inadequately understood. Portal hypertension is necessary but insufficient to develop PHG because many patients have portal hypertension without PHG. PHG increases in frequency with more severe portal hypertension, advanced liver disease, longer liver disease duration, presence of esophageal varices, and endoscopic variceal obliteration. PHG pathogenesis is related to a hyperdynamic circulation, induced by portal hypertension, characterized by increased intrahepatic resistance to flow, increased splanchnic flow, increased total gastric flow, and most likely decreased gastric mucosal flow. Gastric mucosa in PHG shows increased susceptibility to gastrotoxic chemicals and poor wound healing. Nitrous oxide, free radicals, tumor necrosis factor-alpha, and glucagon may contribute to PHG development. Acute and chronic gastrointestinal bleeding are the only clinical complications. Bleeding is typically mild-to-moderate. Endoscopic therapy is rarely useful because the bleeding is typically diffuse. Acute bleeding is primarily treated with octreotide, often with concomitant proton pump inhibitor therapy, or secondarily treated with vasopressin or terlipressin. Nonselective β-adrenergic receptor antagonists, particularly propranolol, are used to prevent bleeding after an acute episode or for chronic bleeding. Iron deficiency anemia from chronic bleeding may require iron replacement therapy. Transjugular-intrahepatic-portosystemic-shunt and liver transplantation are highly successful ultimate therapies because they reduce the underlying portal hypertension.

CONCLUSION

PHG is important to recognize in patients with cirrhotic or non-cirrhotic portal hypertension because it can cause acute or chronic GI bleeding that often requires pharmacologic therapy.

Prognostic performance of clinical indices and model scorings for acute-on-chronic liver failure: A study of 164 patients

The present study aimed to analyze the prognostic factors of acute-on-chronic liver failure (ACLF), with the perspective of an improved selection of optimal therapeutic schemes. A retrospective analysis was used to study 164 patients with ACLF hospitalized between 2010 and 2014 in a single center. Patients were divided into favorable and unfavorable groups, according to the treatment outcomes. General characteristics and clinical manifestations were analyzed to determine whether they would affect the prognosis of the patients with ACLF, with a particular focus on the scoring systems Child-Pugh, model for end-stage liver disease (MELD), MELD with incorporation of sodium (MELD-Na), MELD and serum sodium ratio (MESO) and integrated MELD (iMELD). Hepatitis B virus infection was the predominant cause of ACLF, accounting for 88 cases (53.7%). Age, prothrombin time, thrombin time, international normalized ratio (INR), prothrombin activity, serum sodium, albumin, total bilirubin, serum creatinine, platelets, fasting blood sugar, infections, hepatic encephalopathy, hepatorenal syndrome (HRS), and electrolyte disorder were revealed to be associated with prognosis. Age, serum sodium, INR, HRS, and infection were independent prognostic risk factors, as determined by multivariate analysis. Child-Pugh, MELD, MELD-Na, MESO and iMELD scoring systems all demonstrated adequate predictive values, with MELD-Na as the most effective scoring system. In conclusion, age, hyponatremia, INR, HRS and bacterial or fungal infections were reported to be independent prognostic risk factors for ACLF. Among the various liver function scoring systems, MELD-Na was the most accurate in predicting the prognosis of ACLF.

Non-variceal upper gastrointestinal bleeding in cirrhotic patients in Nile Delta

BACKGROUND AND STUDY AIMS

Acute upper gastrointestinal bleeding (AUGIB) in cirrhotic patients occurs mainly from esophageal and gastric varices; however, quite a large number of cirrhotic patients bleed from other sources as well. The aim of the present work is to determine the prevalence of non-variceal UGIB as well as its different causes among the cirrhotic portal hypertensive patients in Nile Delta.

METHODS

Emergency upper gastrointestinal (UGI) endoscopy for AUGIB was done in 650 patients. Out of these patients, 550 (84.6%) patients who were proved to have cirrhosis were the subject of the present study.

RESULTS

From all cirrhotic portal hypertensive patients, 415 (75.5%) bled from variceal sources (esophageal and gastric) while 135 (24.5%) of them bled from non-variceal sources. Among variceal sources of bleeding, esophageal varices were much more common than gastric varices. Peptic ulcer was the most common non-variceal source of bleeding.

CONCLUSIONS

Non-variceal bleeding in cirrhosis was not frequent, and sources included peptic ulcer, portal hypertensive gastropathy, and erosive disease of the stomach and duodenum.

Diagnostic Accuracy of APRI, AAR, FIB-4, FI, and King Scores for Diagnosis of Esophageal Varices in Liver Cirrhosis: A Retrospective Study

