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Ichita C, Shimizu S, Goto T, Haruki U, Itoh N, Iwagami M, Sasaki A. Effectiveness of antibiotic prophylaxis for acute esophageal variceal bleeding in patients with band ligation: A large observational study. World J Gastroenterol 2024; 30:238-251. [PMID: 38314133 PMCID: PMC10835525 DOI: 10.3748/wjg.v30.i3.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/12/2023] [Accepted: 01/03/2024] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Esophageal variceal bleeding is a severe complication associated with liver cirrhosis and typically necessitates endoscopic hemostasis. The current standard treatment is endoscopic variceal ligation (EVL), and Western guidelines recommend antibiotic prophylaxis following hemostasis. However, given the improvements in prognosis for variceal bleeding due to advancements in the management of bleeding and treatments of liver cirrhosis and the global concerns regarding the emergence of multidrug-resistant bacteria, there is a need to reassess the use of routine antibiotic prophylaxis after hemostasis. AIM To evaluate the effectiveness of antibiotic prophylaxis in patients treated for EVL. METHODS We conducted a 13-year observational study using the Tokushukai medical database across 46 hospitals. Patients were divided into the prophylaxis group (received antibiotics on admission or the next day) and the non-prophylaxis group (did not receive antibiotics within one day of admission). The primary outcome was composed of 6-wk mortality, 4-wk rebleeding, and 4-wk spontaneous bacterial peritonitis (SBP). The secondary outcomes were each individual result and in-hospital mortality. A logistic regression with inverse probability of treatment weighting was used. A subgroup analysis was conducted based on the Child-Pugh classification to determine its influence on the primary outcome measures, while sensitivity analyses for antibiotic type and duration were also performed. RESULTS Among 980 patients, 790 were included (prophylaxis: 232, non-prophylaxis: 558). Most patients were males under the age of 65 years with a median Child-Pugh score of 8. The composite primary outcomes occurred in 11.2% of patients in the prophylaxis group and 9.5% in the non-prophylaxis group. No significant differences in outcomes were observed between the groups (adjusted odds ratio, 1.11; 95% confidence interval, 0.61-1.99; P = 0.74). Individual outcomes such as 6-wk mortality, 4-wk rebleeding, 4-wk onset of SBP, and in-hospital mortality were not significantly different between the groups. The primary outcome did not differ between the Child-Pugh subgroups. Similar results were observed in the sensitivity analyses. CONCLUSION No significant benefit to antibiotic prophylaxis for esophageal variceal bleeding treated with EVL was detected in this study. Global reassessment of routine antibiotic prophylaxis is imperative.
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Affiliation(s)
- Chikamasa Ichita
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura 247-8533, Kanagawa, Japan
- Department of Health Data Science, Yokohama City University, Yokohama 236-0027, Kanagawa, Japan
| | - Sayuri Shimizu
- Department of Health Data Science, Yokohama City University, Yokohama 236-0027, Kanagawa, Japan
| | - Tadahiro Goto
- Department of Health Data Science, Yokohama City University, Yokohama 236-0027, Kanagawa, Japan
- TXP Research, TXP Medical Co., Ltd., Chiyoda-ku 101-0042, Tokyo, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku 113-0033, Tokyo, Japan
| | - Uojima Haruki
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura 247-8533, Kanagawa, Japan
- Department of Genome Medical Sciences Project, Research Institute, National Center for Global Health and Medicine, Ichikawa 272-8516, Chiba, Japan
| | - Naoya Itoh
- Division of Infectious Diseases, Aichi Cancer Center, Nagoya 464-8681, Aichi, Japan
| | - Masao Iwagami
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Tsukuba 305-8575, Ibaraki, Japan
| | - Akiko Sasaki
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura 247-8533, Kanagawa, Japan
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Ueno M, Fujiwara T, Tokumasu H, Mano T, Kayahara T, Takabatake H, Morimoto Y, Matsueda K, Fukuoka T, Mizuno M. Real-world efficacy of antibiotic prophylaxis for upper gastrointestinal bleeding in cirrhotic patients in Japan. J Gastroenterol 2023; 58:766-777. [PMID: 37171554 DOI: 10.1007/s00535-023-02000-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/03/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND AND AIMS Antibiotic prophylaxis is recommended for cirrhotic patients with upper gastrointestinal bleeding (UGIB). However, the frequency of bacterial infection in such patients has remarkably decreased over the decades, which has reduced the necessity for prophylaxis. Therefore, here we investigated the real-world adherence and effectiveness of antibiotic prophylaxis in cirrhotic patients with UGIB in Japan. METHODS This population-based study was conducted with a Japanese real-world database of the Health, Clinic, and Education Information Evaluation Institute. We enrolled cirrhotic patients who were hospitalized for UGIB between April 2010 and March 2020. After those who died within 24 h and who had aspiration pneumonia at admission were excluded, 1232 patients were analyzed. Rates of 6-week mortality, in-hospital bacterial infection, 30-day readmission, and length of hospital stay were evaluated. RESULTS Prophylactic antibiotics were prescribed in 142 (11.5%) patients. Multivariate analysis revealed that antibiotic prophylaxis was not significantly associated with either 6-week mortality or bacterial infection. After propensity score matching, the rates of 6-week mortality (7.2% vs. 8.4%, P = 0.810), bacterial infection (9.6% vs. 4.2%, P = 0.082), and 30-day unexpected readmission (7.2% vs. 7.8%, P = 1.000) were similar in patients with and without prophylaxis, whereas the median length of hospital stay was significantly longer in patients with prophylaxis (17 days vs. 13 days, P = 0.013). CONCLUSIONS Under current real-world circumstances in Japan, prophylactic antibiotics were prescribed in only 11.5% of cirrhotic patients with UGIB and were not associated with better clinical outcomes.
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Affiliation(s)
- Masayuki Ueno
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki, Okayama, 710-8602, Japan.
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Takashi Fujiwara
- Department of Public Health Research, Kurashiki Clinical Research Institute, Okayama, Japan
- Department of Otolaryngology/Head and Neck Surgery, Kurashiki Central Hospital, Okayama, Japan
| | - Hironobu Tokumasu
- Department of Public Health Research, Kurashiki Clinical Research Institute, Okayama, Japan
| | - Toshifumi Mano
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki, Okayama, 710-8602, Japan
| | - Takahisa Kayahara
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki, Okayama, 710-8602, Japan
| | - Hiroyuki Takabatake
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki, Okayama, 710-8602, Japan
| | - Youichi Morimoto
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki, Okayama, 710-8602, Japan
| | - Kazuhiro Matsueda
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki, Okayama, 710-8602, Japan
| | - Toshio Fukuoka
- Emergency and Critical Care Center, Kurashiki Central Hospital, Okayama, Japan
| | - Motowo Mizuno
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki, Okayama, 710-8602, Japan
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Gao Y, Qian B, Zhang X, Liu H, Han T. Prophylactic antibiotics on patients with cirrhosis and upper gastrointestinal bleeding: A meta-analysis. PLoS One 2022; 17:e0279496. [PMID: 36548353 PMCID: PMC9778565 DOI: 10.1371/journal.pone.0279496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To evaluate the effect of different prophylactic antibiotic treatments for cirrhosis patients with upper gastrointestinal bleeding (UGIB) and to investigate whether prophylactic antibiotics are equally beneficial to reducing the risk of adverse outcomes in A/B with low Child-Pugh scores. METHODS Relevant studies were searched via PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Internet (CNKI), Wanfang, and VIP databases up to July 16, 2021. The heterogeneity test was conducted for each outcome measuring by I2 statistics. Subgroup analysis was performed regarding antibiotic types. Relative risk (RR) and 95% confidence interval (CI) were used to evaluate prophylactic antibiotics on the risk of adverse outcomes in cirrhosis patients with UGIB. RESULTS Twenty-six studies involving 12,440 participants fulfilled our inclusion criteria. Antibiotic prophylaxis was associated with a reduced overall mortality (RR: 0.691, 95%CI: 0.518 to 0.923), mortality due to bacterial infections (RR: 0.329, 95%CI: 0.144 to 0.754), bacterial infections (RR: 0.389, 95%CI: 0.340 to 0.444), rebleeding (RR: 0.577, 95%CI: 0.433 to 0.767) and length of hospitalization [weighted mean difference (WMD): -3.854, 95%CI: -6.165 to -1.543] among patients with UGIB. Nevertheless, prophylactic antibiotics may not benefit to A/B population with low Child-Pugh scores. In our subgroup analysis, quinolone, beta-lactams alone or in combination reduced adverse outcomes in cirrhosis patients with UGIB. CONCLUSION Administration of antibiotics was associated with a reduction in mortality, bacterial infections, rebleeding, and length of hospitalization. Quinolone, beta-lactams alone or in combination can be used in cirrhosis patients with UGIB. Nevertheless, targeted efforts are needed to promote the appropriate use of antibiotics among patients with cirrhosis and UGIB.
