1
|
Jaan A, Sarfraz Z, Farooq U, Gutman J, McFarland JE, Mahmood S, Dunnigan K, Cryer B, Okolo P. Nonvariceal upper gastrointestinal bleeding in COVID-19 patients: insights from the National Inpatient Sample. Scand J Gastroenterol 2024; 59:615-622. [PMID: 38305194 DOI: 10.1080/00365521.2024.2310161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 01/21/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND This retrospective study, conducted using the U.S. National Inpatient Sample (NIS), examines the outcomes and management of nonvariceal upper gastrointestinal bleeding (NVUGIB) in COVID-19 patients and identifies predictive factors to enhance patient prognosis. METHODS We analyzed the 2020 U.S. NIS data involving adult patients (≥18 years) admitted with NVUGIB and categorized them based on the presence of COVID-19. Primary and secondary outcomes, NVUGIB-related procedures, and predictive factors were evaluated. RESULTS Of 184,885 adult patients admitted with NVUGIB, 1.6% (2990) had COVID-19. Patients with NVUGIB and COVID-19 showed higher inpatient mortality, acute kidney injury, need for intensive care, and resource utilization metrics. Notably, there was a lower rate of early esophagogastroduodenoscopy (EGD). Multivariate logistic regression revealed conditions like peptic ulcer disease, mechanical ventilation, and alcohol abuse as significant positive predictors for NVUGIB in COVID-19 patients, whereas female gender and smoking were negative predictors. CONCLUSION Our findings suggest that COVID-19 significantly increases the risk of mortality and complications in NVUGIB patients. The observed decrease in early EGD interventions, potentially contributing to higher mortality rates, calls for a review of treatment strategies. Further multicenter, prospective studies are needed to validate these results and improve patient care strategies.
Collapse
Affiliation(s)
- Ali Jaan
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Zouina Sarfraz
- Department of Medicine, Fatima Jinnah Medical University, Lahore, Pakistan
| | - Umer Farooq
- Department of Gastroenterology and Hepatology, Saint Louis University, St. Louis, MO, USA
| | - Jason Gutman
- Department of Gastroenterology and Hepatology, Rochester General Hospital, Rochester, NY, USA
| | - Joel E McFarland
- Department of Gastroenterology and Hepatology, Rochester General Hospital, Rochester, NY, USA
| | - Sultan Mahmood
- Department of Gastroenterology and Hepatology, University of Pittsburgh Medical Center Pittsburgh, PA, USA
| | - Karin Dunnigan
- Department of Gastroenterology and Hepatology, Rochester General Hospital, Rochester, NY, USA
| | - Byron Cryer
- Department of Gastroenterology and Hepatology, Baylor University Medical Center, Dallas, TX, USA
| | - Patrick Okolo
- Department of Gastroenterology and Hepatology, Rochester General Hospital, Rochester, NY, USA
| |
Collapse
|
2
|
Zeng A, Li Y, Lyu L, Zhang S, Zhang Y, Ding H, Li L. Risk factors and predictive nomograms for bedside emergency endoscopic treatment following endotracheal intubation in cirrhotic patients with esophagogastric variceal bleeding. Sci Rep 2024; 14:9467. [PMID: 38658605 DOI: 10.1038/s41598-024-59802-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 04/15/2024] [Indexed: 04/26/2024] Open
Abstract
Data on emergency endoscopic treatment following endotracheal intubation in patients with esophagogastric variceal bleeding (EGVB) remain limited. This retrospective study aimed to explore the efficacy and risk factors of bedside emergency endoscopic treatment following endotracheal intubation in severe EGVB patients admitted in Intensive Care Unit. A total of 165 EGVB patients were enrolled and allocated to training and validation sets in a randomly stratified manner. Univariate and multivariate logistic regression analyses were used to identify independent risk factors to construct nomograms for predicting the prognosis related to endoscopic hemostasis failure rate and 6-week mortality. In result, white blood cell counts (p = 0.03), Child-Turcotte-Pugh (CTP) score (p = 0.001) and comorbid shock (p = 0.005) were selected as independent clinical predictors of endoscopic hemostasis failure. High CTP score (p = 0.003) and the presence of gastric varices (p = 0.009) were related to early rebleeding after emergency endoscopic treatment. Furthermore, the 6-week mortality was significantly associated with MELD scores (p = 0.002), the presence of hepatic encephalopathy (p = 0.045) and postoperative rebleeding (p < 0.001). Finally, we developed practical nomograms to discern the risk of the emergency endoscopic hemostasis failure and 6-week mortality for EGVB patients. In conclusion, our study may help identify severe EGVB patients with higher hemostasis failure rate or 6-week mortality for earlier implementation of salvage treatments.
Collapse
Affiliation(s)
- Ajuan Zeng
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, 100069, China
| | - Yangjie Li
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, 100069, China
| | - Lingna Lyu
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, 100069, China
| | - Shibin Zhang
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, 100069, China
| | - Yuening Zhang
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, 100069, China
| | - Huiguo Ding
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, 100069, China.
| | - Lei Li
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, 100069, China.
- Department of Gastroenterology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 102208, China.
| |
Collapse
|
3
|
Kanbakan A, Cakmak F, Ipekci A, Akdeniz YS, Ikizceli I. Geriatric mortality risk factors in emergency department for non-traumatic abdominal pain. BRATISL MED J 2023; 124:718-722. [PMID: 37635670 DOI: 10.4149/bll_2023_109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
OBJECTIVES The study aimed to determine the factors affecting the mortality of geriatric patients presenting to the emergency department with non-traumatic abdominal pain, as well as the associations of these factors with mortality. BACKGROUND With the increasing number of elderly patients, early recognition of patients with risk-bearing diagnoses is crucial. METHODS This prospective cross-sectional study included 466 patients over 65 years of age who were admitted to THE emergency department of a tertiary hospital and consented to participate. Data was collected on patient demographics, vital signs, chronic diseases, laboratory investigations, diagnoses, disposition, and 30-day mortality. RESULTS The results showed that the mean patient age was 74.42 years, with 47.4 % being male and 52.6 % female. 15.6 % of the patients had nonspecific causes. The risk of mortality within one month was 5.797 times higher in patients with neurological diseases and 5.183 times higher in those with a history of surgery. A one-unit decrease in hemoglobin increased the mortality risk by 0.656 times. CONCLUSION This study highlights the importance of careful evaluation of elderly patients with neurological diseases, previous surgical history, and anemia in the emergency department with non-traumatic abdominal pain (Tab. 5, Ref. 18).
Collapse
|
4
|
Hong C, Zhu Q, Li Y, Tang S, Lin S, Yang Y, Yuan S, Shao L, Wu Y, Liu B, Li B, Meng F, Chen Y, Hong M, Qi X. Acute kidney injury defined by cystatin C may be superior for predicting the outcomes of liver cirrhosis with acute gastrointestinal bleeding. Ren Fail 2022; 44:398-406. [PMID: 35225149 PMCID: PMC8890530 DOI: 10.1080/0886022x.2022.2039193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND & AIMS Acute kidney injury (AKI) is conventionally evaluated by a dynamic change of serum creatinine (Scr). Cystatin C (CysC) seems to be a more accurate biomarker for assessing kidney function. This retrospective multicenter study aims to evaluate whether AKI re-defined by CysC can predict the in-hospital outcomes of patients with liver cirrhosis and acute gastrointestinal bleeding. METHODS Overall, 677 cirrhotic patients with acute gastrointestinal bleeding, in whom both Scr and CysC levels were detected at admissions, were screened. eGFRScr, eGFRCysC, and eGFRScr-CysC were calculated. MELD-Na score and AKI were re-evaluated by CysC instead of Scr. Odds ratios (ORs) were calculated in the logistic regression analyses. The receiver operating characteristic (ROC) curve analyses were performed. RESULTS Univariate logistic regression analyses demonstrated that baseline Scr and CysC levels, eGFRScr, eGFRCysC, eGFRScr-CysC, original MELD-Na score defined by Scr, MELD-Na score re-defined by CysC, and AKI re-defined by CysC, but not conventional AKI defined by Scr, were significantly associated with in-hospital death. ROC analyses showed that baseline CysC level, eGFRScr, eGFRCysC, eGFRScr-CysC, original MELD-Na score defined by Scr, and MELD-Na score re-defined by CysC, but not baseline Scr level, could significantly predict the risk of in-hospital death. CONCLUSIONS AKI re-defined by CysC may be superior for predicting the in-hospital mortality of cirrhotic patients with acute gastrointestinal bleeding.
Collapse
Affiliation(s)
- Cen Hong
- Department of Gastroenterology, General Hospital of Northern Theater Command (formally called General Hospital of Shenyang Military Area), Shenyang, China
| | - Qiang Zhu
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong Frist Medical University, Jinan, China
| | - Yiling Li
- Department of Gastroenterology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Shanhong Tang
- Department of Gastroenterology, General Hospital of Western Theater Command, Chengdu, China
| | - Su Lin
- Department of Hepatology, Hepatology Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yida Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Shanshan Yuan
- Department of Gastroenterology, Xi'an Central Hospital, Xi'an, China
| | - Lichun Shao
- Department of Gastroenterology, Air Force Hospital of Northern Theater Command, Shenyang, China
| | - Yunhai Wu
- Department of Critical Care Medicine, The Sixth People's Hospital of Shenyang, Shenyang, China
| | - Bang Liu
- Department of Hepatobiliary Disease, Fuzong Clinical Medical College of Fujian Medical University & 900 Hospital of the Joint Logistics Team, Fuzhou, China
| | - Bimin Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Fanping Meng
- Department of Biological Therapy, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Yu Chen
- Fourth Department of Liver Disease (Difficult & Complicated Liver Diseases and Artificial Liver Center), Beijing You’an Hospital, Affiliated to Capital Medical University, Beijing, China
| | - Min Hong
- Department of Nephrology, General Hospital of Northern Theater Command (formally called General Hospital of Shenyang Military Area), Shenyang, China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command (formally called General Hospital of Shenyang Military Area), Shenyang, China
- CONTACT Xingshun Qi Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, Liaoning Province, China
| |
Collapse
|
5
|
Bello FPS, Cardoso S, Tannuri AC, Preto-Zamperlini M, Schvartsman C, Farhat SCL. Acute upper gastrointestinal bleeding due to portal hypertension in children: What is the best timing of endoscopy? Dig Liver Dis 2022; 54:63-68. [PMID: 34625365 DOI: 10.1016/j.dld.2021.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To compare initial clinical/laboratory parameters and outcomes of mortality/rebleeding of endoscopy performed <12 h(early UGIE) versus endoscopy performed after 12-24h(late UGIE) of ED admission in children with acute upper gastrointestinal bleeding(AUGIB) due to portal hypertension. METHODS This is a retrospective cohort study. From January 2010 to July 2017, medical records of all children admitted to a tertiary care hospital with AUGIB due to portal hypertension were reviewed until 60 days after ED admission. RESULTS A total of 98 ED admissions occurred from 73 patients. Rebleeding was identified in 8/98(8%) episodes, and 9 deaths were observed. UGIE was performed in 92(94%) episodes, and 53(58%) of them occurred within 12 h of ED admission. Episodes with early UGIE and late UGIE were similar in terms of history/complaints/laboratory data at admission, chronic liver disease associated, AUGIB duration, and initial management. No statistically significant associations were found between early UGIE and the outcomes of death/rebleeding and prevalence of endoscopic hemostatic treatment (band ligation or sclerotherapy) compared to late UGIE. In the multivariable logistic regression model, the endoscopic hemostatic treatment showed a negative association with early UGIE(OR=0.33;95%CI=0.1-0.9;p = 0.04). CONCLUSIONS This study suggests that in pediatric patients with AUGIB and portal hypertension, UGIE may be performed after 12-24 h without harm to the patient, facilitating better initial clinical stabilization/treatment and optimization of resources.