BACKGROUND Aspartate aminotransferase-to-platelet ratio index (APRI), aspartate aminotransferase-to-alanine aminotransferase ratio (AAR), FIB-4, fibrosis index (FI), and King scores might be alternatives to the use of upper gastrointestinal endoscopy for the diagnosis of esophageal varices (EVs) in liver cirrhosis. This study aimed to evaluate their diagnostic accuracy in predicting the presence and severity of EVs in liver cirrhosis. MATERIAL AND METHODS All patients who were consecutively admitted to our hospital and underwent upper gastrointestinal endoscopy between January 2012 and June 2014 were eligible for this retrospective study. Areas under curve (AUCs) were calculated. Subgroup analyses were performed according to the history of upper gastrointestinal bleeding (UGIB) and splenectomy. RESULTS A total of 650 patients with liver cirrhosis were included, and 81.4% of them had moderate-severe EVs. In the overall analysis, the AUCs of these non-invasive scores for predicting moderate-severe EVs and presence of any EVs were 0.506-0.6 and 0.539-0.612, respectively. In the subgroup analysis of patients without UGIB, their AUCs for predicting moderate-severe varices and presence of any EVs were 0.601-0.664 and 0.596-0.662, respectively. In the subgroup analysis of patients without UGIB or splenectomy, their AUCs for predicting moderate-severe varices and presence of any EVs were 0.627-0.69 and 0.607-0.692, respectively. CONCLUSIONS APRI, AAR, FIB-4, FI, and King scores had modest diagnostic accuracy of EVs in liver cirrhosis. They might not be able to replace the utility of upper gastrointestinal endoscopy for the diagnosis of EVs in liver cirrhosis.

Ectopic Jejunal Variceal Rupture in a Liver Transplant Recipient Successfully Treated With Percutaneous Transhepatic Coil Embolization: A Case Report

Here we present the rupture of ectopic jejunal varices developing in a liver transplant recipient without portal hypertension, which was successfully treated with percutaneous transhepatic coil embolization.A 48-year-old man with massive melena was admitted to our department. He had undergone liver transplantation for hepatitis B virus-related liver cirrhosis 8 months before, and his postoperative course was satisfactory except for an acute cellular rejection. No evidence of bleeding was detected by upper endoscopy or colonoscopy, but dynamic multidetector computed tomography of the whole abdomen revealed an intestinal varix protruding into the lumen of the jejunum with suspected extravasation. There was no evidence of portal venous stenosis or thrombosis. Immediately upon diagnosis of the ruptured ectopic jejunal varix, percutaneous transhepatic coil embolization was performed, achieving complete hemostasis. The portal venous pressure measured during the procedure was within normal limits. He was discharged from the hospital 11 days after embolization and remained in stable condition without re-bleeding 6 months after discharge.This is the first report of an ectopic intestinal variceal rupture in an uneventful liver transplant recipient that was successfully treated with interventional percutaneous transhepatic coil embolization. Clinicians encountering liver transplant recipients with melena should be aware of the possibility of late-onset rupture of ectopic varices, even in those having an uneventful post-transplant course without portal hypertension.

Gastrointestinal endoscopy in the cirrhotic patient

As advances in liver disease continue, including the increasing use of liver transplantation, the endoscopist needs to be familiar with the standards of care and potential complications in the management of the cirrhotic population. This includes both elective endoscopic procedures, such as screening colonoscopies and variceal banding, as well as the acutely bleeding cirrhotic patient. Peri-procedural management and standards of care for acute gastrointestinal hemorrhaging of cirrhotic patients will be emphasized. This article will focus on the plethora of data available to highlight the benefits of endoscopic intervention in the care of patients with liver disease and outline the areas of future emphasis.

Downhill oesophageal variceal bleeding: A rare complication in Behçet's disease-related superior vena cava syndrome

Behçet's disease (BD) is a multisystemic disorder that involves vessels of all sizes. Superior vena cava (SVC) thrombosis is a rare complication that can lead to the development of various collateral pathways. A 31-year-old man presented with SVC syndrome. He had a history of recurrent genital aphthosis. Computed tomography revealed extensive thrombosis of the right internal jugular, axillary, and subclavian veins with collateral circulation. The patient was diagnosed with BD, and he was started on anticoagulation and immunosuppressive therapy. One week later, he presented with haematemesis. Upper gastrointestinal endoscopy disclosed varices in the upper third of the oesophagus with stigmata of recent bleeding. Portal hypertension was ruled out. Anticoagulation therapy was discontinued. He was discharged on immunosuppressive therapy. Bleeding from downhill oesophageal varices should be suspected in any patient presenting with upper gastrointestinal bleeding and a history of SVC syndrome due to BD.

Child-Pugh versus MELD score for predicting the in-hospital mortality of acute upper gastrointestinal bleeding in liver cirrhosis

A retrospective study was conducted to compare the performance of Child-Pugh and Model for End-Stage Liver Diseases (MELD) scores for predicting the in-hospital mortality of acute upper gastrointestinal bleeding (UGIB) in patients with liver cirrhosis. A total of 145 patients with a diagnosis of liver cirrhosis and acute UGIB between July 2013 and June 2014 were retrospectively analyzed (male/female: 94/51; mean age: 56.77±11.33 years; Child-Pugh class A/B/C: 46/64/35; mean Child-Pugh score: 7.88±2.17; mean MELD score: 7.86±7.22). The in-hospital mortality was 8% (11/145). Areas under receiving-operator characteristics curve (AUROC) for predicting the in-hospital mortality were compared between MELD and Child-Pugh scores. AUROCs for predicting the in-hospital mortality for Child-Pugh and MELD scores were 0.796 (95% confidence interval [CI]: 0.721-0.858) and 0.810 (95% CI: 0.736-0.870), respectively. The discriminative ability was not significant different between the two scoring systems (P=0.7241). In conclusion, Child-Pugh and MELD scores were similar for predicting the in-hospital mortality of acute UGIB in cirrhotic patients.