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Affiliation(s)
- Yanying Gao
- Department of Gastroenterology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin, P.R. China
| | - Baoxin Qian
- Department of Gastroenterology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin, P.R. China
| | - Xu Zhang
- Department of Gastroenterology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin, P.R. China
| | - Hua Liu
- Department of Gastroenterology, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin, P.R. China
| | - Tao Han
- Department of Gastroenterology, People’s Hospital Affiliated to Nankai University of Tianjin, Tianjin, P.R. China
- * E-mail:
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Triantos C, Kalafateli M, Assimakopoulos SF, Karaivazoglou K, Mantaka A, Aggeletopoulou I, Spantidea PI, Tsiaoussis G, Rodi M, Kranidioti H, Goukos D, Manolakopoulos S, Gogos C, Samonakis DN, Daikos GL, Mouzaki A, Thomopoulos K. Endotoxin Translocation and Gut Barrier Dysfunction Are Related to Variceal Bleeding in Patients With Liver Cirrhosis. Front Med (Lausanne) 2022; 9:836306. [PMID: 35308545 PMCID: PMC8929724 DOI: 10.3389/fmed.2022.836306] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/10/2022] [Indexed: 12/15/2022] Open
Abstract
Background Bacterial infections are associated with the risk of variceal bleeding through complex pathophysiologic pathways. Objectives The primary objective of the present case-control study was to investigate the role of bacterial translocation and intestinal barrier dysfunction in the pathogenesis of variceal bleeding. A secondary objective was to determine independent predictors of key outcomes in variceal bleeding, including bleeding-related mortality. Methods Eighty-four (n = 84) consecutive patients participated in the study, 41 patients with acute variceal bleeding and 43 patients with stable cirrhosis, and were followed up for 6 weeks. Peripheral blood samples were collected at patient admission and before any therapeutic intervention. Results Child-Pugh (CP) score (OR: 1.868; p = 0.044), IgM anti-endotoxin antibody levels (OR: 0.954; p = 0.016) and TGF-β levels (OR: 0.377; p = 0.026) were found to be significant predictors of variceal bleeding. Regression analysis revealed that albumin (OR: 0.0311; p = 0.023), CRP (OR: 3.234; p = 0.034) and FABP2 levels (OR:1.000, p = 0.040), CP score (OR: 2.504; p = 0.016), CP creatinine score (OR: 2.366; p = 0.008), end-stage liver disease model (MELD), Na (OR: 1.283; p = 0.033), portal vein thrombosis (OR: 0.075; p = 0.008), hepatocellular carcinoma (OR: 0.060; p = 0.003) and encephalopathy (OR: 0.179; p = 0.045) were significantly associated with 6-week mortality. Conclusions Bacterial translocation and gut barrier impairment are directly related to the risk of variceal bleeding. Microbiota-modulating interventions and anti-endotoxin agents may be promising strategies to prevent variceal bleeding.
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Affiliation(s)
- Christos Triantos
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | - Maria Kalafateli
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | | | - Katerina Karaivazoglou
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | - Aikaterini Mantaka
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion, Greece
| | - Ioanna Aggeletopoulou
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, Patras, Greece.,Division of Hematology, Department of Internal Medicine, Medical School, University of Patras, Patras, Greece
| | - Panagiota I Spantidea
- Division of Hematology, Department of Internal Medicine, Medical School, University of Patras, Patras, Greece
| | - Georgios Tsiaoussis
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | - Maria Rodi
- Division of Hematology, Department of Internal Medicine, Medical School, University of Patras, Patras, Greece
| | - Hariklia Kranidioti
- 2nd Department of Internal Medicine, Hippokration General Hospital of Athens, Athens, Greece
| | - Dimitrios Goukos
- Department of Propedeutic Medicine, Laiko General Hospital, Athens, Greece
| | - Spilios Manolakopoulos
- 2nd Department of Internal Medicine, Hippokration General Hospital of Athens, Athens, Greece
| | - Charalambos Gogos
- Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | | | - Georgios L Daikos
- Department of Propedeutic Medicine, Laiko General Hospital, Athens, Greece
| | - Athanasia Mouzaki
- Division of Hematology, Department of Internal Medicine, Medical School, University of Patras, Patras, Greece
| | - Konstantinos Thomopoulos
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, Patras, Greece
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Abstract
Massive gastrointestinal hemorrhage is a life-threatening condition that can result from numerous causes and requires skilled resuscitation to decrease patient morbidity and mortality. Successful resuscitation begins with placement of large-bore intravenous or intraosseous access; early blood product administration; and early consultation with a gastroenterologist, interventional radiologist, and/or surgeon. Activate a massive transfusion protocol when initial red blood cell transfusion does not restore effective perfusion or the patient's shock index is greater than 1.0. Promptly reverse coagulopathies secondary to oral anticoagulant or antiplatelet use. Use thromboelastography or rotational thromboelastometry to guide further transfusions. Secure a definitive airway and minimize aspiration.
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Affiliation(s)
- Katrina D'Amore
- Department of Emergency Medicine, Good Samaritan Hospital Medical Center, 1000 Montauk Highway, West Islip, NY 11795, USA.
| | - Anand Swaminathan
- St. Joseph's University Medical Center, 703 Main Street, Paterson, NJ 07503, USA
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Ueno M, Kayahara T, Sunami T, Takayama H, Takabatake H, Morimoto Y, Yamamoto H, Mizuno M. Universal antibiotic prophylaxis may no longer be necessary for patients with acute variceal bleeding: A retrospective observational study. Medicine (Baltimore) 2020; 99:e19981. [PMID: 32443300 PMCID: PMC7253534 DOI: 10.1097/md.0000000000019981] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
A few decades ago, antibiotic prophylaxis for patients with acute variceal bleeding was reported beneficial. However, endoscopic and systemic therapy for variceal bleeding has dramatically improved since then, so the necessity of prophylactic antibiotics can be questioned. In this study, we reevaluated the efficacy of antibiotic prophylaxis in acute variceal bleeding, using the most recent data in our hospital.We retrospectively analyzed the medical records of 150 patients with acute variceal bleeding who were admitted to Kurashiki Central Hospital between January 2012 and December 2016. We compared the rates of bacterial infection, in-hospital mortality, 5-day rebleeding rate, and 30-day emergency readmission between patients treated or not treated with antibiotic prophylaxis.Forty-six patients (30.7%) received antibiotic prophylaxis; 104 (69.3%) did not. The rates of the outcomes in patients with antibiotic prophylaxis were 6.5% (bacterial infection), 4.3% (in-hospital mortality), 2.2% (5-day rebleeding), and 10.9% (30-day emergency readmission) and were not significantly different form the corresponding figures in those without antibiotic prophylaxis (1.9%, 7.7%, 1.9%, and 10.6%, respectively). Moreover, these rates in our patients, even without antibiotic prophylaxis, were much lower than rates reported in past years, perhaps because of improvements in care of patients with variceal hemorrhage.Antibiotic prophylaxis was not associated with significantly better outcomes of bacterial infection, mortality, rebleeding or readmission rate in patients with acute variceal bleeding. Universal antibiotic prophylaxis for patients with acute variceal bleeding should be reconsidered.
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Abstract
Bacterial infection remains a leading cause of mortality and morbidity for patients with cirrhosis, with hospitalization, alterations in the intestinal microbiota, and therapeutic drugs all implicated in its development. Bacterial infections also remain the most common precipitant of acute-on-chronic liver failure, with infection occurring as a direct consequence of the progression of this syndrome. Furthermore, recent epidemiological analyses have demonstrated that infections due to multidrug-resistant bacteria are occurring with increasing frequency in patients with cirrhosis. Despite significant advances in the understanding of the pathophysiological processes triggered by an infection in patients with cirrhosis, a demonstrable survival benefit for the sickest patients who require ICU admission has not yet occurred. Early diagnosis of infection and appropriate antimicrobial treatment is essential to ensuring optimal outcomes for these patients. This review provides an evidence-based analysis of both the current strategies for prevention and the recommended management of common bacterial infections in patients with cirrhosis.
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Affiliation(s)
- Mary D Cannon
- Institute of Liver Studies, King's College Hospital, London, SE5 9RS, UK.
| | - Paul Martin
- Division of Gastroenterology and Hepatology, University of Miami, Miami, FL, USA
| | - Andres F Carrion
- Division of Gastroenterology and Hepatology, University of Miami, Miami, FL, USA
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Efeoğlu C, Sipahi Çalış A, Karasu Z, Koca H, Boyacıoğlu H. Prospective randomized single-blind study of post-operative bleeding after minor oral surgery in patients with cirrhosis. TURKISH JOURNAL OF GASTROENTEROLOGY 2019; 30:171-176. [PMID: 30457557 DOI: 10.5152/tjg.2018.18078] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND/AIMS The management of patients with cirrhosis requiring dental extractions is complicated due to an increased risk of post-operative bleeding. Topical hemostatic agents are usually required to control bleeding in these cases, as an adjunct to systemic measures of hemostasis. The aims of this randomized, prospective, single-blind clinical study are twofold. The primary aim is to compare the hemostatic efficacy of chitosan and surgicel in patients with cirrhosis after a tooth extraction, and the secondary aim is to assess the value of the current setting as a clinical model of post-operative bleeding following minor oral surgery. MATERIAL AND METHODS Fifty patients with cirrhosis scheduled for a tooth extraction under local anesthesia were prospectively included in the study in a randomized fashion. Patients were blinded to the treatment group they were in. The cirrhosis classification, bleeding time, trauma score, and corrected bleeding time (during post-operative reviews) were recorded. Statistical evaluations were done. RESULTS Study groups had an equal number of teeth extractions (40 teeth each). There were no statistically significant differences between the groups with respect to patient demographics, cirrhosis classification, trauma score, and bleeding time. No side effects were noted. CONCLUSION Both Celox and Surgicel are effective for controlling bleeding and are safe after a tooth extraction in patients with cirrhosis.