Collapse
Affiliation(s)
| | - Silvia Cardoso
- Emergency Department, Children's Institute, Faculdade de Medicina da Universidade de Sao Paulo, Brazil; Endoscopy Unit, Children's Institute, Faculdade de Medicina da Universidade de Sao Paulo, Brazil; Pediatric Surgery Unit Children's Institute, Faculdade de Medicina da Universidade de Sao Paulo, Brazil; Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Ana Cristina Tannuri
- Emergency Department, Children's Institute, Faculdade de Medicina da Universidade de Sao Paulo, Brazil
| | - Marcela Preto-Zamperlini
- Emergency Department, Children's Institute, Faculdade de Medicina da Universidade de Sao Paulo, Brazil
| | - Cláudio Schvartsman
- Emergency Department, Children's Institute, Faculdade de Medicina da Universidade de Sao Paulo, Brazil; Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Sylvia Costa Lima Farhat
- Emergency Department, Children's Institute, Faculdade de Medicina da Universidade de Sao Paulo, Brazil.
| |
Collapse
|
6
|
Luo X, Xiang T, Wu J, Wang X, Zhu Y, Xi X, Yan Y, Yang J, García-Pagán JC, Yang L. Endoscopic Cyanoacrylate Injection Versus Balloon-Occluded Retrograde Transvenous Obliteration for Prevention of Gastric Variceal Bleeding: A Randomized Controlled Trial. Hepatology 2021; 74:2074-2084. [PMID: 33445218 DOI: 10.1002/hep.31718] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 12/29/2020] [Accepted: 01/05/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS The optimal treatment for gastric varices (GVs) is a topic that remains open for study. This study compared the efficacy and safety of endoscopic cyanoacrylate injection and balloon-occluded retrograde transvenous obliteration (BRTO) to prevent rebleeding in patients with cirrhosis and GVs after primary hemostasis. APPROACH AND RESULTS Patients with cirrhosis and history of bleeding from gastroesophageal varices type 2 or isolated gastric varices type 1 were randomized to cyanoacrylate injection (n = 32) or BRTO treatment (n = 32). Primary outcomes were gastric variceal rebleeding or all-cause rebleeding. Patient characteristics were well balanced between two groups. Mean follow-up time was 27.1 ± 12.0 months in a cyanoacrylate injection group and 27.6 ± 14.3 months in a BRTO group. Probability of gastric variceal rebleeding was higher in the cyanoacrylate injection group than in the BRTO group (P = 0.024). Probability of remaining free of all-cause rebleeding at 1 and 2 years for cyanoacrylate injection versus BRTO was 77% versus 96.3% and 65.2% versus 92.6% (P = 0.004). Survival rates, frequency of complications, and worsening of esophageal varices were similar in both groups. BRTO resulted in fewer hospitalizations, inpatient stays, and lower medical costs. CONCLUSIONS BRTO is more effective than cyanoacrylate injection in preventing rebleeding from GVs, with similar frequencies of complications and mortalities.
Collapse
Affiliation(s)
- Xuefeng Luo
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Tong Xiang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Junchao Wu
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoze Wang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Yongjun Zhu
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaotan Xi
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
| | - Yuling Yan
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Jinlin Yang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, Barcelona, Spain
| | - Li Yang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
7
|
Sun Y, Li S, Li F. The efficacy and safety of beta-blockers versus cyanoacrylate injection for gastric variceal bleeding: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e26039. [PMID: 34032728 PMCID: PMC8154464 DOI: 10.1097/md.0000000000026039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/04/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The benefit of beta-blockers for secondary prophylaxis of gastric variceal bleeding has limited evidence. Therefore, a systematic review and meta-analysis was conducted to systematically analyze and compare the effect of beta-blockers versus cyanoacrylate injection for patients with gastric variceal bleeding. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines will be followed to conduct the present meta-analysis. From the inception to June 2021, the Web of Science, EMBASE, PubMed, and Cochrane Library electronic databases will be searched using the key phrases "beta-blockers," "cyanoacrylate," and "gastric variceal bleeding" for all relevant English-language trials. Study included in our meta-analysis has to meet the following criteria: observational or randomized controlled trial focusing on assessing the effectiveness of beta-blockers and cyanoacrylate injection for gastric variceal bleeding; the following outcome measures are reported: bleeding from gastric variceal, overall mortality, bleed related mortality, and complications. RESULTS This study expects to provide credible and scientific evidence for the efficacy and safety of beta-blockers versus cyanoacrylate injection for patients with gastric variceal bleeding. REGISTRATION NUMBER 10.17605/OSF.IO/CPV9T.
Collapse
Affiliation(s)
| | - Sheng Li
- Department of Radiology, Weifang People's Hospital, Shandong 261041, China
| | - Feng Li
- Department of Emergency Surgery
| |
Collapse
|
8
|
Rustgi SD, Yang JY, Luther S, David Y, Dixon RE, Simoes PK, Kumta NA. Anticoagulation does not increase risk of mortality or ICU admission in hospitalized COVID-19 patients with gastrointestinal bleeding: Results from a New York health system. Clin Res Hepatol Gastroenterol 2021; 45:101602. [PMID: 33607549 PMCID: PMC7834436 DOI: 10.1016/j.clinre.2020.101602] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 12/12/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Sheila D Rustgi
- Henry D Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Jeong Yun Yang
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Sanjana Luther
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Yakira David
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Rebekah E Dixon
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Priya K Simoes
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Nikhil A Kumta
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
| |
Collapse
|
9
|
Roberts D, Best LM, Freeman SC, Sutton AJ, Cooper NJ, Arunan S, Begum T, Williams NR, Walshaw D, Milne EJ, Tapp M, Csenar M, Pavlov CS, Davidson BR, Tsochatzis E, Gurusamy KS. Treatment for bleeding oesophageal varices in people with decompensated liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev 2021; 4:CD013155. [PMID: 33837526 PMCID: PMC8094233 DOI: 10.1002/14651858.cd013155.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Approximately 40% to 95% of people with liver cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed within about one to three years after diagnosis. Several different treatments are available, including, among others, endoscopic sclerotherapy, variceal band ligation, somatostatin analogues, vasopressin analogues, and balloon tamponade. However, there is uncertainty surrounding the individual and relative benefits and harms of these treatments. OBJECTIVES To compare the benefits and harms of different initial treatments for variceal bleeding from oesophageal varices in adults with decompensated liver cirrhosis, through a network meta-analysis; and to generate rankings of the different treatments for acute bleeding oesophageal varices, according to their benefits and harms. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until 17 December 2019, to identify randomised clinical trials (RCTs) in people with cirrhosis and acute bleeding from oesophageal varices. SELECTION CRITERIA We included only RCTs (irrespective of language, blinding, or status) in adults with cirrhosis and acutely bleeding oesophageal varices. We excluded RCTs in which participants had bleeding only from gastric varices, those who failed previous treatment (refractory bleeding), those in whom initial haemostasis was achieved before inclusion into the trial, and those who had previously undergone liver transplantation. DATA COLLECTION AND ANALYSIS We performed a network meta-analysis with OpenBUGS software, using Bayesian methods, and calculated the differences in treatments using odds ratios (OR) and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. We performed also the direct comparisons from RCTs using the same codes and the same technical details. MAIN RESULTS We included a total of 52 RCTs (4580 participants) in the review. Forty-eight trials (4042 participants) were included in one or more comparisons in the review. The trials that provided the information included people with cirrhosis due to varied aetiologies and those with and without a previous history of bleeding. We included outcomes assessed up to six weeks. All trials were at high risk of bias. A total of 19 interventions were compared in the trials (sclerotherapy, somatostatin analogues, vasopressin analogues, sclerotherapy plus somatostatin analogues, variceal band ligation, balloon tamponade, somatostatin analogues plus variceal band ligation, nitrates plus vasopressin analogues, no active intervention, sclerotherapy plus variceal band ligation, balloon tamponade plus sclerotherapy, balloon tamponade plus somatostatin analogues, balloon tamponade plus vasopressin analogues, variceal band ligation plus vasopressin analogues, balloon tamponade plus nitrates plus vasopressin analogues, balloon tamponade plus variceal band ligation, portocaval shunt, sclerotherapy plus transjugular intrahepatic portosystemic shunt (TIPS), and sclerotherapy plus vasopressin analogues). We have reported the effect estimates for the primary and secondary outcomes when there was evidence of differences between the interventions against the reference treatment of sclerotherapy, but reported the other results of the primary and secondary outcomes versus the reference treatment of sclerotherapy without the effect estimates when there was no evidence of differences in order to provide a concise summary of the results. Overall, 15.8% of the trial participants who received the reference treatment of sclerotherapy (chosen because this was the commonest treatment compared in the trials) died during the follow-up periods, which ranged from three days to six weeks. Based on moderate-certainty evidence, somatostatin analogues alone had higher mortality than sclerotherapy (OR 1.57, 95% CrI 1.04 to 2.41; network estimate; direct comparison: 4 trials; 353 participants) and vasopressin analogues alone had higher mortality than sclerotherapy (OR 1.70, 95% CrI 1.13 to 2.62; network estimate; direct comparison: 2 trials; 438 participants). None of the trials reported health-related quality of life. Based on low-certainty evidence, a higher proportion of people receiving balloon tamponade plus sclerotherapy had more serious adverse events than those receiving only sclerotherapy (OR 4.23, 95% CrI 1.22 to 17.80; direct estimate; 1 RCT; 60 participants). Based on moderate-certainty evidence, people receiving vasopressin analogues alone and those receiving variceal band ligation had fewer adverse events than those receiving only sclerotherapy (rate ratio 0.59, 95% CrI 0.35 to 0.96; network estimate; direct comparison: 1 RCT; 219 participants; and rate ratio 0.40, 95% CrI 0.21 to 0.74; network estimate; direct comparison: 1 RCT; 77 participants; respectively). Based on low-certainty evidence, the proportion of people who developed symptomatic rebleed was smaller in people who received sclerotherapy plus somatostatin analogues than those receiving only sclerotherapy (OR 0.21, 95% CrI 0.03 to 0.94; direct estimate; 1 RCT; 105 participants). The evidence suggests considerable uncertainty about the effect of the interventions in the remaining comparisons where sclerotherapy was the control intervention. AUTHORS' CONCLUSIONS Based on moderate-certainty evidence, somatostatin analogues alone and vasopressin analogues alone (with supportive therapy) probably result in increased mortality, compared to endoscopic sclerotherapy. Based on moderate-certainty evidence, vasopressin analogues alone and band ligation alone probably result in fewer adverse events compared to endoscopic sclerotherapy. Based on low-certainty evidence, balloon tamponade plus sclerotherapy may result in large increases in serious adverse events compared to sclerotherapy. Based on low-certainty evidence, sclerotherapy plus somatostatin analogues may result in large decreases in symptomatic rebleed compared to sclerotherapy. In the remaining comparisons, the evidence indicates considerable uncertainty about the effects of the interventions, compared to sclerotherapy.
