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Osman KT, Nayfeh T, Abdelfattah AM, Alabdallah K, Hasan B, Firwana M, Alabaji H, Elkhabiry L, Mousa J, Prokop LJ, Murad MH, Gordon F. Secondary Prophylaxis of Gastric Variceal Bleeding: A Systematic Review and Network Meta-Analysis. Liver Transpl 2022; 28:945-958. [PMID: 34860458 DOI: 10.1002/lt.26383] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/21/2021] [Accepted: 11/26/2021] [Indexed: 12/12/2022]
Abstract
There is no clear consensus regarding the optimal approach for secondary prophylaxis of gastric variceal bleeding (GVB) in patients with cirrhosis. We conducted a systematic review and network meta-analysis (NMA) to compare the efficacy of available treatments. A comprehensive search of several databases from each database's inception to March 23, 2021, was conducted to identify relevant randomized controlled trials (RCTs). Outcomes of interest were rebleeding and mortality. Results were expressed as relative risk (RR) and 95% confidence interval (CI). We followed the Grading of Recommendations Assessment, Development, and Evaluation approach to rate the certainty of evidence. We included 9 RCTs with 647 patients who had histories of GVB and follow-ups >6 weeks. A total of 9 interventions were included in the NMA. Balloon-occluded retrograde transvenous obliteration (BRTO) was associated with a lower risk of rebleeding when compared with β-blockers (RR, 0.04; 95% CI, 0.01-0.26; low certainty), and endoscopic injection sclerotherapy (EIS)-cyanoacrylate (CYA) (RR, 0.18; 95% CI, 0.04-0.77; low certainty). β-blockers were associated with a higher risk of rebleeding compared with most interventions and with increased mortality compared with EIS-CYA (RR, 4.12, 95% CI, 1.50-11.36; low certainty), and EIS-CYA + nonselective β-blockers (RR, 5.61; 95% CI, 1.91-16.43; low certainty). Analysis based on indirect comparisons suggests that BRTO may be the best intervention in preventing rebleeding, whereas β-blocker monotherapy is likely the worst in preventing rebleeding and mortality. Head-to-head RCTs are needed to validate these results.
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Affiliation(s)
- Karim T Osman
- Department of Internal Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Clinic, Burlington, MA
| | - Tarek Nayfeh
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN
| | - Ahmed M Abdelfattah
- Division of Gastroenterology, Lahey Hospital and Medical Center, Beth Israel Lahey Clinic, Burlington, MA.,Department of Medicine, Division of Gastroenterology, University of Massachusetts Medical School, Worcester, MA
| | | | - Bashar Hasan
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN
| | | | - Homam Alabaji
- Department of Internal Medicine, Wertachklinik Schwabmünchen, Bavaria, Germany
| | - Lina Elkhabiry
- Department of Internal Medicine, University of Alexandria, Alexandria, Egypt
| | - Jehan Mousa
- Department of Internal Medicine, Damascus University, Damascus, Syria
| | - Larry J Prokop
- Department of Library Services, Mayo Clinic, Rochester, MN
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN
| | - Fredric Gordon
- Division of Gastroenterology, Lahey Hospital and Medical Center, Beth Israel Lahey Clinic, Burlington, MA.,Department of Transplantation and Hepatobiliary Diseases, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, MA
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Cap-Assisted Endoscopic Sclerotherapy vs Ligation in the Long-Term Management of Medium Esophageal Varices: A Randomized Trial. Clin Transl Gastroenterol 2021; 11:e00285. [PMID: 33512812 PMCID: PMC7743838 DOI: 10.14309/ctg.0000000000000285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Compared with endoscopic variceal ligation (EVL), cap-assisted endoscopic sclerotherapy (CAES) improves efficacy in the treatment of small esophageal varices (EVs) but has not been evaluated in the management of medium EVs. The aim of this study was to compare CAES with EVL in the long-term management of patients exhibiting cirrhosis with medium EVs and a history of esophageal variceal bleeding (EVB), with respect to variceal eradication and recurrence, adverse events, rebleeding, and survival.