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Affiliation(s)
- Candan Efeoğlu
- Department of Oral Surgery, Ege University School of Dentistry, İzmir, Turkey
| | - Aylin Sipahi Çalış
- Department of Oral Surgery, Ege University School of Dentistry, İzmir, Turkey
| | - Zeki Karasu
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - Hüseyin Koca
- Department of Oral Surgery, Ege University School of Dentistry, İzmir, Turkey
| | - Hayal Boyacıoğlu
- Department of Statistics, Ege University School of Science, İzmir, Turkey
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Comparison of various prognostic scores in variceal and non-variceal upper gastrointestinal bleeding: A prospective cohort study. Indian J Gastroenterol 2019; 38:158-166. [PMID: 30830583 DOI: 10.1007/s12664-018-0928-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 12/19/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Various prognostic scores like Glasgow-Blatchford bleeding score (GBS), modified Glasgow-Blatchford bleeding score (mGBS), full Rockall score (FRS) including endoscopic findings, clinical Rockall score (CRS), and albumin, international normalized ratio (INR), mental status, systolic blood pressure, age >65 (AIMS65) are used for risk stratification in patients with upper gastrointestinal bleeding (UGIB). The utility of these scores in variceal UGIB (VUGIB) is not well defined. In this prospective study, we aimed to assess the performance of these scores in patients with non-variceal (NVUGIB) and VUGIB. METHODS We included 1011 patients (during March 2017 and August 2018) including 439 with NVUGIB and 572 VUGIB. Performance of GBS, mGBS, FRS, CRS, and AIMS65 for various outcome measures was analyzed using the area under receiver operator characteristic curve (AUROC). RESULTS The accuracy of prognostic scores in predicting the composite outcome including the need of hospital-based intervention and 42-day mortality was higher in NVUGIB as compared with VUGIB, AUROC: CRS: 0.641 vs. 0.537; FRS: 0.669 vs. 0.625; GBS: 0.719 vs. 0.587; mGBS: 0.711 vs. 0.594; AIMS65: 0.567 vs. 0.548. GBS and mGBS at a cut-off score of 1 had the highest negative predictive value, 91.7% and 91.3%, respectively, for predicting composite outcome in NVUGIB. Similarly, these scores had better accuracy for predicting 42-day rebleeding in NVUGIB as compared to VUGIB, AUROC: CRS: 0.680 vs. 0.537; FRS: 0.698 vs. 0.565; GBS: 0.661 vs. 0.543; mGBS: 0.627 vs. 0.540; AIMS65: 0.695 vs. 0.606. CONCLUSION The prognostic scores such as CRS, FRS, GBS, mGBS, and AIMS65 predict the need for hospital-based management, rebleeding, and mortality better among patients with NVUGIB than VUGIB.
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10
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Efeoğlu C, Sipahi Çalış A, Karasu Z, Koca H, Boyacıoğlu H. Prospective randomized single-blind study of post-operative bleeding after minor oral surgery in patients with cirrhosis. TURKISH JOURNAL OF GASTROENTEROLOGY 2018. [PMID: 30457557 DOI: 10.5152/tjg.2018.18078.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND/AIMS The management of patients with cirrhosis requiring dental extractions is complicated due to an increased risk of post-operative bleeding. Topical hemostatic agents are usually required to control bleeding in these cases, as an adjunct to systemic measures of hemostasis. The aims of this randomized, prospective, single-blind clinical study are twofold. The primary aim is to compare the hemostatic efficacy of chitosan and surgicel in patients with cirrhosis after a tooth extraction, and the secondary aim is to assess the value of the current setting as a clinical model of post-operative bleeding following minor oral surgery. MATERIAL AND METHODS Fifty patients with cirrhosis scheduled for a tooth extraction under local anesthesia were prospectively included in the study in a randomized fashion. Patients were blinded to the treatment group they were in. The cirrhosis classification, bleeding time, trauma score, and corrected bleeding time (during post-operative reviews) were recorded. Statistical evaluations were done. RESULTS Study groups had an equal number of teeth extractions (40 teeth each). There were no statistically significant differences between the groups with respect to patient demographics, cirrhosis classification, trauma score, and bleeding time. No side effects were noted. CONCLUSION Both Celox and Surgicel are effective for controlling bleeding and are safe after a tooth extraction in patients with cirrhosis.
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Affiliation(s)
- Candan Efeoğlu
- Department of Oral Surgery, Ege University School of Dentistry, İzmir, Turkey
| | - Aylin Sipahi Çalış
- Department of Oral Surgery, Ege University School of Dentistry, İzmir, Turkey
| | - Zeki Karasu
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - Hüseyin Koca
- Department of Oral Surgery, Ege University School of Dentistry, İzmir, Turkey
| | - Hayal Boyacıoğlu
- Department of Statistics, Ege University School of Science, İzmir, Turkey
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Han D, Wang R, Yu Y, Sun M, Teschke R, Romeiro FG, Mancuso A, Song T, Peng Z, Han B, Zhou X, Bao W, Li Q, Zheng K, Li Y, Bai Z, Guo X, Qi X. Xuebijing Injection Combined with Antibiotics for the Treatment of Spontaneous Bacterial Peritonitis in Liver Cirrhosis: A Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2018; 2018:2989846. [PMID: 29743922 PMCID: PMC5884321 DOI: 10.1155/2018/2989846] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 01/12/2018] [Accepted: 02/15/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Spontaneous bacterial peritonitis (SBP) is one of the most common complications of liver cirrhosis. Antibiotics are the main treatment regimen of SBP. Traditional Chinese medicine Xuebijing injection has been used in such patients. Our study aimed to overview the efficacy of Xuebijing injection combined with antibiotics for the treatment of SBP. METHOD We searched the PubMed, Embase, China National Knowledge Infrastructure, VIP, and Wanfang databases. The search items included "Xuebijing", "peritonitis", "liver cirrhosis", and "random" to identify all relevant randomized controlled trials (RCTs). The Cochrane risk of bias tool was used to assess the study quality. The odd ratios (ORs) with 95% confidence intervals (CIs) were calculated by using a random-effect model. Heterogeneity was also calculated. RESULTS A total of 9 RCTs were included. The study quality was unsatisfied. The overall (OR = 2.95, 95% CI = 1.97-4.42, p < 0.00001) and complete (OR = 2.18, 95% CI = 1.57-3.04, p < 0.00001) responses were significantly higher in the Xuebijing injection combined with antibiotics group than the antibiotics alone group. The incidence of cirrhosis related complications, including hepatic encephalopathy and hepatorenal syndrome, was lower in the Xuebijing injection combined with antibiotics group than the antibiotics alone group. No significant heterogeneity was observed among studies. CONCLUSION Additional use of Xuebijing injection may improve the efficacy of antibiotics for the treatment of SBP in liver cirrhosis. However, due to a low level of current evidence, we did not establish any recommendation regarding the use of Xuebijing injection for the treatment of SBP.
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Affiliation(s)
- Dan Han
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- 2Postgraduate College, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Ran Wang
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
| | - Yang Yu
- 2Postgraduate College, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Mingyu Sun
- 3Institute of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Rolf Teschke
- 4Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Hanau, Germany
- 5Teaching Hospital of the Medical Faculty, Goethe University, Frankfurt/Main, Germany
| | - Fernando Gomes Romeiro
- 6Department of Internal Medicine, Botucatu Medical School, Universidade Estadual Paulista (UNESP), Av. Prof. Mário Rubens Guimarães Montenegro, s/n, Distrito de Rubião Jr., 18 608 917 Botucatu, SP, Brazil
| | | | - Tingxue Song
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- 2Postgraduate College, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Zhong Peng
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- 8Postgraduate College, Dalian Medical University, Dalian, China
| | - Bing Han
- 9Postgraduate College, Jinzhou Medical University, Jinzhou, China
| | - Xinmiao Zhou
- 9Postgraduate College, Jinzhou Medical University, Jinzhou, China
| | - Wenchun Bao
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- 2Postgraduate College, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Qianqian Li
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- 8Postgraduate College, Dalian Medical University, Dalian, China
| | - Kexin Zheng
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- 9Postgraduate College, Jinzhou Medical University, Jinzhou, China
| | - Yingying Li
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- 9Postgraduate College, Jinzhou Medical University, Jinzhou, China
| | - Zhaohui Bai
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- 10Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Xiaozhong Guo
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- 2Postgraduate College, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Xingshun Qi
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
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Moon AM, Dominitz JA, Ioannou GN, Lowy E, Beste LA. Use of Antibiotics Among Patients With Cirrhosis and Upper Gastrointestinal Bleeding Is Associated With Reduced Mortality. Clin Gastroenterol Hepatol 2016; 14:1629-1637.e1. [PMID: 27311621 DOI: 10.1016/j.cgh.2016.05.040] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/12/2016] [Accepted: 05/19/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Prophylactic antibiotics are recommended for all patients with cirrhosis hospitalized for upper gastrointestinal bleeding (UGIB). We evaluated the association between use of antibiotics, outcomes of re-admissions, and mortality in these patients. METHODS We performed a retrospective study of 6451 patients with cirrhosis (mean age, 60.6 y) in the Veterans Affairs health care system hospitalized for UGIB from January 1, 2005, through December 31, 2013 (8655 hospitalizations). We collected information on patients' baseline features, hospitalizations, etiology of UGIB, antibiotics given, hospital re-admission within 30 days of discharge, and mortality. We defined timely administration of antibiotics as receipt from 8 hours before admission through 48 hours afterward. RESULTS Timely administration of antibiotics occurred during 48.6% of admissions (n = 4210), increasing from 30.6% in 2005 to 58.1% in 2013. Independent predictors of antibiotic receipt included ascites, high model for end-stage liver disease score, esophageal variceal hemorrhage, and administration of octreotide or intravenous proton pump inhibitors. Variables associated with decreased odds of antibiotic provision included black race and nonalcoholic fatty liver disease. In multivariate analysis, timely administration of antibiotics was associated with a reduced 30-day mortality rate (adjusted odds ratio, 0.70; 95% confidence interval, 0.52-0.93; P = .012). CONCLUSIONS In a study of patients with cirrhosis and UGIB in the VA health care system, timely administration of antibiotics was associated with a 30% reduction in 30-day mortality. The proportion of patients with cirrhosis and UGIB receiving timely antibiotics nearly doubled from 2005 to 2013, but many patients-particularly those with less-advanced cirrhosis-did not receive this intervention. Targeted efforts are needed to promote the appropriate use of antibiotics among patients with cirrhosis and UGIB.
