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Daðadóttir SM, Ingason AB, Hreinsson JP, Björnsson ES. Comparison of gastrointestinal bleeding in patients with and without liver cirrhosis. Scand J Gastroenterol 2024; 59:1081-1086. [PMID: 39105571 DOI: 10.1080/00365521.2024.2386451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2024] [Revised: 07/15/2024] [Accepted: 07/26/2024] [Indexed: 08/07/2024]
Abstract
OBJECTIVES Upper gastrointestinal bleeding (GIB) in patients has been well-characterized in liver cirrhosis but studies on lower GIB are limited. The clinical characteristics, management and outcomes in patients with and without liver cirrhosis was compared to determine the overall features of GIB in patients with liver cirrhosis compared with non-cirrhotics. METHODS A retrospective study on cirrhotics hospitalized for GIB 2010-2021, matched with control group of non-cirrhotics (1:4) for upper vs. lower GIB. Patients with overt bleeding leading to hospitalization were included. RESULTS Overall, 396 patients had cirrhosis, 267 (67%) men, median age 62, alcoholic etiology 177/396 (45%), median MELD 12 (range 6-32). Overall 102 cirrhotics had GIB, matched with 391 non-cirrhotics. Overall 87 (85%) cirrhotic patients had upper and 15% lower GIB. Compared to non-cirrhotics, the cause of GIB was more commonly acute variceal bleeding (AVB) (42% vs. 1%), hemorrhoids 40% vs. 6% (p = 0.002), less commonly gastric ulcer 13% vs. 31% (p < 0.001), duodenal ulcer 9% vs. 29% (p < 0.001), 5% of cirrhotics used NSAIDs vs. 26% of controls (p < 0.001). Rebleeding occurred in 14% of cirrhotics vs. 3% in controls (p < 0.001). Only one cirrhotic patient (1%) died from GIB vs. 0.8% of controls within 45 days. Overall mortality 45 days after hospitalization was 10% in cirrhotics vs. 5% in controls (p < 0.001). CONCLUSIONS Bleeding from gastric and duodenal ulcers were less common in cirrhotics than in controls. Bleeding from hemorrhoids was more common in cirrhotics. Mortality due to GIB was low in both groups but overall mortality was significantly higher in cirrhotics.
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Affiliation(s)
| | | | - Johann Pall Hreinsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Einar Stefan Björnsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Division of Gastroenterology, Landspitali University, Reykjavik, Iceland
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Kinami T, Uchikawa S, Kawaoka T, Yamasaki S, Kosaka M, Johira Y, Yano S, Amioka K, Naruto K, Yamaoka K, Fujii Y, Fujino H, Nakahara T, Ono A, Murakami E, Okamoto W, Yamauchi M, Miki D, Tsuge M, Oka S. Efficacy and safety of atezolizumab plus bevacizumab in patients with portal hypertension for unresectable hepatocellular carcinoma. Cancer Med 2024; 13:e7025. [PMID: 38477514 DOI: 10.1002/cam4.7025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 12/20/2023] [Accepted: 02/07/2024] [Indexed: 03/14/2024] Open
Abstract
AIM Atezolizumab plus bevacizumab combination therapy (Atezo + Beva) is used as the first-line therapy for unresectable hepatocellular carcinoma (u-HCC). Serious adverse events (AEs), including rupture of esophagogastric varices, have been seen during treatment. Therefore, the relationships of efficacy, safety, and portal hypertension (PH) were analyzed. METHODS A total of 146 patients with u-HCC and Child-Pugh Scores of 5-7 received Atezo + Beva. Prophylactic treatment for varices was performed for patients with the risk of rupture of varices before the start of Atezo + Beva. A propensity score-matched cohort was created to minimize the risk of potential confounders. Efficacy was assessed in 41 propensity score-matched pairs. AEs were assessed between patients without PH (n = 80) and with PH (n = 66). RESULTS In patients without PH and with PH, median overall survival was 18.4 months and 18.8 months (p = 0.71), and median progression-free survival was 8.6 months and 5.8 months (p = 0.92), respectively. On the best radiological response evaluation for Response Evaluation Criteria in Solid Tumors, the objective response rate was 31.7% and 26.8% (p = 0.81), respectively. Variceal rupture occurred in three patients with PH, but there were no significant differences in the occurrence of variceal rupture (p = 0.090) and Grade 3-4 AEs between patients without and with PH. CONCLUSIONS No significant differences in efficacy and safety were observed with PH. Prophylactic treatment for varices before the start of Atezo + Beva would allow treatment to continue relatively safely.