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Increase in Free Hepatic Venous Pressure Response to Beta-Blockers Predicts Variceal Bleeding in Cirrhotic Patients. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5587566. [PMID: 33997022 PMCID: PMC8096544 DOI: 10.1155/2021/5587566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 04/05/2021] [Accepted: 04/15/2021] [Indexed: 11/17/2022]
Abstract
Background and Aims Nonselective beta-blockers (NSBBs) are the main drug to prevent portal hypertension. It could alter free hepatic venous pressure (FHVP); however, the significance is unknown. This prospective study was to explore the change of FHVP after use of NSBBs and its predictive value for gastroesophageal varices (GOV) bleeding in cirrhotic patients. Patients and Methods. Cirrhotic patients with medium-large GOV between September 2014 and January 2019 were enrolled. After initial hepatic venous pressure gradient (HVPG) measurement, patients received oral NSBBs. Seven days later, the secondary HVPG was examined to evaluate the FHVP alteration and hemodynamic response. The variceal bleeding between patients with FHVP increased and decreased/unchanged was compared. Results A total of 74 patients were enrolled, and 62 patients completed the secondary HVPG measurement and was followed up. The cumulative bleeding rate was significantly higher in patients with FHVP increased ≥ 1.75 mmHg than those with FHVP decreased/unchanged (54.5% vs. 22.5%, p = 0.021), while there was no significant difference in bleeding between HVPG responders and nonresponders (32.6% vs. 37.5%, p = 0.520). For HVPG responders, variceal bleeding in patients with FHVP increased ≥ 1.75 mmHg was significantly more than that in patients with FHVP decreased/unchanged (57.9% vs. 28.6%, p = 0.041). Cox regression analysis showed that change of FHVP was an independent predictor of variceal bleeding. Conclusion Increase ≥ 1.75 mmHg in FHVP responding to beta-blockers in cirrhotic patients with GOV indicates high risk of variceal bleeding. Besides HVPG response, change of FHVP should also be valued in hemodynamic evaluation to beta-blockers. This trial is registered with Chinese Clinical Trial Registry ChiCTR-IPR-17012836.
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Wang X, Wu B. Endoscopic sequential therapy for portal hypertension: Concept and clinical efficacy. LIVER RESEARCH 2021. [DOI: 10.1016/j.livres.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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An Y, Xu X, Ren T, Tong Z, Romeiro FG, Mancuso A, Guo X, Qi X. Adherence to Non-Selective Beta Blockers for Prevention of Variceal Bleeding in Cirrhotic Patients. Int J Gen Med 2021; 14:6713-6724. [PMID: 34675632 PMCID: PMC8520848 DOI: 10.2147/ijgm.s326192] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/30/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND AIM Long-term use of non-selective beta blockers (NSBBs) is essential for the prevention of esophageal variceal bleeding in liver cirrhosis but may impair the patient's adherence. The present study aimed to investigate the adherence to NSBBs to prevent variceal bleeding in cirrhotic patients. METHODS All patients who had an indication of NSBBs for the prophylaxis of variceal bleeding between February 2018 and June 2019 were screened. Clinical pharmacists gave pre-medication education and recorded the adherence to NSBBs during the patients' hospitalizations. Factors associated with poor adherence were evaluated by univariate logistic regression analysis. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. The relationship between poor adherence during follow-up and variceal bleeding after discharge was also evaluated. RESULTS Overall, 108 patients were screened, of whom 12 were intolerant to NSBBs. Among the 96 remaining patients who could take NSBBs, the average change of heart rate after NSBBs was -10.49 b.p.m. Twenty-two (22.9%) patients had poor adherence to NSBBs due to their refusal to take NSBBs (n = 2), complete forgetfulness to take NSBBs (n = 10), and refusal or forgetfulness to monitor heart rate (n = 10). Univariate logistic regression analysis demonstrated that only older age was significantly associated with poor adherence (OR: 1.065, 95% CI: 1.019-1.114, P = 0.005). Patients with poor adherence during follow-up were more likely to develop variceal bleeding after discharge. CONCLUSION A significant proportion of cirrhotic patients had poor adherence to NSBBs during their hospitalizations. Further studies should explore how to improve the patient's adherence to NSBBs.