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Affiliation(s)
- Andrew M Moon
- Department of Medicine, University of Washington, Seattle, Washington
| | - Jason A Dominitz
- Department of Medicine, University of Washington, Seattle, Washington; VA Puget Sound Health Care System, Seattle, Washington
| | - George N Ioannou
- Department of Medicine, University of Washington, Seattle, Washington; VA Puget Sound Health Care System, Seattle, Washington
| | - Elliott Lowy
- VA Puget Sound Health Care System, Seattle, Washington; School of Public Health, University of Washington, Seattle, Washington
| | - Lauren A Beste
- Department of Medicine, University of Washington, Seattle, Washington; VA Puget Sound Health Care System, Seattle, Washington.
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Lee TH, Huang CT, Lin CC, Chung CS, Lin CK, Tsai KC. Similar rebleeding rate in 3-day and 7-day intravenous ceftriaxone prophylaxis for patients with acute variceal bleeding. J Formos Med Assoc 2016; 115:547-52. [PMID: 26899745 DOI: 10.1016/j.jfma.2016.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 01/13/2016] [Accepted: 01/17/2016] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND/PURPOSE Although prophylactic antibiotics have been recommended for cirrhotic patients with upper gastrointestinal bleeding, the duration of its use remains an inconclusive issue. We designed this study to investigate the duration of antibiotic prophylaxis for cirrhotic patients with acute esophageal variceal bleeding. METHODS We enrolled those patients suffering from acute esophageal variceal bleeding and receiving band ligation. They were randomly allocated to two groups to receive prophylactic antibiotics; Group I: receiving intravenous ceftriaxone 500 mg every 12 hours for 3 days, and Group II: same regimen for 7 days. We used rebleeding rate within 14 days as the primary end point and also evaluated the survival rate within 28 days and the amount of transfusion during admission. RESULTS There were 38 patients in Group I and 33 patients in Group II that completed the study course for analysis. Overall, there was no significant difference in the baseline characteristics between these two groups. There were three patients both in Group I and Group II who developed rebleeding within 14 days (8% vs. 9%, p > 0.99). There was also no difference between Group I and Group II in transfusion amount (2.71 ± 2.84 units vs. 3.18 ± 4.07, p = 0.839) and survival rate in 28 days (100 vs. 97%, p = 0.465). CONCLUSION Our small scale study demonstrated that there was no difference in the rebleeding rate between 3-day and 7-day ceftriaxone prophylaxis for cirrhotic patients with acute esophageal variceal bleeding. There was also no difference in 28 day survival rate between these two groups.
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Affiliation(s)
- Tzong-Hsi Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei, Taiwan; Department of Nursing, Oriental Institute of Technology, New Taipei, Taiwan.
| | - Chung-Tsui Huang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei, Taiwan
| | - Chien-Chu Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei, Taiwan
| | - Chen-Shuan Chung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei, Taiwan
| | - Cheng-Kuan Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei, Taiwan
| | - Kuang-Chau Tsai
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei, Taiwan
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14
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Jairath V, Desborough MJR. Modern-day management of upper gastrointestinal haemorrhage. Transfus Med 2015; 25:351-7. [DOI: 10.1111/tme.12266] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 11/08/2015] [Accepted: 11/16/2015] [Indexed: 12/12/2022]
Affiliation(s)
- V. Jairath
- Gastroenterology Unit; Oxford University Hospitals Foundation Trust; Oxford UK
- Nuffield Department of Medicine; University of Oxford; Oxford UK
- Department of Medicine; Western University; London Canada
| | - M. J. R. Desborough
- NHS Blood and Transplant; John Radcliffe Hospital; Oxford UK
- Department of Haematology; Oxford University Hospitals Foundation Trust; Oxford UK
- Radcliffe Department of Medicine; University of Oxford; Oxford UK
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15
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Asrani SK, Simonetto DA, Kamath PS. Acute-on-Chronic Liver Failure. Clin Gastroenterol Hepatol 2015; 13:2128-39. [PMID: 26188138 PMCID: PMC4625547 DOI: 10.1016/j.cgh.2015.07.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 06/30/2015] [Accepted: 07/09/2015] [Indexed: 12/18/2022]
Abstract
Over the past 2 decades, the concept of acute-on-chronic liver failure (ACLF) has been proposed as an alternate path in the natural history of decompensated cirrhosis. ACLF thus is characterized by the presence of a precipitating event (identified or unidentified) in subjects with underlying chronic liver disease leading to rapid progression of liver injury and ending in multi-organ dysfunction characterized by high short-term mortality. Multiple organ failure and an increased risk for mortality are key to the diagnosis of ACLF. The prevalence of ACLF ranges from 24% to 40% in hospitalized patients. The pathophysiological basis of ACLF can be explained using the following 4-part model: predisposing event, injury caused by a precipitating event, response to injury, and organ failure. Although several mathematic scores have been proposed for identifying outcomes with ACLF, it is as yet unclear whether these organ failure scores are truly prognostic or only reflective of the dying process. Treatment paradigms continue to evolve but consist of early recognition, supportive intensive care, and consideration of liver transplantation before onset of irreversible multiple organ failure.
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Affiliation(s)
- Sumeet K Asrani
- Division of Hepatology, Baylor University Medical Center, Dallas, Texas
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Patrick S Kamath
- Division of Hepatology, Baylor University Medical Center, Dallas, Texas; Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota.
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16
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Risk of Bacterial Infection in Patients With Cirrhosis and Acute Variceal Hemorrhage, Based on Child-Pugh Class, and Effects of Antibiotics. Clin Gastroenterol Hepatol 2015; 13:1189-96.e2. [PMID: 25460564 DOI: 10.1016/j.cgh.2014.11.019] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 11/13/2014] [Accepted: 11/17/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Antibiotics frequently are overused and are associated with serious adverse events in patients with cirrhosis. However, these drugs are recommended for all patients presenting with acute variceal hemorrhage (AVH). We investigated whether patients should be stratified for antibiotic prophylaxis based on Child-Pugh scores, to estimate risks of bacterial infection, rebleeding, and mortality, and whether antibiotics have equal effects on patients of all Child-Pugh classes. We performed a sensitivity analysis using model for end-stage liver disease (MELD) scores. METHODS In a retrospective study, we analyzed data from 381 adult patients with cirrhosis and AVH (70% men; mean age, 56 y), admitted from 2000 through 2009 to 2 tertiary care hospitals in Edmonton, Alberta, Canada. We excluded patients with bacterial infection on the day of AVH. The association between antibiotic prophylaxis and outcomes was adjusted by liver disease severity and by a propensity score. RESULTS The patients included in the study had mean MELD scores of 16, and 54% received antibiotic prophylaxis. Overall, antibiotic therapy was associated with lower risks of infection (adjusted odds ratio, 0.37; 95% confidence interval, 0.91-0.74) and mortality (adjusted odds ratio, 0.63; 95% confidence interval, 0.31-1.29). Among patients categorized as Child-Pugh class A given antibiotics, only 2% developed infections and the mortality rate was 0.4%. Among patients categorized as Child-Pugh class B given antibiotics, 6% developed infections, compared with 14% of patients who did not receive antibiotics; antibiotics did not affect mortality. Administration of antibiotics to patients categorized as Child-Pugh class C reduced infections and mortality by approximately 50%, compared with patients who did not receive antibiotics. MELD scores were not as useful as Child-Pugh class in identifying patients at risk for infection. CONCLUSIONS Based on a retrospective analysis of patients with cirrhosis and AVH, those categorized as Child-Pugh class A had lower rates of bacterial infection and lower mortality rates in the absence of antibiotic prophylaxis than patients categorized as classes B or C. The recommendation for routine antibiotic prophylaxis for this subgroup requires further evaluation.
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Agarwal A, Kumar SS, Sadasivan J, Kate V. Antibiotic prophylaxis in the prevention of rebleeding in acute variceal hemorrhage: A randomized trial. J Pharmacol Pharmacother 2015; 6:24-9. [PMID: 25709348 PMCID: PMC4319243 DOI: 10.4103/0976-500x.149139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 08/08/2014] [Accepted: 09/11/2014] [Indexed: 12/19/2022] Open
Abstract
Objective: To assess the role of antibiotic prophylaxis in the prevention of rebleeding in acute variceal hemorrhage. Materials and Methods: A total of 60 patients who underwent endoscopic therapy for bleeding esophageal varices were randomized into the prophylaxis group and the on-demand group. Patients in the prophylaxis group received antibiotic prophylaxis using intravenous ofloxacin till the patient resumed oral fluids, followed by oral ofloxacin tablet for a total of 7 days. In the on-demand group, antibiotics were used only when infection was evident. Patients were monitored for rebleeding and infection during the hospital stay. Results: A total of 30 patients in the prophylaxis group and 26 patients in the on-demand group were analyzed. The clinical characteristics in both the groups were similar. The Child–Pugh score was around 7 in both the groups. The incidence of infection was 5/30 (16.7%) in the prophylaxis group and 7/26 (26.9%) in the on-demand group (P = 0.52). The incidence of early rebleeding in the prophylaxis vs. the on-demand group was 3 vs. 5 (P = 0.69), and the incidence of late rebleeding was 6 vs. 8 (P = 0.48). The differences were not significant. Conclusion: The present study shows a trend toward lower rate of early and late rebleeding, infection rate and mortality in the prophylaxis group; hence, routine use of antibiotics in all such patients may not be necessary. Further studies with a larger sample size and a longer follow-up period are required to validate the usefulness of antibiotics in these patients.
