Application of endoscopy in improving survival of cirrhotic patients with acute variceal hemorrhage

Effects of Preoperative Oral Carbohydrate on Cirrhotic Patients under Endoscopic Therapy with Anesthesia: A Randomized Controlled Trial

Preoperative fasting causes significant perioperative discomfort in patients. Preoperative oral carbohydrate (POC) is an important element of the enhanced recovery after surgery protocol, but its effect on cirrhotic patients who tend to have abnormal gastric emptying remains unclarified. We investigated the influence of POC on gastric emptying and preprocedural well-being in cirrhotic patients. A prospective, randomized, controlled study of cirrhotic patients with gastroesophageal varices scheduled for elective therapeutic endoscopy under intravenous anesthesia was conducted. We enrolled 180 patients and divided them into three groups: those not supplemented with carbohydrates for 8 h before therapeutic endoscopy (control group) and those administered a carbohydrate beverage 2 h (2 h group) and 4 h (4 h group) before endoscopy. The residual gastric volume was quantified before anesthesia, gastric emptying was evaluated using gastric ultrasonography, and preprocedural well-being was assessed using the visual analogue scale (VAS). Preanesthesia gastric sonography scores were similar among the three groups. No patient had residual gastric volume > 1.5 ml/kg in the control and 4 h groups, but six patients (11%) had a residual gastric volume of >1.5 ml/kg in the 2 h group, hence were at a risk of regurgitation and aspiration. Moreover, VAS scores for six parameters (thirst, hunger, mouth dryness, nausea, vomiting, and fatigue) in the 2 h group and three parameters (thirst, hunger, and mouth dryness) in the 4 h group were significantly lower than those in the control group, suggesting a beneficial effect on cirrhotic patients' well-being. Preoperative gastric peristaltic and operation scores, postoperative complications, length of hospital stay, and in-hospital expenses were not significantly different among the three groups. Our study indicated that avoiding preoperative fasting with oral carbohydrates administered 4 h before anesthesia can be achieved in cirrhotic patients. Further studies to assess whether POC can help improve postoperative outcomes in cirrhotic patients are needed.

Timing of Emergency Endoscopy for Acute Upper Gastrointestinal Bleeding: A Literature Review

Upper gastrointestinal (GI) bleeding is a common cause for Emergency Department and hospital admissions and has significant mortality and morbidity if it remains untreated. Upper endoscopy is the key procedure for both diagnosis and treatment of acute upper GI bleeding. The aim of this article is to review the optimal timing of endoscopy in patients with acute upper GI bleeding. The cost-effectiveness and the influence of urgent or emergent endoscopy on patients' outcomes are discussed. Also, we compare and contrast the available evidence and guidelines regarding the recommended time points for performing endoscopy in different clinical settings.

Self-Expandable Metal Stents for Persisting Esophageal Variceal Bleeding after Band Ligation or Injection-Therapy: A Retrospective Study

BACKGROUND AND STUDY AIMS

Despite a pronounced reduction of lethality rates due to upper gastrointestinal bleeding, esophageal variceal bleeding remains a challenge for the endoscopist and still accounts for a mortality rate of up to 40% within the first 6 weeks. A relevant proportion of patients with esophageal variceal bleeding remains refractory to standard therapy, thus making a call for additional tools to achieve hemostasis. Self-expandable metal stents (SEMS) incorporate such a tool.

METHODS

We evaluated a total number of 582 patients admitted to our endoscopy unit with the diagnosis "gastrointestinal bleeding" according to our documentation software between 2011 and 2014. 82 patients suffered from esophageal variceal bleeding, out of which 11 cases were refractory to standard therapy leading to SEMS application. Patients with esophageal malignancy, fistula, or stricture and a non-esophageal variceal bleeding source were excluded from the analysis. A retrospective analysis reporting a series of clinically relevant parameters in combination with bleeding control rates and adverse events was performed.

RESULTS

The initial bleeding control rate after SEMS application was 100%. Despite this success, we observed a 27% mortality rate within the first 42 days. All of these patients died due to non-directly hemorrhage-associated reasons. The majority of patients exhibited an extensive demand of medical care with prolonged hospital stay. Common complications were hepatic decompensation, pulmonary infection and decline of renal function. Interestingly, we found in 7 out of 11 patients (63.6%) stent dislocation at time of control endoscopy 24 h after hemostasis or at time of stent removal. The presence of hiatal hernia did not affect obviously stent dislocation rates. Refractory patients had significantly longer hospitalization times compared to non-refractory patients.

CONCLUSIONS

Self-expandable metal stents for esophageal variceal bleeding seem to be safe and efficient after failed standard therapy. Stent migration appeared to be a common incident that did not lead to reactivation of bleeding in any of our patients. SEMS should be considered a reasonable treatment option for refractory esophageal variceal bleeding after treatment failure of ligature and sclerotherapy and non-availability of or contraindication for other measures (e.g. TIPS).

Effect of intravariceal sclerotherapy combined with esophageal mucosal sclerotherapy using small-volume sclerosant for cirrhotic patients with high variceal pressure

AIM: To explore the effect of intravariceal-mucosal sclerotherapy using small dose of sclerosant on the recurrence of esophageal varices.

METHODS: We randomly assigned 38 cirrhotic patients with previous variceal bleeding and high variceal pressure (> 15.2 mmHg) to receive endoscopic variceal ligation (EVL) and combined intravariceal and esophageal mucosal sclerotherapy (combined group) using small-volume sclerosant. The end-points of the study were rebleeding and recurrence of esophageal varices.