Collapse
Affiliation(s)
- Danielle Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Lawrence Mj Best
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Nicola J Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Sivapatham Arunan
- General and Colorectal Surgery, Ealing Hospital and Imperial College, London, Northwood, UK
| | | | - Norman R Williams
- Surgical & Interventional Trials Unit (SITU), UCL Division of Surgery & Interventional Science, London, UK
| | - Dana Walshaw
- Acute Medicine, Barts and The London NHS Trust, London, UK
| | | | | | - Mario Csenar
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Chavdar S Pavlov
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Kurinchi Selvan Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| |
Collapse
|
10
|
Razavilar N, Taleshi JM. Cost-Effectiveness Analysis of Transcatheter Arterial Embolization Techniques for the Treatment of Gastrointestinal Bleeding in the United States. Value Health 2021; 24:477-485. [PMID: 33840425 DOI: 10.1016/j.jval.2020.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 09/04/2020] [Accepted: 10/30/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Gastrointestinal (GI) bleeding is a common medical emergency associated with significant mortality. Transcatheter arterial embolization first was introduced by Rosch et al as an alternative to surgery for upper GI bleeding. The clinical success in patients with GI bleeding treated with transcatheter arterial embolization previously has been reported. However, there are no cost-effectiveness analyses reported to date. Here we report cost-effectiveness analysis of N-butyl 2-cyanoacrylate glue (NBCA) and ethylene-vinyl alcohol copolymer (Onyx) versus coil (gold standard) for treatment of GI bleeding from a healthcare payer perspective. METHODS Fixed-effects modeling with a generalized linear mixed method was used in NBCA and coil intervention arms to determine the pooled probabilities of clinical success and mortality with complications with their confidence intervals, while the Clopper-Pearson model was used for Onyx to determine the same parameters. Models were provided by the "Meta-Analysis with R" software package. A decision tree was built for cost-effectiveness analysis, and Microsoft Excel was used for probabilistic sensitivity analysis. The cost-effective option was determined based on the incremental cost-effectiveness ratio and scatter plots of incremental cost versus incremental quality-adjusted life-years. RESULTS Comparing scatter plots and incremental cost-effectiveness ratio results, -$1024 and -$1349 per quality-adjusted life-year for Onyx and N-butyl 2-cyanoacrylate glue, respectively, Onyx was the least expensive and most effective intervention. CONCLUSION Onyx was the dominant strategy regardless of threshold values. Our analyses provide a framework for researchers to predict the target clinical effectiveness for early-stage TAE interventions and guide resource allocation decisions.
Collapse
Affiliation(s)
- Negin Razavilar
- RAZN Health Decision Modelling LTD, University of Alberta Health Accelerator, Edmonton, Canada; Faculty of Sciences, University of Alberta, Edmonton, Canada.
| | | |
Collapse
|
11
|
Plaz Torres MC, Best LM, Freeman SC, Roberts D, Cooper NJ, Sutton AJ, Roccarina D, Benmassaoud A, Iogna Prat L, Williams NR, Csenar M, Fritche D, Begum T, Arunan S, Tapp M, Milne EJ, Pavlov CS, Davidson BR, Tsochatzis E, Gurusamy KS. Secondary prevention of variceal bleeding in adults with previous oesophageal variceal bleeding due to decompensated liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev 2021; 3:CD013122. [PMID: 33784794 PMCID: PMC8094621 DOI: 10.1002/14651858.cd013122.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Approximately 40% to 95% of people with cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed in about one to three years of diagnosis. Several different treatments are available, which include endoscopic sclerotherapy, variceal band ligation, beta-blockers, transjugular intrahepatic portosystemic shunt (TIPS), and surgical portocaval shunts, among others. However, there is uncertainty surrounding their individual and relative benefits and harms. OBJECTIVES To compare the benefits and harms of different initial treatments for secondary prevention of variceal bleeding in adults with previous oesophageal variceal bleeding due to decompensated liver cirrhosis through a network meta-analysis and to generate rankings of the different treatments for secondary prevention according to their safety and efficacy. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until December 2019 to identify randomised clinical trials in people with cirrhosis and a previous history of bleeding from oesophageal varices. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or status) in adults with cirrhosis and previous history of bleeding from oesophageal varices. We excluded randomised clinical trials in which participants had no previous history of bleeding from oesophageal varices, previous history of bleeding only from gastric varices, those who failed previous treatment (refractory bleeding), those who had acute bleeding at the time of treatment, and those who had previously undergone liver transplantation. DATA COLLECTION AND ANALYSIS We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the differences in treatments using hazard ratios (HR), odds ratios (OR) and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. MAIN RESULTS We included a total of 48 randomised clinical trials (3526 participants) in the review. Forty-six trials (3442 participants) were included in one or more comparisons. The trials that provided the information included people with cirrhosis due to varied aetiologies. The follow-up ranged from two months to 61 months. All the trials were at high risk of bias. A total of 12 interventions were compared in these trials (sclerotherapy, beta-blockers, variceal band ligation, beta-blockers plus sclerotherapy, no active intervention, TIPS (transjugular intrahepatic portosystemic shunt), beta-blockers plus nitrates, portocaval shunt, sclerotherapy plus variceal band ligation, beta-blockers plus nitrates plus variceal band ligation, beta-blockers plus variceal band ligation, sclerotherapy plus nitrates). Overall, 22.5% of the trial participants who received the reference treatment (chosen because this was the commonest treatment compared in the trials) of sclerotherapy died during the follow-up period ranging from two months to 61 months. There was considerable uncertainty in the effects of interventions on mortality. Accordingly, none of the interventions showed superiority over another. None of the trials reported health-related quality of life. Based on low-certainty evidence, variceal band ligation may result in fewer serious adverse events (number of people) than sclerotherapy (OR 0.19; 95% CrI 0.06 to 0.54; 1 trial; 100 participants). Based on low or very low-certainty evidence, the adverse events (number of participants) and adverse events (number of events) may be different across many comparisons; however, these differences are due to very small trials at high risk of bias showing large differences in some comparisons leading to many differences despite absence of direct evidence. Based on low-certainty evidence, TIPS may result in large decrease in symptomatic rebleed than variceal band ligation (HR 0.12; 95% CrI 0.03 to 0.41; 1 trial; 58 participants). Based on moderate-certainty evidence, any variceal rebleed was probably lower in sclerotherapy than in no active intervention (HR 0.62; 95% CrI 0.35 to 0.99, direct comparison HR 0.66; 95% CrI 0.11 to 3.13; 3 trials; 296 participants), beta-blockers plus sclerotherapy than sclerotherapy alone (HR 0.60; 95% CrI 0.37 to 0.95; direct comparison HR 0.50; 95% CrI 0.07 to 2.96; 4 trials; 231 participants); TIPS than sclerotherapy (HR 0.18; 95% CrI 0.08 to 0.38; direct comparison HR 0.22; 95% CrI 0.01 to 7.51; 2 trials; 109 participants), and in portocaval shunt than sclerotherapy (HR 0.21; 95% CrI 0.05 to 0.77; no direct comparison) groups. Based on low-certainty evidence, beta-blockers alone and TIPS might result in more, other compensation, events than sclerotherapy (rate ratio 2.37; 95% CrI 1.35 to 4.67; 1 trial; 65 participants and rate ratio 2.30; 95% CrI 1.20 to 4.65; 2 trials; 109 participants; low-certainty evidence). The evidence indicates considerable uncertainty about the effect of the interventions including those related to beta-blockers plus variceal band ligation in the remaining comparisons. AUTHORS' CONCLUSIONS The evidence indicates considerable uncertainty about the effect of the interventions on mortality. Variceal band ligation might result in fewer serious adverse events than sclerotherapy. TIPS might result in a large decrease in symptomatic rebleed than variceal band ligation. Sclerotherapy probably results in fewer 'any' variceal rebleeding than no active intervention. Beta-blockers plus sclerotherapy and TIPS probably result in fewer 'any' variceal rebleeding than sclerotherapy. Beta-blockers alone and TIPS might result in more other compensation events than sclerotherapy. The evidence indicates considerable uncertainty about the effect of the interventions in the remaining comparisons. Accordingly, high-quality randomised comparative clinical trials are needed.
Collapse
Affiliation(s)
| | - Lawrence Mj Best
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Danielle Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Nicola J Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Davide Roccarina
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Amine Benmassaoud
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Laura Iogna Prat
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Norman R Williams
- Surgical & Interventional Trials Unit (SITU), UCL Division of Surgery & Interventional Science, London, UK
| | - Mario Csenar
- Division of Surgery and Interventional Science, University College London, London, UK
| | | | | | - Sivapatham Arunan
- General and Colorectal Surgery, Ealing Hospital and Imperial College, London, Northwood, UK
| | | | | | - Chavdar S Pavlov
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Kurinchi Selvan Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| |
Collapse
|
12
|
Tranexamic acid should be avoided for acute gastrointestinal bleeds. Drug Ther Bull 2021; 59:84. [PMID: 33753352 DOI: 10.1136/dtb.2021.000016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Overview of: The HALT-IT Trial Collaborators. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet 2020; 395:1927-36.