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Affiliation(s)
- Ajit Agarwal
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Sathasivam Suresh Kumar
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Jagdish Sadasivan
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Vikram Kate
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
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18
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Lee YY, Tee HP, Mahadeva S. Role of prophylactic antibiotics in cirrhotic patients with variceal bleeding. World J Gastroenterol 2014; 20:1790-1796. [PMID: 24587656 PMCID: PMC3930977 DOI: 10.3748/wjg.v20.i7.1790] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 10/21/2013] [Accepted: 01/06/2014] [Indexed: 02/06/2023] Open
Abstract
Bacterial infections are common in cirrhotic patients with acute variceal bleeding, occurring in 20% within 48 h. Outcomes including early rebleeding and failure to control bleeding are strongly associated with bacterial infection. However, mortality from variceal bleeding is largely determined by the severity of liver disease. Besides a higher Child-Pugh score, patients with hepatocellular carcinoma are particularly susceptible to infections. Despite several hypotheses that include increased use of instruments, greater risk of aspiration pneumonia and higher bacterial translocation, it remains debatable whether variceal bleeding results in infection or vice versa but studies suggest that antibiotic prophylaxis prior to endoscopy and up to 8 h is useful in reducing bacteremia and spontaneous bacterial peritonitis. Aerobic gram negative bacilli of enteric origin are most commonly isolated from cultures, but more recently, gram positives and quinolone-resistant organisms are increasingly seen, even though their clinical significance is unclear. Fluoroquinolones (including ciprofloxacin and norfloxacin) used for short term (7 d) have the most robust evidence and are recommended in most expert guidelines. Short term intravenous cephalosporin (especially ceftriaxone), given in a hospital setting with prevalent quinolone-resistant organisms, has been shown in studies to be beneficial, particularly in high risk patients with advanced cirrhosis.
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Abstract
Variceal bleeding remains a life-threatening condition with a 6-week mortality rate of ∼20%. Prevention of variceal bleeding can be achieved using nonselective β-blockers (NSBBs) or endoscopic band ligation (EBL), with NSBBs as the first-line treatment. EBL should be reserved for cases of intolerance or contraindications to NSBBs. Although NSBBs cannot be used to prevent varices, if the hepatic venous pressure gradient (HVPG) is ≤10 mmHg, prognosis is excellent. Survival after acute variceal bleeding has improved over the past three decades, but patients with Child-Pugh grade C cirrhosis remain at greatest risk. Vasoactive drugs combined with endoscopic therapy and antibiotics are the best therapeutic strategy for these patients. Transjugular intrahepatic portosystemic shunts (TIPS) should be used in patients with uncontrolled bleeding or those who are likely to have difficult-to-control bleeding. Rebleeding from varices occurs in ∼60% of patients 1-2 years after the initial bleeding episode, with a mortality rate of 30%. Secondary prophylaxis should start at day 6 after initial bleeding using a combination of NSBBs and EBL. TIPS with polytetrafluoroethylene-covered stents are the preferred option in patients who fail combined treatment with NSBBs and EBL. Despite the improvement in patient survival, further studies are needed to direct the management of patients with gastro-oesophageal varices and variceal bleeding.
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20
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Acute on chronic liver failure: From pathophysiology to clinical management. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2013. [DOI: 10.1016/j.tacc.2013.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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21
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Hong HJ, Jun CH, Lee DH, Cho EA, Park SY, Cho SB, Park CH, Joo YE, Kim H, Choi SK, Rew JS. Comparison of Endoscopic Variceal Ligation and Endoscopic Variceal Obliteration in Patients with GOV1 Bleeding. Chonnam Med J 2013; 49:14-9. [PMID: 23678472 PMCID: PMC3651981 DOI: 10.4068/cmj.2013.49.1.14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Revised: 02/05/2013] [Accepted: 02/06/2013] [Indexed: 12/16/2022] Open
Abstract
The aim of this study was to compare the efficacy, rebleeding rates, survival, and complications of endoscopic variceal ligation (EVL) with those of endoscopic variceal obliteration (EVO) in patients with acute type 1 gastroesophageal variceal (GOV1) bleeding. Data were collected retrospectively at a single center. A total of 84 patients were selected (20 patients underwent EVL; 64 patients underwent EVO) from February 2004 to September 2011. Their clinical characteristics, laboratory results, vital signs, Child-Pugh score, Model for End-stage Liver Disease (MELD) score, and overall mortality were evaluated. There were no significant differences in baseline characteristics between the two groups. The success rate in initial control of active bleeding was not significantly different between the EVL and EVO groups (18/20 EVL, or 90.0%, compared with 62/64 EVO, or 96.9%; p=0.239). The early rebleeding rate was also not significantly different between the groups (3/18 EVL, or 16.7% compared with 17/62 EVO, or 27.4%; p=0.422). The late rebleeding rate of the EVL group was lower than that of the EVO group (3/18 EVL, or 16.7%, compared with 26/59 EVO, or 44.1%; p=0.042). The time-to-rebleeding was 594 days for the EVL group and 326 days for the EVO group (p=0.054). In the multivariate analysis, portal vein thrombosis (PVT) was a significant risk factor for early rebleeding. Hepatocellular carcinoma (HCC) and previous history of bleeding were significant risk factors for very late rebleeding. In conclusion, EVL is better than EVO in reducing late rebleeding in acute GOV1 bleeding. HCC, PVT, and previous bleeding history were significant risk factors for rebleeding.
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Affiliation(s)
- Hyoung Ju Hong
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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22
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Jalan R, Gines P, Olson JC, Mookerjee RP, Moreau R, Garcia-Tsao G, Arroyo V, Kamath PS. Acute-on chronic liver failure. J Hepatol 2012; 57:1336-48. [PMID: 22750750 DOI: 10.1016/j.jhep.2012.06.026] [Citation(s) in RCA: 426] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 06/19/2012] [Accepted: 06/19/2012] [Indexed: 12/12/2022]
Abstract
Acute-on-chronic liver failure (ACLF) is an increasingly recognised entity encompassing an acute deterioration of liver function in patients with cirrhosis, which is usually associated with a precipitating event and results in the failure of one or more organs and high short term mortality. Prospective data to define this is lacking but there is a large body of circumstantial evidence suggesting that this condition is a distinct clinical entity. From the pathophysiologic perspective, altered host response to injury and infection play important roles in its development. This review focuses upon the current understanding of this syndrome from the clinical, prognostic and pathophysiologic perspectives and indicates potential biomarkers and therapeutic targets for intervention.
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Affiliation(s)
- Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, Rowland Hill Street, London, United Kingdom.
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23
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Kim TW, Kim HJ, Chon CU, Won HS, Park JH, Park DI, Cho YK, Sohn CI, Jeon WK, Kim BI. Is there any vindication for low dose nonselective β-blocker medication in patients with liver cirrhosis? Clin Mol Hepatol 2012; 18:203-12. [PMID: 22893871 PMCID: PMC3415875 DOI: 10.3350/cmh.2012.18.2.203] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Revised: 04/30/2012] [Accepted: 05/02/2012] [Indexed: 01/06/2023] Open
Abstract
Background/Aims Nonselective β-blockers (NSBBs), such as propranolol, reportedly exert a pleiotropic effect in liver cirrhosis. A previous report suggested that survival was higher in patients receiving adjusted doses of NSBBs than in ligation patients. This study investigated whether low-dose NSBB medication has beneficial effects in patients with liver cirrhosis, especially in terms of overall survival. Methods We retrospectively studied 273 cirrhotic patients (199 males; age 53.6±10.2 years, mean±SD) who visited our institution between March 2003 and December 2007; follow-up data were collected until June 2011. Among them, 138 patients were given a low-dose NSBB (BB group: propranolol, 20-60 mg/day), and the remaining 135 patients were not given an NSBB (NBB group). Both groups were stratified randomly according to Child-Turcotte-Pugh (CTP) classification and age. Results The causes of liver cirrhosis were alcohol (n=109, 39.9%), hepatitis B virus (n=125, 45.8%), hepatitis C virus (n=20, 7.3%), and cryptogenic (n=19, 7.0%). The CTP classes were distributed as follows: A, n=116, 42.5%; B, n=126, 46.2%; and C, n=31, 11.4%. Neither the overall survival (P=0.133) nor the hepatocellular carcinoma (HCC)-free survival (P=0.910) differed significantly between the BB and NBB groups [probability of overall survival at 4 years: 75.1% (95% CI=67.7-82.5%) and 81.2% (95% CI=74.4-88.0%), respectively; P=0.236]. In addition, the delta CTP score did not differ significantly between the two groups. Conclusions Use of low-dose NSBB medication in patients with liver cirrhosis is not indicated in terms of overall and HCC-free survival.