RESULTS: During a median follow-up period of 16 mo, varices recurred in 1 patient in the combined group as compared with 7 patients in the EVL group (P = 0.045). Rebleeding occurred in 3 patients in the EVL group as compared with 1 patient in the combined group (P = 0.687). No patient died in the two groups. No significant differences were observed between the two groups with respect to serious adverse events.

CONCLUSION: Intravariceal-mucosal sclerotherapy using small dose of sclerosant is more effective than EVL in decreasing the incidence of variceal recurrence for cirrhotic patients.

Early Endoscopy Can Shorten the Duration of Hospitalization in Suspected Variceal Hemorrhage

Background. Endoscopic treatment in patients with acute variceal hemorrhage should be performed within 12 hours, but the recommendation is based on the experts’ opinion. Objective. Our study investigated if time to endoscopy was a significant factor that could alter the outcomes of patients with suspected variceal hemorrhage. The primary outcome was the length of hospital stay and the mortality. The secondary outcomes were complications during observation periods. Methods. Patients were included if variceal hemorrhage was suspected in the emergency department. Patients were further divided into early (receiving endoscopy within 12 hours) and delayed groups (receiving endoscopy after 12 hours), and each patient was matched using a standard propensity score greedy-matching algorithm. The primary and secondary outcomes were compared accordingly. Results. 1442 patients met our inclusion criteria and therefore were enrolled for further analysis. In the Cox regression model, log time to endoscopy was not a significant factor. In the propensity score assignment, 566 patients (283 in each group) were further selected into the subcohort (P value = 0.8001). Kaplan-Meier curves showed a discharge benefit favoring the early endoscopy over the control group. The mortality rates and complications were not statistically different between the two groups (P value = 0.0045). Conclusion. Early endoscopy before 12 hours in patients with suspected variceal hemorrhage could result in shorter length of hospitalization without increasing the mortalities and complications. The results would help emergency physicians in decisions making when these patients are encountered.

Esophageal variceal ligation in the secondary prevention of variceal bleeding: Result of long term follow-up

Introduction

Long-term outcome of patients after band ligation have been poorly defined. Therefore, we conducted a long-term follow-up study to delineate the outcome of ligation in patients with portal hypertension in the Hassan II university hospital, Fes, Morocco.

Methods

Over 118 months patients treated by endoscopic variceal ligation were received regular follow- up and detailed clinical assessment of at least 24 months.

Results

One hundred twenty five patients were followed up for a mean of 31 months (range 12-107 months). Obliteration of the varices was achieved in 89.6 % (N = 112) of patients, with 3 +/-1.99 (range 1-8) endoscopy sessions over a period of 14 + /-6.8 weeks (range 3-28). The percentage of variceal recurrence during follow-up after ligation was 20.5 % (N = 23). Recurrence were observed in a mean of 22 months +/- 7.3 (range 3-48). Bleeding rate from recurrent varices was 30.4 % (7/23). Rebleeding from esophageal ulcers occurred in 5.6 % (7/125) of patients. Portal hypertensive gastropathy before and after eradication of varices was 17.6% (N = 22) and 44.6% (N = 50) respectively; p< 0.05. Fundal gastric varices was 30.4% (N = 38) and 35.7% (N = 40) before and after eradication of varices respectively; p> 0.05. The overall mortality was 4 % (N = 5).

Conclusion

Band ligation was an effective technical approach for variceal obliteration with low rates of variceal recurrence, rebleeding and development of gastric varices. Furthermore, it was associated with frequent development of portal hypertensive gastropathy.

Efficacy of endoscopic intervention alone versus endoscopic intervention plus propranolol in the prophylaxis of esophageal variceal rebleeding

AIM: To compar e the efficacy of endoscopic variceal ligation (EVL) or endoscopic injection sclerotherapy (EIS) alone versus EVL or EIS plus propranolol in the prophylaxis of esophageal variceal rebleeding.

METHODS: Sixty-nine cirrhotic patients were divided randomly into endoscopic intervention group (EIG, n = 40; EVL or EIS) and combination intervention group (CIG, n = 29; EVL or EIS plus propranolol). The mortality, mortality due to rebleeding, and rate of rebleeding were compared between the two groups. All patients were followed for more than one year. In addition, changes in endoscopic characteristics of esophageal varices were evaluated according to the criterion of the Japan Society for Portal Hypertension.

RESULTS: There were no significantly differences in liver function, routine blood parameters, and serum electrolytes between the two groups. After intervention, the diameter of varices decreased significantly in the EIG group (10.92 ± 2.91 vs 8.45 ± 2.26, P < 0.05), but showed no significance in the CIG group (10.14 ± 2.46 vs 8.95 ± 2.21, P > 0.05). The distance from the proximal end of varices to the fore-tooth (22.79 ± 2.83 vs 24.85 ± 3.96, P < 0.05) and the rate of recurrence of red signs in varices (100% vs 76.19%, P < 0.05) decreased significantly after intervention in the CIG group. The morbidity of gastric varices and portal hypertensive gastropathy were both higher after intervention in the CIG group (10.34% vs 28.10%, P < 0.05; 10.34% vs 42.86%, P < 0.05). The appearance of varices in both groups changed from rosary-like to earthworm-like pattern. The rate of rebleeding between two groups displayed no significant difference (50.00% vs 51.71%, P > 0.05). However, the mortality in the CIG group was significantly lower than that in the EIG group (27.50% vs 7.41%, P < 0.05), and the main cause of death in both groups was upper gastrointestinal bleeding.

CONCLUSION: Endoscopic intervention combined with propranolol can decrease the risk of death and reduce endoscopic re-bleeding in the prevention of esophageal variceal re-bleeding.