Collapse
|
13
|
Park SH, Mun YG, Lim CH, Cho YK, Park JM. C-reactive protein for simple prediction of mortality in patients with acute non-variceal upper gastrointestinal bleeding: A retrospective analysis. Medicine (Baltimore) 2020; 99:e23689. [PMID: 33371112 PMCID: PMC7748191 DOI: 10.1097/md.0000000000023689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 11/15/2020] [Indexed: 01/26/2023] Open
Abstract
In upper gastrointestinal bleeding (UGIB), scoring systems using multiple variables were developed to predict patient outcomes. We evaluated serum C-reactive protein (CRP) for simple prediction of patient mortality after acute non-variceal UGIB.The associated factors for 30-day mortality was investigated by regression analysis in patients with acute non-variceal UGIB (N = 1232). The area under the receiver operating characteristics (AUROC) curve was analyzed with serum CRP in these patients and a prospective cohort (N = 435). The discriminant validity of serum CRP was compared to other prognostic scoring systems by means of AUROC curve analysis.Serum CRP was significantly higher in the expired than survived patients (median, 4.53 vs 0.49; P < .001). The odds ratio of serum CRP was 4.18 (2.10-9.27) in multivariate analysis. The odds ratio of high serum CRP was higher than Rockall score (4.15 vs 1.29), AIMS65 (3.55 vs 1.71) and Glasgow-Blatchford score (4.32 vs 1.08) in multivariate analyses. The AUROC of serum CRP at bleeding was 0.78 for 30-day mortality (P < .001). In the validation set, serum CRP was also significantly higher in the expired than survived patients, of which AUROC was 0.73 (P < .001). In predicting 30-day mortality, the AUROC with serum CRP was not inferior to that of other scoring systems.Serum CRP at bleeding can be simply used to identify the patients with high mortality after acute non-variceal UGIB.
Collapse
Affiliation(s)
- Se Hwan Park
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea
| | - Yoon Gwon Mun
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea
- Catholic Photomedicine Research Institute, Seoul, Korea
| | - Chul-Hyun Lim
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea
- Catholic Photomedicine Research Institute, Seoul, Korea
| | - Yu Kyung Cho
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea
- Catholic Photomedicine Research Institute, Seoul, Korea
| | - Jae Myung Park
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea
- Catholic Photomedicine Research Institute, Seoul, Korea
| |
Collapse
|
14
|
Tejedor-Tejada J, Fuentes-Valenzuela E, García-Pajares F, Nájera-Muñoz R, Almohalla-Álvarez C, Sánchez-Martín F, Calero-Aguilar H, Villacastín-Ruiz E, Pintado-Garrido R, Sánchez-Antolín G. Long-term clinical outcome and survival predictors in patients with cirrhosis after 10-mm-covered transjugular intrahepatic portosystemic shunt. Gastroenterol Hepatol 2020; 44:620-627. [PMID: 33249114 DOI: 10.1016/j.gastrohep.2020.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 10/07/2020] [Accepted: 10/22/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS Transjugular intrahepatic portosystemic shunts (TIPS) are successfully used in the management of portal hypertension (PH)-related complications. Debate surrounds the diameter of the dilation. The aim was to analyse the outcomes of and complications deriving from TIPS in patients with cirrhosis and identify predictors of survival. METHODS This was a retrospective single-centre study, which included patients with cirrhosis who had a TIPS procedure for PH from 2009 to October 2018. Demographic, clinical and radiological data were collected. The Kaplan-Meier method was used to measure survival and predictors of survival were identified with the Cox regression model. RESULTS A total of 98 patients were included (78.6% male), mean age was 58.5 (SD±/-9.9) and the median MELD was 13.3 (IQR 9.5-16). The indications were refractory ascites (RA), variceal bleeding (VB) and hepatic hydrothorax (HH). Median survival was 72 months (RA 46.4, VB 68.5 and HH 64.7) and transplant-free survival was 26 months. Clinical and technical success rates were 70.5% and 92.9% respectively. Age (HR 1.05), clinical success (HR 0.33), sodium (HR 0.92), renal failure (HR 2.46) and albumin (HR 0.35) were predictors of survival. Hepatic encephalopathy occurred in 28.6% of patients and TIPS dysfunction occurred in 16.3%. CONCLUSIONS TIPS with 10-mm PTFE-covered stent is an effective and safe treatment for PH-related complications in patients with cirrhosis. Age, renal failure, sodium, albumin and clinical success are independent predictors of long-term survival.
Collapse
Affiliation(s)
- Javier Tejedor-Tejada
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain.
| | - Esteban Fuentes-Valenzuela
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Félix García-Pajares
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Rodrigo Nájera-Muñoz
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Carolina Almohalla-Álvarez
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Fátima Sánchez-Martín
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Hermógenes Calero-Aguilar
- Department of Radiology, Division of Vascular and Interventional Radiology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Elena Villacastín-Ruiz
- Department of Radiology, Division of Vascular and Interventional Radiology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Rebeca Pintado-Garrido
- Department of Radiology, Division of Vascular and Interventional Radiology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Gloria Sánchez-Antolín
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| |
Collapse
|
15
|
Abstract
IMPORTANCE Epidemiological data on lower gastrointestinal bleeding (GIB) in the general population are sparse. OBJECTIVE To describe the incidence, recurrence, mortality, and case fatality rates of major upper GIB and lower GIB in the general population of Finland between 1987 and 2016. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study used data from the 1987 to the 2012 cycles of the National FINRISK Study, a health examination survey that was conducted every 5 years in Finland. Survey participants were adults aged 25 to 74 years who were recruited from a population register by random sampling; those with a history of hospitalization for GIB were excluded. Participants were followed up from survey enrollment to onset of GIB that led to hospitalization, death from any cause, or study end (December 31, 2016). Follow-up was performed through linkage with national electronic health registers. Data were analyzed from February 1, 2019, to January 31, 2020. MAIN OUTCOMES AND MEASURES Incidence, recurrence, mortality, and case fatality rates for all, upper, lower, and unspecified GIB. Outcome measures were stratified by sex and age group. RESULTS Among the 39 054 participants included in the study, 494 (1.3%) experienced upper GIB (321 men [65.0%]; mean [SD] age, 52.8 [12.1] years) and 645 (1.7%) had lower GIB (371 men [57.5%]; mean [SD] age, 54.0 [11.7] years). The age-standardized incidence rate was 0.94 per 1000 person-years (95% CI, 0.85-1.04) for upper GIB and 1.26 per 1000 person-years (95% CI, 1.15-1.38) for lower GIB; the incidence was higher in men than in women. Between 1987 and 2016 the incidence rate of upper GIB remained mostly stable, ranging from 0.40 to 0.66 per 1000 person-years, whereas constant increases occurred in the incidence of lower GIB until the rate stabilized. The proportion of recurrent GIB events showed an increasing trend from 1987 to 2016. The upper GIB-specific mortality was higher (0.07 per 1000 person-years; 95% CI, 0.04-0.09) than the lower GIB-specific mortality (0.01 per 1000 person-years; 95% CI, 0.001-0.03). Case fatality was high for those with upper GIB (7.0%; 95% CI, 4.7-10.1) compared with those with lower GIB (0.4%; 95% CI, 0.1-1.3). Case fatality remained stable over the years but was higher in men (between 5% and 10%) than women (<2%) with GIB. CONCLUSIONS AND RELEVANCE This study found that the overall incidence rate of upper GIB was lower than the incidence of lower GIB, but the recurrence, mortality, and 28-day case fatality were higher in participants with upper GIB. These data can serve as a reference when putting into context the rates of drug-associated GIB and can inform efforts to improve GIB care and outcome and to prevent rebleeding or death for patients with major GIB.
Collapse
Affiliation(s)
- Pareen Vora
- Epidemiology, Bayer AG, Berlin, Germany
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig Maximilians Universität Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Arto Pietila
- Department of Public Health Solutions, Finnish Institute for Health and Welfare (THL), Helsinki, Finland
| | - Markku Peltonen
- Department of Public Health Solutions, Finnish Institute for Health and Welfare (THL), Helsinki, Finland
| | | | - Veikko Salomaa
- Department of Public Health Solutions, Finnish Institute for Health and Welfare (THL), Helsinki, Finland
| |
Collapse
|
16
|
Benites-Goñi H, Pascacio-Fiori M, Monge-Del Valle F, Plácido-Damián Z, Gonzales-Carazas E, Padilla-Espinoza M, Prado-Bustamante J, Llatas-Pérez J, Dávalos-Moscol M. Impact of the COVID-19 pandemic in the time to endoscopy in patients with upper gastrointestinal bleedin. Rev Gastroenterol Peru 2020; 40:219-223. [PMID: 33181807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION During the COVID-19 pandemic, endoscopic procedures are associated with a high risk of SARS-CoV-2 infection. However, in cases of upper gastrointestinal bleeding (UGIB), priority should be given to an early endoscopy. OBJECTIVE The main objective was to compare the time since arrival at the hospital and the performance of the endoscopy between both groups. MATERIALS AND METHODS We performed a retrospective study. Data contains information of patients who attended to the hospital with UGIB and underwent an endoscopy between October 19th, 2019 and June 6th, 2020. Patients were divided into 2 phases: pre-pandemic and pandemic. The time between arrival at the hospital and the performance of the endoscopy in both phases were compared as well as other indicators such hospital stay and in-hospital mortality. RESULTS With information from 219 patients, the median age was 69 years. 154 and 65 endoscopies were performed in pre-pandemic and pandemic phase, respectively. The time between arrival at the hospital and the performance of the endoscopy was significantly longer during the pandemic (10.00 vs. 13.08 hours, p-value = 0.019). Nevertheless, there were no significant differences in hospital stay or mortality. CONCLUSION The management of patients with UGIB during the COVID-19 pandemic is complex and requires the application of clinical judgment to decide the best timing to perform an endoscopy without affecting patient care.
Collapse
|
17
|
HALT-IT Trial Collaborators. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet 2020; 395:1927-36. [PMID: 32563378 DOI: 10.1016/S0140-6736(20)30848-5] [Citation(s) in RCA: 169] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Tranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding. METHODS We did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124. FINDINGS Between July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82-1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98). INTERPRETATION We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial. FUNDING UK National Institute for Health Research Health Technology Assessment Programme.
Collapse
|
18
|
Pioppo L, Bhurwal A, Raj Mutneja H, Rattan P, Reja D, Tawadros A, Patel A, Rustgi V. Portal Hypertension and Chronic Kidney Disease Significantly Increase the Risk of Early Unplanned Readmissions in GAVE- Related Admissions. J Gastrointestin Liver Dis 2020; 29:151-157. [PMID: 32530981 DOI: 10.15403/jgld-804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/20/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND AND AIMS Gastric antral vascular ectasia (GAVE) is an uncommon cause of non-variceal upper gastrointestinal bleeding that is characterized by dilation of blood vessels in the antrum of the stomach. Various co-morbidities are associated with the development of GAVE, but the impact of co-morbidities on unplanned GAVE readmissions is unclear. The aim of this study was to assess the national incidence, 30-day mortality rate, and 30-day readmissions related to GAVE. Secondary outcomes were evaluation of predictors of early readmission, hospital length of stay (LOS) and total hospitalization charges. METHODS Using the 2016 National Readmission Database, we analyzed discharges for GAVE. ICD-10 CM codes were utilized to identify associated comorbidities and inpatient procedures during the index admission. 30-day readmissions were identified for GAVE. Secondary measures of outcomes including LOS and hospitalization charges were also calculated. Risk factors for early readmission were also evaluated using multivariate analysis to adjust for confounders. RESULTS A total of 18,375 index admissions for GAVE were identified. 20.49% (n=3,720) of the discharged patients were readmitted within 30 days. 30-day mortality of GAVE-related admissions was 1.82% (n=335). Early readmissions accounted for 20,157 hospital days along with $189 million in hospitalization costs. Multivariate analysis revealed that the presence of portal hypertension (OR 1.63; 95% CI 1.37-1.93; p=0.0001) and chronic kidney disease (CKD) (OR 1.62, 95% CI 1.44-1.82; p<0.0001) significantly increased the odds of early readmission. CONCLUSIONS Our analysis demonstrates that the overall 30-day mortality rate of GAVE-related admissions is relatively low, but the 30-day readmission rate is significantly high. Patients with comorbid CKD and portal hypertension have a significantly higher risk of readmission. Further studies are required to determine if therapeutic interventions such as argon plasma coagulation or radiofrequency ablation during the index admission may prevent readmissions in these specific subgroups.