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Affiliation(s)
- Tae Wan Kim
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Saraswat VA, Verma A. Gluing gastric varices in 2012: lessons learnt over 25 years. J Clin Exp Hepatol 2012; 2:55-69. [PMID: 25755406 PMCID: PMC3940364 DOI: 10.1016/s0973-6883(12)60088-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Accepted: 02/22/2011] [Indexed: 02/06/2023] Open
Abstract
Bleeding from gastric varices (GV) continues to pose a challenge to the endoscopist and no consensus has been reached on the best way for treating these patients. Gastric variceal obturation (GVO) with the tissue adhesive, N-2-butyl-cyanoacrylate (NBC), is considered the treatment of first-choice for this condition in most parts of the world. The liquid monomer polymerizes into a solid cast, obturating the vessel within 10-20 s of coming in contact with ionic solutions such as blood. Gastric variceal obturation achieves hemostasis in over 90% of patients with active bleeding, eradicates GV in over 80% of these patients, and re-bleeding occurs in 3-30%. These results are comparable with those of transjugular intrahepatic portosystemic shunting (TIPS; over 90% hemostasis in acute bleeding with re-bleeding in 15-30%). Though, there has been no direct comparison with GVO, balloon-occluded retrograde transvenous obliteration of GV (BRTO) achieves near 100% obliteration with recurrence in 0-10% and is superior to TIPS for hemostasis in active bleeding when used in combination with transcatheter sclerotherapy. Several complications have been described for GVO including thromboembolic complications which occur in 0.5-4.3% and may be devastating in some. Many of the complications and the variability in results of GVO can be attributed to variations in injection technique. The use of a standardized injection technique has been reported to achieve 100% hemostasis and obliteration with 6.9% re-bleeding and no embolic complications. Gastric variceal obturation with NBC continues to be the first-choice therapy for GV bleeding outside Japan. Adherence to a standard injection technique will maximize hemostasis and eradication of GV while minimizing complications of therapy.
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Affiliation(s)
- Vivek A Saraswat
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
- Address for correspondence: Vivek A Saraswat, Professor, Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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25
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The news of treatment of variceal upper gastrointestinal bleeding. J Med Life 2011; 4:395-8. [PMID: 22514572 PMCID: PMC3227155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 10/12/2011] [Indexed: 11/29/2022] Open
Abstract
Variceal bleeding is one of the dreaded complications of portal hypertension. Although its prognosis has improved over the last several decades, it still carries substantial mortality. Although most portal hypertensive bleeds result from the ruptured distal esophageal varices, bleeding from other sources such gastric varices, portal hypertensive gastropathy, and ectopic varices can lead to clinically significant bleeding. Variceal bleeding typically presents as massive gastrointestinal (GI) bleeding with hematemesis, melena or hematochezia. In general, the terapeutic aims of management are to initially correct hypovolemia, to control bleeding, to prevent complications of bleeding, such as infection and renal failure and to prevent early rebleeding. The treatment of bleeding esophageal varices differs substantially foom the treatment of other lesions of the upper gastrointestinal tract. Moreover, patients with esophageal varices typically have severe liver disease and thus are likely from poor nutrition, blood clotting disorders, and encephalopathy, all of which can adversaly affect morbidity and mortality.
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Bonnel AR, Bunchorntavakul C, Reddy KR. Immune dysfunction and infections in patients with cirrhosis. Clin Gastroenterol Hepatol 2011; 9:727-38. [PMID: 21397731 DOI: 10.1016/j.cgh.2011.02.031] [Citation(s) in RCA: 251] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 02/22/2011] [Accepted: 02/27/2011] [Indexed: 02/06/2023]
Abstract
Patients with cirrhosis are immunocompromised and susceptible to infections. Although detection and treatment of spontaneous bacterial peritonitis (SBP) have improved, overall survival rates have not increased greatly in recent decades-infection still increases mortality 4-fold among patients with cirrhosis. Hospitalized patients with cirrhosis have the highest risk of developing infections, especially patients with gastrointestinal (GI) hemorrhage. Bacterial infections occur in 32% to 34% of patients with cirrhosis who are admitted to the hospital and 45% of patients with GI hemorrhage. These rates are much higher than the overall rate of infection in hospitalized patients (5%-7%). The most common are SBP (25% of infections), urinary tract infection (20%), and pneumonia (15%). Bacterial overgrowth and translocation from the GI tract are important steps in the pathogenesis of SBP and bacteremia-these processes increase levels of endotoxins and cytokines that induce the inflammatory response and can lead to septic shock, multiorgan dysfunction, and death. A number of other bacterial and fungal pathogens are more common and virulent in patients with cirrhosis than in the overall population. We review the pathogenesis of infections in these patients, along with diagnostic and management strategies.
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Affiliation(s)
- Alexander R Bonnel
- Division of Gastroenterology/Hepatology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila F, Soares-Weiser K, Mendez-Sanchez N, Gluud C, Uribe M. Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding - an updated Cochrane review. Aliment Pharmacol Ther 2011; 34:509-18. [PMID: 21707680 DOI: 10.1111/j.1365-2036.2011.04746.x] [Citation(s) in RCA: 161] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Antibiotic prophylaxis seems to decrease the incidence of bacterial infections in patients with cirrhosis and upper gastrointestinal bleeding and is considered standard of care. However, there is no updated information regarding the effects of this intervention. AIM To assess the benefits and harms of antibiotic prophylaxis in cirrhotic patients with gastrointestinal bleeding by performing a systematic review of randomised trials. METHODS We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE and Science Citation Index EXPANDED until June 2010. We statistically combined data calculating relative risk (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes. RESULTS Twelve trials (1241 patients) evaluating antibiotic prophylaxis against placebo or no antibiotic prophylaxis were included. Antibiotic prophylaxis was associated with reduced mortality (RR 0.79, 95% CI 0.63-0.98), mortality from bacterial infections (RR 0.43, 95% CI 0.19-0.97), bacterial infections (RR 0.35, 95% CI 0.26-0.47), rebleeding (RR 0.53, 95% CI 0.38-0.74) and days of hospitalisation (MD -1.91, 95% CI -3.80-0.02). Trials analysing rebleeding rate and hospitalisation length are still scarce, thus, caution should be exerted when interpreting the results. CONCLUSIONS Antibiotic prophylaxis in patients with cirrhosis and upper gastrointestinal bleeding significantly reduced bacterial infections, and reduce all-cause mortality, bacterial infection mortality, rebleeding events and hospitalisation length. Novel clinically significant outcomes were included in this meta-analysis. Some benefits are biased and the risks are not yet properly assessed, this encourages future research in this field.
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Abstract
PURPOSE OF REVIEW A population of patients with previously compensated cirrhosis will develop acute deterioration resulting in multiorgan failure and high short-term mortality. Complications of cirrhosis frequently culminate in admissions to the ICU. This review advances the concept of acute-on-chronic liver failure as a distinct clinical entity. RECENT FINDINGS Recently, the American Association for the Study of Liver Disease and the European Association for the Study of the Liver created a research consortium to advance the state of the science of acute-on-chronic liver failure. The goal of this consortium is aimed at improving outcomes, identification of a subset of patients with cirrhosis at high risk for deterioration, and the inciting events that lead to this deterioration. Liver transplant remains the only curative option for advanced cirrhosis; however, the limited number of available organs necessitates innovations in the care of advanced liver disease. Liver replacement therapies have not as yet demonstrated reduction in mortality, but have demonstrated improvements in other measures. Large-scale prospective studies of cirrhosis are required. SUMMARY Acute-on-chronic liver failure may be a distinct clinical entity with a potential for reversibility when identified early and managed with aggressive critical care support.
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Sharma P, Sarin SK. Improved survival with the patients with variceal bleed. Int J Hepatol 2011; 2011:356919. [PMID: 21994853 PMCID: PMC3170765 DOI: 10.4061/2011/356919] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2011] [Accepted: 05/12/2011] [Indexed: 01/06/2023] Open
Abstract
Variceal hemorrhage is a major cause of death in patients with cirrhosis. Over the past two decades new treatment modalities have been introduced in the management of acute variceal bleeding (AVB) and several recent studies have suggested that the outcome of patients with cirrhosis and AVB has improved. Improved supportive measures, combination therapy which include early use of portal pressure reducing drugs with low rates of adverse effects (somatostatin, octerotide or terlipressin) and endoscopic variceal ligation has become the first line treatment in the management of AVB. Short-term antibiotic prophylaxis, early use of lactulose for prevention of hepatic encephalopathy, application of early transjugular intrahepatic portasystemic shunts (TIPS), fully covered self-expandable metallic stent in patients for AVB may be useful in those cases where balloon tamponade is considered. Early and wide availability of liver transplantation has changed the armamentarium of the clinician for patients with AVB. High hepatic venous pressure gradient (HVPG) >20 mmHg in AVB has become a useful predictor of outcomes and more aggressive therapies with early TIPS based on HVPG measurement may be the treatment of choice to reduce mortality further.