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Affiliation(s)
- Takahiro Kinami
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinsuke Uchikawa
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tomokazu Kawaoka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shintaro Yamasaki
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masanari Kosaka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yusuke Johira
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shigeki Yano
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kei Amioka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kensuke Naruto
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kenji Yamaoka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yasutoshi Fujii
- Department of Clinical Oncology, Hiroshima University Hospital, Hiroshima, Japan
| | - Hatsue Fujino
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takashi Nakahara
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Atsushi Ono
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Eisuke Murakami
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Wataru Okamoto
- Department of Clinical Oncology, Hiroshima University Hospital, Hiroshima, Japan
| | - Masami Yamauchi
- Department of Clinical Oncology, Hiroshima University Hospital, Hiroshima, Japan
| | - Daiki Miki
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masataka Tsuge
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Kruger AJ, Abougergi MS, Jalil S, Sobotka LA, Wellner MR, Porter KM, Conteh LF, Kelly SG, Mumtaz K. Outcomes of Nonvariceal Upper Gastrointestinal Bleeding in Patients With Cirrhosis: A National Analysis. J Clin Gastroenterol 2023; 57:848-853. [PMID: 35960536 DOI: 10.1097/mcg.0000000000001746] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 06/26/2022] [Indexed: 12/10/2022]
Abstract
GOALS We sought to evaluate hospital outcomes of cirrhosis patients with nonvariceal upper gastrointestinal bleeding (NVUGIB). BACKGROUND NVUGIB is common in patients with cirrhosis. However, national outcome studies of these patients are lacking. STUDY We utilized the 2014 Nationwide Readmission Database to evaluate NVUGIB in patients with cirrhosis, further stratified as no cirrhosis (NC), compensated cirrhosis (CC), or decompensated cirrhosis (DC). Validated International Classification of Diseases, Ninth Revision, Clinical Modification codes captured diagnoses and interventions. Outcomes included 30-day readmission rates, index admission mortality rates, health care utilization, and predictors of readmission and mortality using multivariable regression analysis. RESULTS Overall, 13,701 patients with cirrhosis were admitted with NVUGIB. The 30-day readmission rate was 20.8%. Patients with CC were more likely to undergo an esophagogastroduodenoscopy (EGD) within 1 calendar day of admission (74.1%) than patients with DC (67.9%) or NC (69.4%). Patients with DC had longer hospitalizations (4.1 d) and higher costs of care ($11,834). The index admission mortality rate was higher in patients with DC (6.2%) than in patients with CC (1.7%, P <0.001) or NC (1.4%, P <0.001). Predictors of 30-day readmission included performing an EGD >1 calendar day from admission (OR: 1.21; 95% CI, 1.00 to 1.46) and DC (OR: 1.78; 95% CI, 1.54 to 2.06). DC was a predictor of index admission mortality (OR: 3.68; 95% CI, 2.67 to 5.05). CONCLUSIONS NVUGIB among patients with DC is associated with higher readmission rates, mortality rates, and health care utilization compared with patients with CC and NC. Early EGD is a modifiable variable associated with reduced readmission rates. Early identification of high-risk patients and adherence to guidelines may improve clinical outcomes.