Collapse
Affiliation(s)
- Lauren Pioppo
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA. .
| | - Abhishek Bhurwal
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Hemant Raj Mutneja
- Department of Gastroenterology and Hepatology, John H Stroger Cook County Hospital, Chicago, IL, USA.
| | - Puru Rattan
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Debashis Reja
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Augustine Tawadros
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Anish Patel
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Vinod Rustgi
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| |
Collapse
|
19
|
Abstract
BACKGROUND Clinical experience with using activated prothrombin complex concentrates (aPCCs) to reverse the effects of factor Xa inhibitors is limited. OBJECTIVES Our objective was to assess the achievement of effective clinical hemostasis using aPCC in patients on chronic apixaban or rivaroxaban therapy presenting with major bleeding in whom a reversal agent is warranted. We also assessed the safety of the drug. METHODS A retrospective medical records review was conducted at a tertiary referral medical center in the USA. Patients presenting with major bleeding while receiving apixaban or rivaroxaban and treated with aPCC were included. Clinical hemostasis was assessed using International Society of Thrombosis and Hemostasis Scientific and Standardization Subcommittee criteria. RESULTS A total of 35 patients were included in the study. The most common site of bleeding was intracerebral hemorrhage (ICH) (n = 18 [51.4%]), followed by gastrointestinal bleed (n = 10 [28.6%]). Clinical hemostasis was achieved in 24 (68.6%) patients; 11 patients (31.4%) did not achieve clinical hemostasis; nine of these patients had ICH. Seven of the patients who did not achieve hemostasis died during hospitalization. Three (8.6%) patients experienced thromboembolic events during hospitalization. In total, 21 (60%) patients were receiving concomitant medications that interact with anti-factor Xa inhibitors and can increase the risk of bleeding. CONCLUSIONS Our study suggests that aPCC could be an option in patients with major bleeding associated with apixaban or rivaroxaban. It may be an alternative for patients who need anticoagulation reversal if the specific antidote, andexanet alfa, is unavailable.
Collapse
Affiliation(s)
- Marwan Sheikh-Taha
- Department of Pharmacy Practice, Lebanese American University, Byblos, Lebanon.
- Department of Pharmacy, Huntsville Hospital, Huntsville, AL, USA.
| | - R Monroe Crawley
- Department of Pharmacy, Huntsville Hospital, Huntsville, AL, USA
| |
Collapse
|
20
|
Jiang S, Huang X, Ni L, Xia R, Nakayama K, Chen S. Positive consequences of splenectomy for patients with schistosomiasis-induced variceal bleeding. Surg Endosc 2020; 35:2339-2346. [PMID: 32440930 DOI: 10.1007/s00464-020-07648-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/13/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with hepatic schistosomiasis are at high risk of gastroesophageal variceal bleeding, which is highly torrential and life threatening. This study aimed to assess the effects of splenectomy on patients with schistosomiasis-induced variceal bleeding, especially those influences related to overall survival (OS) rate. METHODS From January 2005 to December 2018, 112 patients with schistosomiasis-induced varices were enrolled. In that period, all the patients with hepatic schistosomiasis who received endoscopic treatment for primary and secondary prophylaxis of gastroesophageal variceal bleeding were found eligible. The patients were divided into splenectomized group (n = 44, 39.3%) and control group (n = 68, 60.7%). RESULTS Multivariate regression analysis of OS showed that splenectomy, hepatic carcinoma, and times of endoscopic treatment were independent prognostic factors for OS. Kaplan-Meier analysis revealed that the 5-year OS rate was 82.7% in splenectomized group versus 53.2% in control group (P = 0.037). The rate of no recurrence of variceal bleeding during 5-year (56.8% vs. 47.7%, P = 0.449) indicated that there was no significant difference between the two groups. Patients who received splenectomy had increased risk of portal vein thrombosis (52.3% vs. 29.4%, P = 0.012) and decreased proportion of severe ascites (20.5% vs 50.0%, P = 0.002). CONCLUSION Splenectomy prior to endoscopic treatment provides a superior long-term survival for patients with schistosomiasis-induced variceal bleeding.
Collapse
Affiliation(s)
- Siyu Jiang
- Department of Gastroenterology and Hepatology, Zhongshan Hospital of Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Xiaoquan Huang
- Department of Gastroenterology and Hepatology, Zhongshan Hospital of Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Liyuan Ni
- Department of Gastroenterology and Hepatology, Zhongshan Hospital of Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Ruiqi Xia
- Department of Gastroenterology and Hepatology, Zhongshan Hospital of Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Kiyoko Nakayama
- Department of Gastroenterology and Hepatology, Zhongshan Hospital of Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Shiyao Chen
- Department of Gastroenterology and Hepatology, Zhongshan Hospital of Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China.
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital of Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China.
| |
Collapse
|
21
|
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] [What about the content of this article? (0)] [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.
Collapse
|
22
|
Martí D, Carballeira D, Morales MJ, Concepción R, Del Castillo H, Marschall A, Delgado-Calva FA, Dejuán-Bitriá C, Pérez-Guzmán J, López-Soberón E, Palazuelos J, Álvarez-Antón S. Impact of Anemia on the Risk of Bleeding Following Percutaneous Coronary Interventions in Patients ≥75 Years of Age. Am J Cardiol 2020; 125:1142-1147. [PMID: 32087994 DOI: 10.1016/j.amjcard.2020.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/18/2020] [Accepted: 01/21/2020] [Indexed: 12/19/2022]
Abstract
Bleeding risk stratification is an unresolved issue in older adults. Anemia may reflect subclinical blood losses that can be exacerbated after percutaneous coronary intervention . We sought to prospectively determine the contribution of anemia to the risk of bleeding in 448 consecutive patients aged 75 or more years, treated by percutaneous coronary interventions without concomitant indication for oral anticoagulation. We evaluated the effect of WHO-defined anemia on the incidence of 1-year nonaccess site-related major bleeding. The prevalence of anemia was 39%, and 13.1% of anemic and 5.2% of nonanemic patients suffered a bleeding event (hazard ratio 2.75, 95% confidence interval 1.37 to 5.54, p = 0.004). Neither PRECISE-DAPT nor CRUSADE scores were superior to hemoglobin for the prediction of bleeding. In conclusion, anemia is a powerful predictor of bleeding with potential utility for simplifying tailoring therapies.
Collapse
Affiliation(s)
- David Martí
- Cardiology Department, Central Defense Hospital, Alcalá University, Madrid, Spain.
| | - Damaris Carballeira
- Cardiology Department, Central Defense Hospital, Alcalá University, Madrid, Spain
| | - María José Morales
- Cardiology Department, Central Defense Hospital, Alcalá University, Madrid, Spain
| | - Ricardo Concepción
- Cardiology Department, Central Defense Hospital, Alcalá University, Madrid, Spain
| | - Hugo Del Castillo
- Cardiology Department, Central Defense Hospital, Alcalá University, Madrid, Spain
| | - Alexander Marschall
- Cardiology Department, Central Defense Hospital, Alcalá University, Madrid, Spain
| | | | - Carmen Dejuán-Bitriá
- Cardiology Department, Central Defense Hospital, Alcalá University, Madrid, Spain
| | - Joaquín Pérez-Guzmán
- Cardiology Department, Central Defense Hospital, Alcalá University, Madrid, Spain
| | - Edurne López-Soberón
- Cardiology Department, Central Defense Hospital, Alcalá University, Madrid, Spain
| | - Jorge Palazuelos
- Cardiology Department, Central Defense Hospital, Alcalá University, Madrid, Spain
| | | |
Collapse
|
23
|
Lau JYW, Yu Y, Tang RSY, Chan HCH, Yip HC, Chan SM, Luk SWY, Wong SH, Lau LHS, Lui RN, Chan TT, Mak JWY, Chan FKL, Sung JJY. Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding. N Engl J Med 2020; 382:1299-1308. [PMID: 32242355 DOI: 10.1056/nejmoa1912484] [Citation(s) in RCA: 146] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is recommended that patients with acute upper gastrointestinal bleeding undergo endoscopy within 24 hours after gastroenterologic consultation. The role of endoscopy performed within time frames shorter than 24 hours has not been adequately defined. METHODS To evaluate whether urgent endoscopy improves outcomes in patients predicted to be at high risk for further bleeding or death, we randomly assigned patients with overt signs of acute upper gastrointestinal bleeding and a Glasgow-Blatchford score of 12 or higher (scores range from 0 to 23, with higher scores indicating a higher risk of further bleeding or death) to undergo endoscopy within 6 hours (urgent-endoscopy group) or between 6 and 24 hours (early-endoscopy group) after gastroenterologic consultation. The primary end point was death from any cause within 30 days after randomization. RESULTS A total of 516 patients were enrolled. The 30-day mortality was 8.9% (23 of 258 patients) in the urgent-endoscopy group and 6.6% (17 of 258) in the early-endoscopy group (difference, 2.3 percentage points; 95% confidence interval [CI], -2.3 to 6.9). Further bleeding within 30 days occurred in 28 patients (10.9%) in the urgent-endoscopy group and in 20 (7.8%) in the early-endoscopy group (difference, 3.1 percentage points; 95% CI, -1.9 to 8.1). Ulcers with active bleeding or visible vessels were found on initial endoscopy in 105 of the 158 patients (66.4%) with peptic ulcers in the urgent-endoscopy group and in 76 of 159 (47.8%) in the early-endoscopy group. Endoscopic hemostatic treatment was administered at initial endoscopy for 155 patients (60.1%) in the urgent-endoscopy group and for 125 (48.4%) in the early-endoscopy group. CONCLUSIONS In patients with acute upper gastrointestinal bleeding who were at high risk for further bleeding or death, endoscopy performed within 6 hours after gastroenterologic consultation was not associated with lower 30-day mortality than endoscopy performed between 6 and 24 hours after consultation. (Funded by the Health and Medical Fund of the Food and Health Bureau, Government of Hong Kong Special Administrative Region; ClinicalTrials.gov number, NCT01675856.).