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Affiliation(s)
- Praveen Sharma
- Department of Hepatology and Transplant Hepatology, Institute of Liver & Biliary Sciences, New Delhi 110 070, India
| | - Shiv K. Sarin
- Department of Hepatology and Transplant Hepatology, Institute of Liver & Biliary Sciences, New Delhi 110 070, India
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Xu HW, Wang JH, Tsai MS, Wu KL, Chiou SS, Changchien CS, Hu TH, Lu SN, Chuah SK. The effects of cefazolin on cirrhotic patients with acute variceal hemorrhage after endoscopic interventions. Surg Endosc 2011; 25:2911-8. [PMID: 21424196 DOI: 10.1007/s00464-011-1642-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Accepted: 02/21/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND The American Association for the Study of Liver Diseases (AASLD) guidelines recommend that antibiotic prophylaxis should be instituted in any patient with cirrhosis and gastrointestinal hemorrhage, and that oral norfloxacin, intravenous ciprofloxacin, and ceftriaxone are preferable. However, the antimicrobial spectrum of the first generation of cephalosporins (cefazolin) covers a wide range of bacteria species, including community-acquired strains of Escherichia coli and Klebsiella pneumoniae, but their efficacy as prophylactic antibiotics in cirrhotic patients with acute hemorrhage was seldom warranted in the literature. This study aimed to explore the effects of cefazolin on the outcome of cirrhotic patients with acute variceal hemorrhage after endoscopic interventions. METHODS A cross-sectional, retrospective chart review study was conducted on cirrhotic patients with acute variceal hemorrhage who underwent endoscopic procedures in a medical center. Cirrhotic patients who did not receive antibiotics were classified as group A (n = 63) while patients who received intravenous cefazolin 1 g q8 h for 2-7 days were classified as group B (n = 50). The end points were the prevention of infection, length of hospital stay, time of rebleeding, and death. RESULTS A total of 113 patients were studied (male/female: 82/31; age: 56.8 ± 13.5 years). The incidence of infection (including proven infections) and bacteremia were significantly lower in group B patients (38.1% vs. 16.0%, P = 0.010; 17.5% vs. 4.0%, P = 0.026; 9.5% vs. 0%, P = 0.033, respectively). The no prophylactic antibiotics treatment was the independent risk factor. There was no significant difference between the two groups with respect to the source of bleeding, type of endoscopic intervention, length of hospital stay, and mortality. Actuarial probability of remaining free of early rebleeding (<7 days) was P = 0.105 by log-rank test for all cirrhosis patients and P = 0.085 for Child-Pugh class A patients. CONCLUSIONS The use of cefazolin in cirrhotic patients after endoscopic interventions for acute variceal hemorrhage reduced infections. A trend of actuarial probability of remaining free of early rebleeding (<7 days) was observed, especially in Child-Pugh class A patients. This study may be hampered by the small sample size and more large-scale studies are mandatory.
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Affiliation(s)
- Huang-Wei Xu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, 123, Ta Pei Road, Niao Sung, Kaohsiung 833, Taiwan
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Tsochatzis EA, Bosch J, Burroughs AK. Prolonging survival in patients with cirrhosis: old drugs with new indications. Gastroenterology 2010; 139:1813-1815.e1. [PMID: 21034779 DOI: 10.1053/j.gastro.2010.10.031] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Emmanuel A Tsochatzis
- The Royal Free Sheila Sherlock Liver Centre, University Department of Surgery, UCL and Royal Free Hospital Hampstead, London, United Kingdom
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Brown MRL, Jones G, Nash KL, Wright M, Guha IN. Antibiotic prophylaxis in variceal hemorrhage: Timing, effectiveness and Clostridium difficile rates. World J Gastroenterol 2010; 16:5317-23. [PMID: 21072894 PMCID: PMC2980680 DOI: 10.3748/wjg.v16.i42.5317] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate if antibiotics administered within 8 h of endoscopy reduce mortality or increase the incidence of Clostridium difficile infection (CDI).
METHODS: A 2-year retrospective analysis of all patients who presented with first variceal hemorrhage was undertaken. The primary outcome measure was 28-d mortality. Secondary outcome measures were 28-d rebleeding rates and 28-d incidence of CDI. All patients were admitted to a tertiary liver unit with a consultant-led, 24-h endoscopy service. Patients received standard care including terlipressin therapy. Data collection included: primary and secondary outcome measures, timing of first administration of intravenous antibiotics, etiology of liver disease, demographics, endoscopy details and complications. A prospective study was undertaken to determine the incidence of CDI in the study population and general medical inpatients admitted for antibiotic therapy of at least 5 d duration. Statistical analysis was undertaken using univariate, non-parametric tests and multivariate logistic regression analysis.
RESULTS: There were 70 first presentations of variceal hemorrhage during the study period. Seventy percent of cases were male and 65.7% were due to chronic alcoholic liver disease. In total, 64/70 (91.4%) patients received antibiotics as prophylaxis during their admission. Specifically, 53/70 (75.7%) received antibiotics either before endoscopy or within 8 h of endoscopy [peri-endoscopy (8 h) group], whereas 17/70 (24.3%) received antibiotics at > 8 h after endoscopy or not at all (non peri-endoscopy group). Overall mortality and rebleeding rates were 13/70 (18.6%) and 14/70 (20%), respectively. The peri-endoscopy (8 h) group was significantly less likely to die compared with the non peri-endoscopy group [13.2% vs 35.3%, P = 0.04, odds ratio (OR) = 0.28 (0.078-0.997)] and showed a trend towards reduced rebleeding [17.0% vs 29.4%, P = 0.27, OR = 0.49 (0.14-1.74)]. On univariate analysis, the non peri-endoscopy group [P = 0.02, OR = 3.58 (1.00-12.81)], higher model for end-stage liver disease (MELD) score (P = 0.02), presence of hepatorenal syndrome [P < 0.01, OR = 11.25 (2.24-56.42)] and suffering a clinical episode of sepsis [P = 0.03, OR = 4.03 (1.11-14.58)] were significant predictors of death at 28 d. On multivariate logistic regression analysis, lower MELD score [P = 0.01, OR = 1.16 (1.04-1.28)] and peri-endoscopy (8 h) group [P = 0.01, OR = 0.15 (0.03-0.68)] were independent predictors of survival at 28 d. The CDI incidence (5.7%) was comparable to that in the general medical population (5%).
CONCLUSION: Antibiotics administered up to 8 h following endoscopy were associated with improved survival at 28 d. CDI incidence was comparable to that in other patient groups.
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Chavez‐Tapia NC, Barrientos‐Gutierrez T, Tellez‐Avila FI, Soares‐Weiser K, Uribe M. Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding. Cochrane Database Syst Rev 2010; 2010:CD002907. [PMID: 20824832 PMCID: PMC7138054 DOI: 10.1002/14651858.cd002907.pub2] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Bacterial infections are a frequent complication in patients with cirrhosis and upper gastrointestinal bleeding. Antibiotic prophylaxis seems to decrease the incidence of bacterial infections. Oral antibiotics, active against enteric bacteria, have been commonly used as antibiotic prophylaxis in patients with cirrhosis and upper gastrointestinal bleeding. This is an update of a Cochrane review first published in 2002. OBJECTIVES To assess the benefits and harms of antibiotic prophylaxis in cirrhotic patients with upper gastrointestinal bleeding. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index EXPANDED until June 2010. In addition, we handsearched the references of all identified studies. SELECTION CRITERIA Randomised clinical trials comparing different types of antibiotic prophylaxis with no intervention, placebo, or another antibiotic to prevent bacterial infections in cirrhotic patients with upper gastrointestinal bleeding. DATA COLLECTION AND ANALYSIS Three authors independently assessed trial quality, risk of bias, and extracted data. We contacted study authors for additional information. Association measures were relative risk (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes. MAIN RESULTS Twelve trials (1241 patients) evaluated antibiotic prophylaxis compared with placebo or no antibiotic prophylaxis. All trials were at risk of bias. Antibiotic prophylaxis compared with no intervention or placebo was associated with beneficial effects on mortality (RR 0.79, 95% CI 0.63 to 0.98), mortality from bacterial infections (RR 0.43, 95% CI 0.19 to 0.97), bacterial infections (RR 0.36, 95% CI 0.27 to 0.49), rebleeding (RR 0.53, 95% CI 0.38 to 0.74), days of hospitalisation (MD -1.91, 95% CI -3.80 to -0.02), bacteraemia (RR 0.25, 95% CI 0.15 to 0.40), pneumonia (RR 0.45, 95% CI 0.27 to 0.75), spontaneous bacterial peritonitis (RR 0.29, 95% CI 0.15 to 0.57), and urinary tract infections (RR 0.23, 95% CI 0.12 to 0.41). No serious adverse events were reported. The trials showed no significant heterogeneity of effects. Another five trials (650 patients) compared different antibiotic regimens. Data could not be combined as each trial used different antibiotic regimen. None of the examined antibiotic regimen was superior to the control regimen regarding mortality or bacterial infections. AUTHORS' CONCLUSIONS Prophylactic antibiotic use in patients with cirrhosis and upper gastrointestinal bleeding significantly reduced bacterial infections, and seems to have reduced all-cause mortality, bacterial infection mortality, rebleeding events, and hospitalisation length. These benefits were observed independently of the type of antibiotic used; thus, no specific antibiotic can be preferred. Therefore, antibiotic selection should be made considering local conditions such as bacterial resistance profile and treatment cost.