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Affiliation(s)
| | - Marwan S Abougergi
- Division of Gastroenterology, Department of Internal Medicine, University of South Carolina School of Medicine, Columbia, SC
| | - Sajid Jalil
- Division of Gastroenterology, Hepatology, and Nutrition
| | | | | | - Kyle M Porter
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Sean G Kelly
- Division of Gastroenterology, Hepatology, and Nutrition
| | - Khalid Mumtaz
- Division of Gastroenterology, Hepatology, and Nutrition
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Liao F, Yang Y, Zhong J, Zhu Z, Pan X, Liao W, Li B, Zhu Y, Chen Y, Shu X. Incidence and risk factors for rebleeding after emergency endoscopic hemostasis for marginal ulcer bleeding. Clin Res Hepatol Gastroenterol 2022; 46:101953. [PMID: 35605892 DOI: 10.1016/j.clinre.2022.101953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/14/2022] [Accepted: 05/04/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Marginal ulcer bleeding is a cause of upper gastrointestinal bleeding, but the efficacy of emergency endoscopic hemostasis and risk factors for rebleeding have not been fully explored. The purpose of the current study was to investigate the rebleeding rate and risk factors after emergency endoscopic hemostasis for marginal ulcer bleeding. METHODS We conducted a retrospective study of 105 patients who underwent emergency endoscopic hemostasis due to marginal ulcer bleeding from January 2015 to July 2021. Patients included in this study were divided into rebleeding and non-rebleeding groups. RESULTS Among the 105 patients, 15.2% (16/105) patients developed rebleeding within 30 days after endoscopic hemostasis, and 87.5% of the patients had rebleeding within 7 days. The mean age of these patients was 60.3 ± 12.3 years, and 95 of them were male. In the univariate analysis, an ulcer size ≥10 mm, a PLT count <100 × 10^9/L and an AIMS65 score ≥2 were risk factors for rebleeding. According to the multivariable analysis, an ulcer size ≥10 mm (OR: 3.715; 95% CIs: 1.060-14.250; p = 0.043) and a PLT count <100 × 10^9/L (OR: 4.480; 95% CIs: 1.099-18.908; p = 0.035) were independent risk factors for rebleeding. CONCLUSION Emergency endoscopic hemostasis is an effective treatment for marginal ulcer bleeding. An ulcer size ≥10 mm and a PLT count <100 × 10^9/L were independent risk factors for rebleeding within 30 days after endoscopic hemostasis for marginal ulcer bleeding.
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Affiliation(s)
- Foqiang Liao
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Yihan Yang
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China; Jiangxi Clinical Research Center for Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Jiawei Zhong
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Zhenhua Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Xiaolin Pan
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Wangdi Liao
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Bimin Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Yin Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China.
| | - Youxiang Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Xu Shu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China; Jiangxi Clinical Research Center for Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China.
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Hsu C, Rimassa L, Sun HC, Vogel A, Kaseb AO. Immunotherapy in hepatocellular carcinoma: evaluation and management of adverse events associated with atezolizumab plus bevacizumab. Ther Adv Med Oncol 2021; 13:17588359211031141. [PMID: 34377156 PMCID: PMC8327224 DOI: 10.1177/17588359211031141] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/21/2021] [Indexed: 12/14/2022] Open
Abstract
In light of positive efficacy and safety findings from the IMbrave150 trial of atezolizumab plus bevacizumab, this novel combination has become the preferred first-line standard of care for patients with unresectable hepatocellular carcinoma (HCC). Several additional trials are ongoing that combine an immune checkpoint inhibitor with another agent such as a multiple kinase inhibitor or antiangiogenic agent. Therefore, the range of first-line treatment options for unresectable HCC is likely to increase, and healthcare providers need succinct information about the use of such combinations, including their efficacy and key aspects of their safety profiles. Here, we review efficacy and safety data on combination immunotherapies and offer guidance on monitoring and managing adverse events, especially those associated with atezolizumab plus bevacizumab. Because of their underlying liver disease and high likelihood of portal hypertension, patients with unresectable HCC are at particular risk of gastrointestinal bleeding, and this risk may be exacerbated by treatments that include antiangiogenic agents. Healthcare providers also need to be alert to the risks of proteinuria and hypertension, colitis, hepatitis, and reactivation of hepatitis B or C virus infection. They should also be aware of the possibility of rarer but potentially life-threatening adverse events such as pneumonitis and cardiovascular events. Awareness of the risks associated with these therapies and knowledge of adverse event monitoring and management will become increasingly important as the therapeutic range broadens in unresectable HCC.