Collapse
Affiliation(s)
- James Y W Lau
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Yuanyuan Yu
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Raymond S Y Tang
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Heyson C H Chan
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Hon-Chi Yip
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Shannon M Chan
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Sally W Y Luk
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Sunny H Wong
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Louis H S Lau
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Rashid N Lui
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Ting T Chan
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Joyce W Y Mak
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Francis K L Chan
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Joseph J Y Sung
- From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong
| |
Collapse
|
24
|
Lu Z, Sun X, Zhang W, Jin B, Han J, Wang Y, Han J, Ma X, Liu B, Wu L, Wu Q, Yu X, Li H. Second urgent endoscopy within 48-hour benefits cirrhosis patients with acute esophageal variceal bleeding. Medicine (Baltimore) 2020; 99:e19485. [PMID: 32176084 PMCID: PMC7440074 DOI: 10.1097/md.0000000000019485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Urgent endoscopy (UE) is important to the diagnosis and treatment of liver cirrhosis patients with esophageal variceal bleeding (EVB). It was reported that a second-look endoscopy may benefit acute upper gastrointestinal bleeding (UGIB) caused by peptic ulcer, while whether it could improve UGIB caused by liver cirrhosis associated EVB remains unclear. This study aimed to investigate the characteristics of second UE for liver cirrhosis with EVB and further examined the potential prognostic factors.Patients aged ≥18 years who underwent UE for EVB within 2 hours after the admission were included and divided into scheduled second-look group (n = 245) and uncontrolled bleeding group (n = 352) based on the indications for second UE within 48 hours after initial endoscopy. Demographic and clinical data were collected and analyzed. Univariate and multivariate analysis were used to identify the risk factors for prognosis. The value of different scoring system was compared.Statistical differences were found on history of bleeding and hepatocellular carcinoma, ascites, endoscopic type of bleeding, between scheduled second-look group and uncontrolled bleeding group. Univariate and multivariate logistic regression analysis confirmed that ascites, hemoglobin <60 g/L, AIMS65 score and failure to identify in initial UE were independent risk factors for bleeding uncontrolled after initial UE, and age, bilirubin level, initial unsatisfactory UE hemostasis, failure to identify bleeding on initial UE and tube/urgent TIPS suggested in initial UE were independent risk factors for 42-day mortality.A second-look UE could bring benefit for liver cirrhosis patients with EVB without increasing the complication rate.
Collapse
Affiliation(s)
- Zheng Lu
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Xiaotian Sun
- Department of Internal Medicine, Clinic of August First Film Studio, Beijing South Medical District, Chinese PLA General Hospital, Beijing, China
| | - Wenhui Zhang
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Bo Jin
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | | | - Yanling Wang
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Jun Han
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Xuemei Ma
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Bo Liu
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Libing Wu
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Qin Wu
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Xiaoli Yu
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| | - Hanwei Li
- Liver Cirrhosis Diagnosis and Treatment Center, the Fifth Medical Center of Chinese PLA General Hospital
| |
Collapse
|
25
|
Turcato G, Bonora A, Zorzi E, Zaboli A, Zannoni M, Ricci G, Pfeifer N, Maccagnani A, Tenci A. Thirty-day mortality in atrial fibrillation patients with gastrointestinal bleeding in the emergency department: differences between direct oral anticoagulant and warfarin users. Intern Emerg Med 2020; 15:311-318. [PMID: 31754969 DOI: 10.1007/s11739-019-02229-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 11/02/2019] [Indexed: 02/07/2023]
Abstract
More clinical data are required on the safety of direct oral anticoagulants (DOACs). Although patients treated with warfarin and DOACs have a similar risk of bleeding, short-term mortality after a gastrointestinal bleeding (GIB) episode in DOAC-treated patients has not been clarified. The objective of this study was to assess differences in 30-day mortality in patients treated with DOACs or warfarin admitted to the emergency department (ED) for GIB. This was a multicentre retrospective study conducted over 2 years. The study included patients evaluated at three different EDs for GIB. The baseline characteristics were included. Subsequently, we assessed the differences in past medical history and clinical data between the two study groups (DOAC and warfarin users). Differences between the two groups were evaluated using Kaplan-Meier curves. Among the 284 patients presenting GIB enrolled in the study period, 39.4% (112/284) were treated with DOACs and 60.6% (172/284) were treated with warfarin. Overall, 8.1% (23/284) of patients died within 30 days. Among the 172 warfarin-treated patients, 8.7% (15/172) died within 30 days from ED evaluation. In the 112 DOAC-treated patients, the mortality rate was 7.1% (8/112). The Cox regression analysis, adjusted for possible clinical confounders, and the Kaplan-Meier curves did not outline differences between the two treatment groups. The present study shows no differences between DOACs and warfarin in short-term mortality after GIB.
Collapse
Affiliation(s)
- Gianni Turcato
- Department of Emergency Medicine, Franz Tappeiner Hospital of Merano, Azienda Sanitaria Dell'Alto Adige, Merano, Bolzano, Italy.
| | - Antonio Bonora
- Department of Emergency Medicine, University of Verona, Verona, Italy
| | - Elisabetta Zorzi
- Department of Cardiology and Intensive Care Cardiology, Girolamo Fracastoro Hospital of San Bonifacio, Azienda Ospedaliera Scaligera, San Bonifacio, Verona, Italy
| | - Arian Zaboli
- Department of Emergency Medicine, Franz Tappeiner Hospital of Merano, Azienda Sanitaria Dell'Alto Adige, Merano, Bolzano, Italy
| | - Massimo Zannoni
- Department of Emergency Medicine, University of Verona, Verona, Italy
| | - Giorgio Ricci
- Department of Cardiology and Intensive Care Cardiology, Girolamo Fracastoro Hospital of San Bonifacio, Azienda Ospedaliera Scaligera, San Bonifacio, Verona, Italy
| | - Norbert Pfeifer
- Department of Emergency Medicine, Franz Tappeiner Hospital of Merano, Azienda Sanitaria Dell'Alto Adige, Merano, Bolzano, Italy
| | | | - Andrea Tenci
- Department of Emergency Medicine, Girolamo Fracastoro Hospital of San Bonifacio, Azienda Ospedaliera Scaligera, San Bonifacio, Verona, Italy
| |
Collapse
|
26
|
Dueñas E, Cachero A, Amador A, Rota R, Salord S, Gornals J, Xiol X, Castellote J. Ulcer bleeding after band ligation of esophageal varices: Risk factors and prognosis. Dig Liver Dis 2020; 52:79-83. [PMID: 31395524 DOI: 10.1016/j.dld.2019.06.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 04/30/2019] [Accepted: 06/23/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Post-banding ulcer bleeding is a rare complication of endoscopic band ligation of esophageal varices with high morbidity and mortality. There exist no management guidelines for this complication. AIMS To determine the incidence, outcome and risk factors of post-banding ulcer bleeding. METHODS Data for cirrhotic patients with acute variceal bleeding during a six-year period were prospectively collected, and all band ligation sessions performed were retrospectively analyzed. Demographic, analytic and endoscopic data were recorded, as well as complications, outcome and management of each episode of post-banding ulcer bleeding. RESULTS The study includes 521 band ligation sessions performed on 175 patients. There were 24 cases of post-banding ulcer bleeding in 21 patients (incidence 4.6%). Independent risk factors for post-banding ulcer bleeding were MELD score, hepatocellular carcinoma and total beta-blocker dose. Mortality during the bleeding episode was 23.8%. Active bleeding or adherent clots at the time of endoscopy was associated with treatment failure or death. CONCLUSIONS Post-banding ulcer bleeding is an uncommon but severe complication of esophageal banding. Patients with hepatocellular carcinoma, poor liver function and a low beta-blocker dose have higher risk of post-banding ulcer bleeding. An aggressive treatment should be considered in case of active bleeding at endoscopy.
Collapse
Affiliation(s)
- Eva Dueñas
- Hepatology Unit. Gastroenterology Department. Hospital of Bellvitge. ICS. Research group of Hepato-biliary and pancreatic diseases. IDIBELL. Barcelona University. L'Hospitalet de LLobregat. Barcelona. Spain
| | - Alba Cachero
- Hepatology Unit. Gastroenterology Department. Hospital of Bellvitge. ICS. Research group of Hepato-biliary and pancreatic diseases. IDIBELL. Barcelona University. L'Hospitalet de LLobregat. Barcelona. Spain
| | - Alberto Amador
- Hepatology Unit. Gastroenterology Department. Hospital of Bellvitge. ICS. Research group of Hepato-biliary and pancreatic diseases. IDIBELL. Barcelona University. L'Hospitalet de LLobregat. Barcelona. Spain
| | - Rosa Rota
- Hepatology Unit. Gastroenterology Department. Hospital of Bellvitge. ICS. Research group of Hepato-biliary and pancreatic diseases. IDIBELL. Barcelona University. L'Hospitalet de LLobregat. Barcelona. Spain
| | - Silvia Salord
- Hepatology Unit. Gastroenterology Department. Hospital of Bellvitge. ICS. Research group of Hepato-biliary and pancreatic diseases. IDIBELL. Barcelona University. L'Hospitalet de LLobregat. Barcelona. Spain
| | - Joan Gornals
- Hepatology Unit. Gastroenterology Department. Hospital of Bellvitge. ICS. Research group of Hepato-biliary and pancreatic diseases. IDIBELL. Barcelona University. L'Hospitalet de LLobregat. Barcelona. Spain
| | - Xavier Xiol
- Hepatology Unit. Gastroenterology Department. Hospital of Bellvitge. ICS. Research group of Hepato-biliary and pancreatic diseases. IDIBELL. Barcelona University. L'Hospitalet de LLobregat. Barcelona. Spain
| | - José Castellote
- Hepatology Unit. Gastroenterology Department. Hospital of Bellvitge. ICS. Research group of Hepato-biliary and pancreatic diseases. IDIBELL. Barcelona University. L'Hospitalet de LLobregat. Barcelona. Spain.
| |
Collapse
|
27
|
Zeng X, Chen J, Sun Z, Zeng H, Xue J, Zhang Y, Liu G, Huang X. Nutrition program selection in acute ischemic stroke patients with GI hemorrhage. Asia Pac J Clin Nutr 2020; 29:55-60. [PMID: 32229442 DOI: 10.6133/apjcn.202003_29(1).0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVES The severity of neurologic impairment is significantly associated with gastrointestinal (GI) hemorrhage. Therefore, the aim of this study was to compare the effect of two nutritional interventions in acute ischemic stroke patients with GI hemorrhage. METHODS AND STUDY DESIGN We retrospectively studied consecutive ischemic stroke patients with GI hemorrhage from January 2014 to December 2018. They were stratified into two programs of nutritional therapy after GI hemorrhage: moderate feeding (more than 70% optimal caloric uptake, 50-100 mL/h) and trophic feeding (16-25% of the target energy expenditure, 25 kcal/kg per day, 10- 30 mL/h) with supplemental parenteral nutrition. RESULTS The group receiving moderate feeding included 30 patients, and the group receiving trophic feeding and supplemental parenteral nutrition included 32 patients. There was no statistically significant difference between the two groups in the baseline characteristics of the patients. Mortality, Glasgow Coma Scale (GCS) score at discharge, and Glasgow Outcome Scale (GOS) score 3 months after discharge were compared between the two groups. In the moderate feeding group, the overall mortality was significantly lower than in the trophic feeding and supplemental parenteral nutrition group (p<0.05). Conscious state and neurological severity were assessed by the GCS score before discharge, and the score was higher in the moderate feeding group than in the other group (p<0.05). The GOS score 3 months after discharge was higher in the moderate feeding group than in the trophic feeding and supplemental parenteral nutrition group (p<0.05). These three items showed that moderate feeding led to a better prognosis: lower occurrence of mortality, higher GCS score at discharge, and higher GOS score 3 months after discharge. CONCLUSIONS This study showed that moderate feeding had a much more profound effect on the outcomes than trophic feeding and supplemental parenteral nutrition, as it was associated with lower mortality, higher GCS score at discharge, and higher GOS score 3 months after discharge.