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Affiliation(s)
| | - Tonatiuh Barrientos‐Gutierrez
- National Institute of Public HealthTobacco Research Department7a Cerrada de Fray Pedro de Gante #50Col Seccion XVI, TlalpanMexico CityMexico CityMexico14000
| | - Felix I Tellez‐Avila
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador ZubiránDepartment of GastroenterologyMexico CityDistrito FederalMexico1400
| | | | - Misael Uribe
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador ZubiránDepartment of GastroenterologyMexico CityDistrito FederalMexico1400
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Lisman T, Caldwell SH, Burroughs AK, Northup PG, Senzolo M, Stravitz RT, Tripodi A, Trotter JF, Valla DC, Porte RJ. Hemostasis and thrombosis in patients with liver disease: the ups and downs. J Hepatol 2010; 53:362-71. [PMID: 20546962 DOI: 10.1016/j.jhep.2010.01.042] [Citation(s) in RCA: 220] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Revised: 01/28/2010] [Accepted: 01/29/2010] [Indexed: 12/13/2022]
Abstract
Patients with chronic or acute liver failure frequently show profound abnormalities in their hemostatic system. Whereas routine laboratory tests of hemostasis suggest these hemostatic alterations result in a bleeding diathesis, accumulating evidence from both clinical and laboratory studies suggest that the situation is more complex. The average patient with liver failure may be in hemostatic balance despite prolonged routine coagulation tests, since both pro- and antihemostatic factors are affected, the latter of which are not well reflected in routine coagulation testing. However, this balance may easily tip towards a hypo- or hypercoagulable situation. Indeed, patients with liver disease may encounter both hemostasis-related bleeding episodes as well as thrombotic events. During the 3rd International Symposium on Coagulopathy and Liver disease, held in Groningen, The Netherlands (18-19 September 2009), a multidisciplinary panel of experts critically reviewed the current data concerning pathophysiology and clinical consequences of hemostatic disorders in patients with liver disease. Highlights of this symposium are summarized in this review.
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Affiliation(s)
- Ton Lisman
- Section Hepatobiliairy Surgery and Liver Transplantation, The Netherlands.
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Thalheimer U, Triantos C, Samonakis D, Patch D, Burroughs AK. Heparin effect on thromboelastography after transjugular intrahepatic portosystemic shunt procedure. Scand J Gastroenterol 2010; 44:1463-70. [PMID: 19958060 DOI: 10.3109/00365520903342174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE In patients with cirrhosis and bacterial infection there is impaired coagulation and a heparin effect on thromboelastography (TEG). Our aim was to assess the presence of a heparin effect on heparinase I-modified TEG in patients before and after transjugular intrahepatic portosystemic shunt (TIPS). Our hypothesis was that, given the presence of a portosystemic gradient of endotoxaemia, and the role of endotoxaemia on the release of heparinoids, the inflow of portal blood after TIPS might reveal heparinoids through a heparin effect on TEG. MATERIAL AND METHODS Blood samples for heparinase I-modified TEG were taken before, 1 h after, 6 h after and the morning after TIPS, with further daily samples being taken until any TEG changes had reverted to baseline. A heparin effect was defined as an improvement of > or =20% in a TEG variable after addition of heparinase I. RESULTS We studied 10 patients (six males, mean age 48.8 years, mean Child score 8.8). The aetiology of liver disease was alcohol in six patients, Budd-Chiari syndrome in two, and hepatitis C virus and cryptogenic cirrhosis in one each. Indications for TIPS were recurrent variceal bleeding in four patients, refractory ascites or hydrothorax in four and Budd-Chiari syndrome in two. There was a statistically significant worsening in TEG parameters after TIPS placement. In eight patients a heparin effect appeared after TIPS and disappeared within 24-48 h. CONCLUSIONS We report the appearance of a transient heparin effect in systemic venous blood after TIPS in patients with cirrhosis or Budd-Chiari syndrome, suggesting the presence of heparinoid substances in the portal venous system in these patients.
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Poordad FF, Sigal SH, Brown RS. Pathophysiologic basis for the medical management of portal hypertension. Expert Opin Pharmacother 2009; 10:453-67. [PMID: 19191681 DOI: 10.1517/14656560802707853] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Portal hypertension is a potentially life-threatening complication of cirrhosis, resulting from increased intrahepatic resistance and portal inflow. OBJECTIVE Given the complex nature of this disorder, a more complete understanding of the pathophysiology of portal hypertension is necessary to develop new therapies that target specific pathways that regulate portal pressure. METHODS This review is based on a literature search of published articles and abstracts on the pathophysiology of portal hypertension, its complications and its treatment. RESULTS/CONCLUSION A number of therapies have been developed or are under investigation for the treatment of portal hypertension and its complications. These agents may reduce mortality and improve quality of life for patients with advanced liver disease.
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Affiliation(s)
- Fred F Poordad
- Cedars-Sinai Medical Center, Center for Liver Disease and Transplantation, 8635 W. Third Street, Suite 1060W, Los Angeles, CA 90048, USA.
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Superimposed coagulopathic conditions in cirrhosis: infection and endogenous heparinoids, renal failure, and endothelial dysfunction. Clin Liver Dis 2009; 13:33-42. [PMID: 19150307 DOI: 10.1016/j.cld.2008.09.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In this article, the authors discuss three pathophysiologic mechanisms that influence the coagulation system in patients who have liver disease. First, bacterial infections may play an important role in the cause of variceal bleeding in patients who have liver cirrhosis, affecting coagulation through multiple pathways. One of the pathways through which this occurs is dependent on endogenous heparinoids, on which the authors focus in this article. Secondly, the authors discuss renal failure, a condition that is frequently encountered in patients who have liver cirrhosis. Finally, they review dysfunction of the endothelial system. The role of markers of endothelial function in cirrhotic patients, such as von Willebrand factor and endothelin-1, is discussed.
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Senzolo M, Cholongitas E, Thalheimer U, Riddell A, Agarwal S, Mallett S, Ferronato C, Burroughs AK. Heparin-like effect in liver disease and liver transplantation. Clin Liver Dis 2009; 13:43-53. [PMID: 19150308 DOI: 10.1016/j.cld.2008.09.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Liver cirrhosis is characterized by impairment of primary and secondary hemostasis but it is not clear how this impairment is related to the bleeding problems seen in cirrhosis. This delicate hemostatic balance can be perturbed by numerous conditions, such as variceal bleeding, renal failure, or infection/sepsis, which may lead to worsening of coagulation status to date. The role of endogenous heparinoids (glycosaminoglycans) in the coagulopathy of patients who have cirrhosis has been demonstrated by thromboelastography with the addition of heparinase I in patients who have recent variceal bleeding and infection. The heparin-like effect has also been demonstrated to be part of the coagulopathy seen after reperfusion in patients who have cirrhosis and are undergoing liver transplant. Therapeutic implications of these findings are not clear at the moment and the use of drugs able to cleave heparinoids should be explored.
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Affiliation(s)
- M Senzolo
- Division of Gastroenterology, Department of Surgical and Gastroenterological Sciences, University Hospital of Padua, Via Giustiniani 2, 35136, Padova, Italy
| | - E Cholongitas
- The Royal Free Sheila Sherlock Liver Centre and Department of Surgery, Royal Free Hospital, Pond Street, London NW3 2QG, UK
| | - U Thalheimer
- The Royal Free Sheila Sherlock Liver Centre and Department of Surgery, Royal Free Hospital, Pond Street, London NW3 2QG, UK
| | - Anne Riddell
- Department of Heamophilia and Haemostasis, Royal Free Hospital, Pond Street, London NW3 2QG, UK
| | - S Agarwal
- Department of Anesthesia, Royal Free Hospital, Pond Street, London NW3 2QG, UK
| | - S Mallett
- Department of Anesthesia, Royal Free Hospital, Pond Street, London NW3 2QG, UK
| | - C Ferronato
- Division of Gastroenterology, Department of Surgical and Gastroenterological Sciences, University Hospital of Padua, Via Giustiniani 2, 35136, Padova, Italy
| | - A K Burroughs
- The Royal Free Sheila Sherlock Liver Centre and Department of Surgery, Royal Free Hospital, Pond Street, London NW3 2QG, UK.
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Triantos CK, Nikolopoulou V, Burroughs AK. Review article: the therapeutic and prognostic benefit of portal pressure reduction in cirrhosis. Aliment Pharmacol Ther 2008; 28:943-52. [PMID: 18627364 DOI: 10.1111/j.1365-2036.2008.03798.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Hepatic venous pressure gradient (HVPG) measurement is not a routinely used technique, despite its therapeutic and prognostic value. AIM To review the role of HVPG from published literature. METHODS Systematic literature review. RESULTS In acute variceal bleeding, HVPG is prognostic identifying 'difficult to treat' group, which now has defined clinical correlations. In secondary prevention of portal hypertensive bleeding, a reduction to < or = 12 mmHg confers near complete protection against rebleeding. The target of > or = 20% HVPG reduction from baseline needs prospective assessment to test a change of therapy, if no reduction occurs. The acute HVPG response to beta-blockade needs further assessment. In primary prevention, the cost-effectiveness of HVPG measurement is not favourable given the efficacy of medical therapy. In chronic liver disease, wedge hepatic venous pressure (WHVP) is prognostic for survival. Pharmacological reduction in portal pressure decreases complications and improves survival, possibly independent of a concomitant improvement in liver function. This latter requires urgent confirmation as it is clinically very relevant. HVPG monitoring can be used to assess anti-viral therapy particularly in cirrhosis, ergonomically combined with transjugular biopsy. CONCLUSIONS The prognostic and therapeutic value of HVPG is established beyond portal hypertensive bleeding for which there are some clinical surrogates. HVPG measurement should now be part of everyday clinical practice.
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Affiliation(s)
- C K Triantos
- Division of Gastroenterology, Department of Internal Medicine, University Hospital, Patras, Greece
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Thalheimer U, Bosch J, Burroughs AK. How to prevent varices from bleeding: shades of grey--the case for nonselective beta blockers. Gastroenterology 2007; 133:2029-36. [PMID: 18054573 DOI: 10.1053/j.gastro.2007.10.028] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2007] [Accepted: 09/27/2007] [Indexed: 12/11/2022]
Affiliation(s)
- Ulrich Thalheimer
- Liver Transplantation and Hepatobiliary Unit, Royal Free Hospital, London, United Kingdom
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