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Affiliation(s)
- Chiun Hsu
- Graduate Institute of Oncology, National University College of Medicine, National University Hospital, and National University Cancer Center, Taipei
| | - Lorenza Rimassa
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Hui-Chuan Sun
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Arndt Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Medical School Hannover, Carl-Neubergstrasse 1, Hannover, 30625, Germany
| | - Ahmed O Kaseb
- Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 426, Houston, TX 77030, USA
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High Rate of Gastrointestinal Bleeding in Patients with Secondary Sclerosing Cholangitis in Critically Ill Patients (SC-CIP). J Clin Med 2021; 10:jcm10091925. [PMID: 33946877 PMCID: PMC8125451 DOI: 10.3390/jcm10091925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/21/2021] [Accepted: 04/27/2021] [Indexed: 11/26/2022] Open
Abstract
Secondary sclerosing cholangitis in critically ill patients (SC-CIP) is a rare cholestatic liver disease triggered by long-term intensive care treatment. The aim of this study was to evaluate the frequency and characteristics of gastrointestinal bleeding in SC-CIP. Patients with diagnosed SC-CIP were retrospectively identified and compared to a control group of patients with cardiac surgery and intensive care treatment but without the development of SC-CIP. Fifty-three patients with SC-CIP and 19 controls were included in the study. The frequency of gastrointestinal bleeding was 30% in SC-CIP (16 patients) and 5% in the control group (1 patient) (p = 0.03). Bleeding occured in the mean 13 months after admission to an intensive care unit in SC-CIP, three patients (19%) suffered bleeding during intensive care treatment. Three SC-CIP patients (19%) had cirrhosis at the time of bleeding, five (31%) had splenomegaly, and four (25%) received oral anticoagulation. In SC-CIP, 13 bleedings were identified in the upper gastrointestinal tract, two in the lower, and one remained unknown. The most common reasons for bleeding were gastroduodenal ulcers. In total, 80% of patients needed blood units, and one death due to bleeding occurred in SC-CIP. In conclusion, gastrointestinal bleeding is a frequent complication in patients with SC-CIP. Whether the liver disease itself or cofactors cause the susceptibility for bleeding remains unclear.
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Hung TH, Tsai CC, Lee HF. Population-based study of Entecavir and long-term mortality in chronic hepatitis B-related decompensated liver cirrhosis. Clin Res Hepatol Gastroenterol 2019; 43:694-699. [PMID: 30922728 DOI: 10.1016/j.clinre.2019.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 02/06/2019] [Accepted: 02/11/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS We lack population-based studies that identify the role of entecavir (ETV) in extending long-term survival in chronic hepatitis B (CHB)-related decompensated liver cirrhotic patients. Since 2010, National Health Insurance in Taiwan has covered long-term medical payment for antiviral therapy in CHB-related cirrhotic patients whose HBV DNA is ≥ 2000 IU/mL. We studied the effect of ETV on the mortality of CHB-related decompensated cirrhosis patients compared with patients who did not receive antiviral agents at baseline. METHODS From the Taiwan National Health Insurance Database, we collected 758 CHB-related decompensated cirrhosis patients with elevated viral loads (HBV DNA ≥ 2000 IU/mL) using ETV and discharged between January 1, 2010, and December 31, 2013. The comparison group consisted of 1516 selected CHB-related decompensated cirrhotic patients without antiviral therapy at baseline using propensity score matching analysis. RESULTS The 1-, 2-, and 3-year mortality probabilities were 34.7%, 42.5%, and 48.5 % in the ETV group and 21.1%, 37.8% and 51.3 % in the non-ETV group, respectively. Based on a Cox proportional hazards regression model adjusted by patients' sex, age, and comorbid disorders, the hazard ratios (HR) in the ETV group for 1-year, 1-2-year, and 2-3-year mortalities were 1.22 (95% confidence interval [CI] 1.05-1.43, P = .010), 1.02 (0.86-1.20, P = .866), and 0.59 (0.38-0.90, P = .016), compared with the non-ETV group. CONCLUSIONS Even in CHB-related decompensated cirrhotic patients, higher initial viral loads were correlated with poor outcomes. However, the long-term usage of ETV can decrease long-term mortality in these patients.
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Affiliation(s)
- Tsung-Hsing Hung
- Division of Gastroenterology, Department of Medicine, Buddhist Dalin Tzu Chi Hospital, Chia-Yi, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chih-Chun Tsai
- Department of Mathematics, Tamkang University, Tamsui, Taiwan
| | - Hsing-Feng Lee
- Division of Gastroenterology, Department of Medicine, Buddhist Dalin Tzu Chi Hospital, Chia-Yi, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan.
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Lo GH, Reiberger T. Peptic ulcer bleeding in patients with cirrhosis: Is it as bad as variceal bleeding? Hepatology 2018; 67:1219-1220. [PMID: 29171065 DOI: 10.1002/hep.29680] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 11/18/2017] [Indexed: 12/29/2022]
Affiliation(s)
- Gin-Ho Lo
- Department of Medical Research, Division of Gastroenterology, Department of Medicine, E-DA Hospital, School of Medicine for international students, I-Shou University, Kaohsiung, Taiwan
| | - Thomas Reiberger
- Hepatic Hemodynamic Lab, Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
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