Collapse
Affiliation(s)
- Xiaoyan Zeng
- Department of Neurology, Hebei Petrochina Central Hospital, Hebei Province, China.
| | - Junhong Chen
- Department of Neurology, Hebei Petrochina Central Hospital, Hebei Province, China
| | - Zhihua Sun
- Department of Neurology, Hebei Petrochina Central Hospital, Hebei Province, China
| | - Heng Zeng
- Department of Neurology, Hebei Petrochina Central Hospital, Hebei Province, China
| | - Junyan Xue
- Department of Neurology, Hebei Petrochina Central Hospital, Hebei Province, China
| | - Yingjie Zhang
- Department of Neurology, Hebei Petrochina Central Hospital, Hebei Province, China
| | - Gang Liu
- Department of Neurology, Hebei Petrochina Central Hospital, Hebei Province, China
| | - Xiaojing Huang
- Department of Neurology, Hebei Petrochina Central Hospital, Hebei Province, China
| |
Collapse
|
28
|
Yoo JJ, Kim SG, Kim YS, Lee B, Jeong SW, Jang JY, Lee SH, Kim HS, Jun BG, Kim YD, Cheon GJ. Propranolol plus endoscopic ligation for variceal bleeding in patients with significant ascites: Propensity score matching analysis. Medicine (Baltimore) 2020; 99:e18913. [PMID: 32000397 PMCID: PMC7004788 DOI: 10.1097/md.0000000000018913] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The use of beta-blockers in decompensated cirrhosis accompanying ascites is still under debate. The aim of this study was to compare overall survival (OS) and incidence of cirrhotic complications between endoscopic variceal ligation (EVL) only and EVL + non-selective beta-blocker (NSBB) combination therapy in cirrhotic patients with significant ascites (≥grade 2).This retrospective study included 271 consecutive cirrhotic patients with ascites who were treated with EVL only or EVL + NSBB combination therapy as a primary prophylaxis of esophageal varices. The primary outcome was all-cause mortality. Propensity score matching was performed between the 2 groups to minimize baseline difference.Median observation period was 42.1 months (interquartile range, 18.4-75.1 months). All patients had deteriorated liver function: 81.1% Child-Pugh class B and 18.9% Child-Pugh class C. All-cause mortality was significantly higher in the EVL + NSBB group than in the EVL only group not only in non-matched cohort, but also in matched cohort (48.9% vs 31.2%; P = .039). More people died from hepatic failure in the EVL + NSBB group than that in the EVL only group (40.5% vs 20.0%; P = .020). However, the incidence of variceal bleeding, hepatorenal syndrome (HRS), or spontaneous bacterial peritonitis (SBP) was not significantly different between the 2 groups.The use of NSBB might worsen the prognosis of cirrhotic patients with significant ascites. These results suggest that EVL alone is a more appropriate treatment option for prophylaxis of esophageal varices than propranolol combination therapy when patients have significant ascites.
Collapse
Affiliation(s)
- Jeong-Ju Yoo
- Department of Gastroenterology and Hepatology, Soon Chun Hyang University School of Medicine
| | - Sang Gyune Kim
- Department of Gastroenterology and Hepatology, Soon Chun Hyang University School of Medicine
| | - Young Seok Kim
- Department of Gastroenterology and Hepatology, Soon Chun Hyang University School of Medicine
| | - Bora Lee
- Department of Statistics, Graduate School, Chung-Ang University, Seoul
| | - Soung Won Jeong
- Department of Gastroenterology and Hepatology, Soon Chun Hyang University School of Medicine
| | - Jae Young Jang
- Department of Gastroenterology and Hepatology, Soon Chun Hyang University School of Medicine
| | - Sae Hwan Lee
- Department of Gastroenterology and Hepatology, Soon Chun Hyang University School of Medicine
| | - Hong Soo Kim
- Department of Gastroenterology and Hepatology, Soon Chun Hyang University School of Medicine
| | - Baek-Gyu Jun
- Department of Internal Medicine, Gangneug Asan Hospital, Republic of Korea
| | - Young Don Kim
- Department of Internal Medicine, Gangneug Asan Hospital, Republic of Korea
| | - Gab Jin Cheon
- Department of Internal Medicine, Gangneug Asan Hospital, Republic of Korea
| |
Collapse
|
29
|
An Y, Bai Z, Xu X, Guo X, Romeiro FG, Philips CA, Li Y, Wu Y, Qi X. No Benefit of Hemostatic Drugs on Acute Upper Gastrointestinal Bleeding in Cirrhosis. Biomed Res Int 2020; 2020:4097170. [PMID: 32685481 PMCID: PMC7336197 DOI: 10.1155/2020/4097170] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/25/2020] [Accepted: 06/01/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Acute upper gastrointestinal bleeding (AUGIB) is one of the most life-threatening emergency conditions. Hemostatic drugs are often prescribed to control AUGIB in clinical practice but have not been recommended by major guidelines and consensus. The aim of this study was to investigate the therapeutic effect of hemostatic drugs on AUGIB in cirrhosis. METHODS All cirrhotic patients with AUGIB who were admitted to our hospital from January 2010 to June 2014 were retrospectively included. Patients were divided into hemostatic drugs and no hemostatic drug groups. A 1 : 1 propensity score matching (PSM) analysis was performed by adjusting age, gender, etiology of liver disease, Child-Pugh score, MELD score, hematemesis, red blood cell transfusion, vasoactive drugs, antibiotics, proton pump inhibitors, and endoscopic variceal therapy. Primary outcomes included 5-day rebleeding and in-hospital mortality. RESULTS Overall, 982 cirrhotic patients with AUGIB were included (870 in hemostatic drugs group and 112 in no hemostatic drug group). In overall analyses, hemostatic drugs group had a significantly higher 5-day rebleeding rate (18.10% versus 5.40%, P = 0.001) than no hemostatic drug group; in-hospital mortality was not significantly different between them (7.10% versus 4.50%, P = 0.293). In PSM analyses, 172 patients were included (86 patients in each group). Hemostatic drugs group still had a significantly higher 5-day rebleeding rate (15.10% versus 5.80%, P = 0.046); in-hospital mortality remained not significantly different (7.00% versus 3.50%, P = 0.304) between them. Statistical results remained in PSM analyses according to the type of hemostatic drugs. CONCLUSIONS The use of hemostatic drugs did not improve the in-hospital outcomes of cirrhotic patients with AUGIB.
Collapse
Affiliation(s)
- Yang An
- 1Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
- 2Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Zhaohui Bai
- 1Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
- 2Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Xiangbo Xu
- 1Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
- 2Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Xiaozhong Guo
- 1Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
| | - Fernando Gomes Romeiro
- 3Department of Internal Medicine, Botucatu Medical School, UNESP-Univ Estadual Paulista. Av. Prof. Mário Rubens Guimarães Montenegro, s/n Distrito de Rubião Jr, Botucatu, Brazil
| | - Cyriac Abby Philips
- 4The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, 682028 Kerala, India
| | - Yingying Li
- 5Department of Gastroenterology, The First People's Hospital of Huainan, Huainan 232007, China
| | - Yanyan Wu
- 1Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
- 6Postgraduate College, Jinzhou Medical University, Jinzhou 121001, China
| | - Xingshun Qi
- 1Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
| |
Collapse
|
30
|
Bai Z, Primignani M, Guo X, Zheng K, Li H, Qi X. Incidence and mortality of renal dysfunction in cirrhotic patients with acute gastrointestinal bleeding: a systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2019; 13:1181-1188. [PMID: 31736376 DOI: 10.1080/17474124.2019.1694904] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background: Gastrointestinal bleeding (GIB) is a common complication in cirrhosis. Renal dysfunction may be crucial for the outcomes of cirrhotic patients with acute GIB. This study aimed to explore the incidence and mortality of renal dysfunction in cirrhotic patients with acute GIB.Methods: The PubMed, EMBASE, and Cochrane Library databases were searched. We pooled the incidence and mortality of renal dysfunction in cirrhotic patients using a random-effect model. Odds ratio (OR) with 95% confidence interval (CI) were calculated.Results: Seventeen studies were included. The pooled incidence of renal dysfunction was 21% (95%CI = 16%-25%) in cirrhosis with acute GIB. In subgroup analyses, the pooled incidence of renal failure, acute kidney injury (AKI), and renal impairment were 21%, 25%, and 15%, respectively. The pooled mortality was 46% (95%CI = 37%-55%) in cirrhosis with acute GIB and renal dysfunction. In subgroup analyses, the pooled mortality in patients with renal failure, AKI, and renal impairment were 42%, 47%, and 49%, respectively. Renal dysfunction significantly increased the mortality of cirrhosis with acute GIB (OR = 4.92; 95%CI = 3.47-6.96; P < 0.001).Conclusion: Renal dysfunction is a common indicator for poor outcome of cirrhosis with acute GIB. Prevention of renal dysfunction in such patients should be further explored.