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Affiliation(s)
- Yang An
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, 110840, People’s Republic of China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, 110016, People’s Republic of China
- Department of Pharmacy, General Hospital of Northern Theater Command, Shenyang, 110840, People’s Republic of China
| | - Xiangbo Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, 110840, People’s Republic of China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, 110016, People’s Republic of China
- Department of Pharmacy, General Hospital of Northern Theater Command, Shenyang, 110840, People’s Republic of China
| | - Tianshu Ren
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, 110840, People’s Republic of China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, 110016, People’s Republic of China
- Department of Pharmacy, General Hospital of Northern Theater Command, Shenyang, 110840, People’s Republic of China
| | - Zhenhua Tong
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, 110840, People’s Republic of China
- Section of Medical Service, General Hospital of Northern Theater Command, Shenyang, 110840, People’s Republic of China
| | - Fernando Gomes Romeiro
- Department of Internal Medicine, Botucatu Medical School, UNESP – Univ Estadual Paulista. Av. Prof. Mário Rubens Guimarães Montenegro, s/n Distrito de Rubião Jr, Botucatu, Brazil
| | - Andrea Mancuso
- Medicina Interna 1, ARNAS-Civico, Di Cristina-Benfratelli, Palermo, Italy
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, 110840, People’s Republic of China
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, 110840, People’s Republic of China
- Correspondence: Xingshun Qi; Xiaozhong Guo Email ;
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Xu X, Xu S, Primignani M, De Stefano V, He Y, Yi F, Guo X, Valla D, Qi X. Nonselective β-Blockers May Progress the Thrombosis of Portal Venous System in Cirrhotic Patients: A Retrospective Observational Study. Adv Ther 2020; 37:1452-1463. [PMID: 32076942 PMCID: PMC7140745 DOI: 10.1007/s12325-020-01250-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Occlusive portal venous system thrombosis (PVT) is significantly associated with poor outcomes in cirrhotic patients. Nonselective β-blockers (NSBBs) may be associated with the development of PVT. However, the role of NSBBs in progressing thrombosis remains unclear. METHODS Forty-three patients on whom contrast-enhanced computed tomography or magnetic resonance imaging was performed twice, and for whom there was detailed information regarding NSBBs, were eligible in this study, including 16 in the NSBBs group and 27 in the no NSBBs group. A composite endpoint of progressing thrombosis included the development of PVT in patients without PVT and aggravation of PVT in patients with PVT. Logistic regression analysis was employed to identify the effect of NSBBs on the progression of PVT. RESULTS At the last admission, 13 patients had progressing thrombosis. The incidence of progressing thrombosis was significantly higher in the NSBBs group than in the no NSBBs group [50.0% (8/16) vs. 18.5% (5/27), P = 0.030]. The use of NSBBs (odds ratio 4.400, 95% confidence interval 1.107-17.482, P = 0.035) was significantly associated with progressing thrombosis in univariate logistic regression analyses, but not significant (odds ratio 4.084, 95% confidence interval 0.488-34.158, P = 0.194) in multivariate logistic regression analyses. CONCLUSIONS NSBBs may play a role in the progression of PVT in liver cirrhosis. The benefits and risks of NSBBs in the management of liver cirrhosis should be fully weighed.
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Affiliation(s)
- Xiangbo Xu
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Shixue Xu
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Massimo Primignani
- CRC "A.M. e A. Migliavacca" Center for the Study of Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico Università degli Studi di Milano, Via F. Sforza 35, 20122, Milan, Italy
| | - Valerio De Stefano
- Fondazione Policlinico A. Gemelli IRCCS, Istituto di Ematologia, Università Cattolica, Rome, Italy
| | - Yanglan He
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Fangfang Yi
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Dominique Valla
- Service d'Hépatologie, Hôpital Beaujon, APHP, Clichy-la-Garenne, France
- CRI, UMR1149, Inserm and Université de Paris, Paris, France
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China.
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