Collapse
Affiliation(s)
- Zhaohui Bai
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, P.R. China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, P.R. China
| | - Massimo Primignani
- CRC "A.M. e A. Migliavacca" Center for the Study of Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico Università degli Studi di Milano Via F., Milan, Italy
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, P.R. China
| | - Kexin Zheng
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, P.R. China
- Postgraduate College, Jinzhou Medical University, Jinzhou, P.R. China
| | - Hongyu Li
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, P.R. China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, P.R. China
| |
Collapse
|
31
|
Li Y, Li H, Zhu Q, Tsochatzis E, Wang R, Guo X, Qi X. Effect of acute upper gastrointestinal bleeding manifestations at admission on the in-hospital outcomes of liver cirrhosis: hematemesis versus melena without hematemesis. Eur J Gastroenterol Hepatol 2019; 31:1334-1341. [PMID: 31524777 DOI: 10.1097/meg.0000000000001524] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Patients with acute upper gastrointestinal bleeding (AUGIB) often manifest as hematemesis and melena. Theoretically, hematemesis will carry worse outcomes of AUGIB. However, there is little real-world evidence. We aimed to compare the outcomes of hematemesis versus no hematemesis as a clinical manifestation of AUGIB at admission in cirrhotic patients. METHODS All cirrhotic patients with AUGIB who were consecutively admitted to our hospital from January 2010 to June 2014 were considered in this retrospective study. Patients were divided into hematemesis with or without melena and melena alone without hematemesis at admission. A 1:1 propensity score matching analysis was performed. Subgroup analyses were performed based on systemic hemodynamics (stable and unstable) and Child-Pugh class (A and B+C). Sensitivity analyses were conducted in patients with moderate and severe esophageal varices confirmed on endoscopy. Primary outcomes included five-day rebleeding and in-hospital death. RESULTS Overall, 793 patients were included. Patients with hematemesis at admission had significantly higher five-day rebleeding rate (17.4 versus 10.1%, P = 0.004) and in-hospital mortality (7.9 versus 2.4%, P = 0.001) than those without hematemesis. In the propensity score matching analyses, 358 patients were included with similar Child-Pugh score (P = 0.227) and MELD score (P = 0.881) between the two groups; five-day rebleeding rate (19.0 versus 10.6%, P = 0.026) and in-hospital mortality (8.4 versus 2.8%, P = 0.021) remained significantly higher in patients with hematemesis. In the subgroup and sensitivity analyses, the statistical results were also similar. CONCLUSIONS Hematemesis at admission indicates worse outcomes of cirrhotic patients with AUGIB, which is useful for the risk stratification of AUGIB.
Collapse
Affiliation(s)
- Yingying Li
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang
- Postgraduate College, Jinzhou Medical University, Jinzhou
| | - Hongyu Li
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang
| | - Qiang Zhu
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Emmanuel Tsochatzis
- University College London Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Ran Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang
| |
Collapse
|
32
|
Kim SM, Song KH, Kang SH, Moon HS, Sung JK, Kim SH, Kim KB, Lee SW, Cho YS, Bang KB. Evaluation of prognostic factor and nature of acute esophageal necrosis: Restropective multicenter study. Medicine (Baltimore) 2019; 98:e17511. [PMID: 31593121 PMCID: PMC6799417 DOI: 10.1097/md.0000000000017511] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Acute esophageal necrosis (AEN) is a serious disease which can causes gastrointestinal bleeding and death. Although black color change is not essential factor of organ necrosis, AEN is also known as "black esophagus." Because of its rarity, there are limited studies regarding risk factors of mortality and recurrence. Thus, we conducted a multicenter retrospective study in order to evaluate the clinical characteristics of AEN. Method Clinical datum of AEN patients from 7 tertiary hospitals located in Daejeon-Choongcheong province were evaluated based on medical records. Our primary endpoint was risk factors for mortality and the secondary endpoint was risk factors for recurrence and clarifying whether "black esophagus" is a right terminology.Fourty one patients were enrolled. Thirty six patients were male, mean age was 69.5 years. Nine patients had died, and 4 patients showed recurrence. Sepsis and white color change in endoscopy were related to high mortality (Chi-Squared test, P < .05). Old age, high pulse rate, low hemoglobin, and low albumin were also related to high mortality. Unexpectedly, heavy drinking showed favorable a mortality. Septic condition and high pulse rate showed poor mortality in logistic regression test (P < .05). Coexisting duodenal ulcer was related to recurrence (Chi-Squared test, P < .05). There was no difference in the underlying condition except patients with a coexisting cancer and white-form displayed lower hemoglobin level. Conclusion: Our results imply that white color change, septic condition, high pulse rate, and low hemoglobin & albumin are poor prognostic factors in AEN. Further evaluation may help clarify the findings of our study.
Collapse
Affiliation(s)
- Sun Moon Kim
- Department of Internal Medicine, College of medicine, Konyang University
| | - Kyung Ho Song
- Department of Internal Medicine, College of medicine, Konyang University
| | - Sun Hyung Kang
- Department of Internal Medicine, Chungnam National University School of Medicine
| | - Hee Seok Moon
- Department of Internal Medicine, Chungnam National University School of Medicine
| | - Jae Kyu Sung
- Department of Internal Medicine, Chungnam National University School of Medicine
| | - Sae Hee Kim
- Department of Internal Medicine, College of medicine, Eulji University
| | - Ki Bae Kim
- Department of Internal Medicine, Chungbuk National University School of Medicine
| | - Seung Woo Lee
- Department of Internal Medicine, Catholic University of Korea School of Medicine
| | - Young Sin Cho
- Department of Internal Medicine, College of medicine, Soonchunhyang University
| | - Ki Bae Bang
- Department of Internal Medicine, College of medicine, Dankook University, Republic of Korea
| |
Collapse
|
33
|
Butt JH, Li A, Xian Y, Peterson ED, Garcia D, Torp-Pedersen C, Køber L, Fosbøl EL. Direct oral anticoagulant- versus vitamin K antagonist-related gastrointestinal bleeding: Insights from a nationwide cohort. Am Heart J 2019; 216:117-124. [PMID: 31425898 DOI: 10.1016/j.ahj.2019.07.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/19/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND The purpose of the study was to examine the association between the type of preceding oral anticoagulant use (warfarin or direct oral anticoagulants [DOACs]) and in-hospital mortality among patients admitted with gastrointestinal bleeding. METHODS In this observational cohort study, all patients admitted with a first-time gastrointestinal bleeding from January 2011 to March 2017 while receiving any oral anticoagulant therapy prior to admission were identified using data from Danish nationwide registries. The risk of in-hospital mortality according to type of oral anticoagulation therapy was examined by multivariable logistic regression models. RESULTS Among 5,774 patients admitted with gastrointestinal bleeding (median age, 78 years [25th-75th percentile, 71-85 years]; 56.8% men), 2,038 (35.3%) were receiving DOACs and 3,736 (64.7%) were receiving warfarin prior to admission. The unadjusted in-hospital mortality rates were 7.5% for DOAC (7.2% for dabigatran, 6.4% for rivaroxaban, and 10.1% for apixaban) and 6.5% for warfarin. After adjustment for baseline demographic and clinical characteristics, there was no statistically significant difference in in-hospital mortality between prior use of any DOAC and warfarin (unadjusted odds ratio [OR] 1.18 [95% CI 0.95-1.45], adjusted OR 0.97 [95% CI 0.77-1.24]). Similar results were found for each individual DOAC as compared with warfarin (dabigatran: unadjusted OR 1.12 [95% CI 0.84-1.49], adjusted OR 0.96 [95% CI 0.71-1.30]); rivaroxaban: unadjusted OR 0.98 [95% CI 0.71-1.37], adjusted OR 0.84 [95% CI 0.59-1.21]; and apixaban: unadjusted OR 1.62 [95% CI 0.84-1.49], adjusted OR 1.22 [95% CI 0.83-1.79]). CONCLUSIONS Among patients admitted with gastrointestinal bleeding, there was no statistically significant difference in in-hospital mortality between prior use of DOAC and warfarin.
Collapse
Affiliation(s)
- Jawad H Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Ang Li
- Division of Hematology, University of Washington School of Medicine, Seattle, WA
| | - Ying Xian
- Duke Clinical Research Institute, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC
| | | | - David Garcia
- Division of Hematology, University of Washington School of Medicine, Seattle, WA
| | | | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| |
Collapse
|
34
|
Tsai MH, Huang HC, Peng YS, Chen YC, Tian YC, Yang CW, Lien JM, Fang JT, Hou MC, Shen CH, Huang CC, Wu CS, Lee FY. Nutrition Risk Assessment Using the Modified NUTRIC Score in Cirrhotic Patients with Acute Gastroesophageal Variceal Bleeding: Prevalence of High Nutrition Risk and its Independent Prognostic Value. Nutrients 2019; 11:E2152. [PMID: 31505759 PMCID: PMC6769743 DOI: 10.3390/nu11092152] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 09/03/2019] [Accepted: 09/04/2019] [Indexed: 12/11/2022] Open
Abstract
Malnutrition is associated with adverse outcomes in patients with liver cirrhosis. Relevant data about nutrition risk in critically ill cirrhotic patients are lacking. The modified Nutrition Risk in Critically Ill (mNUTRIC) score is a novel nutrition risk assessment tool specific for intensive care unit (ICU) patients. This retrospective study was conducted to evaluate the prevalence and prognostic significance of nutrition risk in cirrhotic patients with acute gastroesophageal variceal bleeding (GEVB) using mNUTRIC scores computed on admission to the intensive care unit. The major outcome was 6-week mortality. One-hundred-and-thirty-one admissions in 120 patients were analyzed. Thirty-eight percent of cirrhotic patients with acute GEVB were categorized as being at high nutrition risk (a mNUTRIC score of ≥5). There was a significantly progressive increase in mortality associated with the mNUTRIC score (χ2 for trend, p < 0.001). By using the area under a receiver operating characteristic (ROC) curve, the mNUTRIC demonstrated good discriminative power to predict 6-week mortality (AUROC 0.859). In multivariate analysis, the mNUTRIC score was an independent factor associated with 6-week mortality. In conclusion, the mNUTRIC score can serve as a tool to assess nutrition risk in cirrhotic patients with acute GEVB.
Collapse
Affiliation(s)
- Ming-Hung Tsai
- Division of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan.
| | - Hui-Chun Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veteran General Hospital, Faculty of Medicine, Yang-Ming University School of Medicine, Taipei 112, Taiwan.
- Division of General Medicine, Department of Medicine, Taipei Veteran General Hospital, Faculty of Medicine Yang-Ming University School of Medicine, Taipei 112, Taiwan.
| | - Yun-Shing Peng
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital, Chia-Yi 613, Taiwan.
| | - Yung-Chang Chen
- Division of Critical Care Nephrology, Kidney Institute, Chang Gung Memorial Hospital, Taipei 105, Taiwan.
| | - Ya-Chung Tian
- Division of Critical Care Nephrology, Kidney Institute, Chang Gung Memorial Hospital, Taipei 105, Taiwan.
| | - Chih-Wei Yang
- Division of Critical Care Nephrology, Kidney Institute, Chang Gung Memorial Hospital, Taipei 105, Taiwan.
| | - Jau-Min Lien
- Division of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan.
| | - Ji-Tseng Fang
- Division of Critical Care Nephrology, Kidney Institute, Chang Gung Memorial Hospital, Taipei 105, Taiwan.
| | - Ming-Chih Hou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veteran General Hospital, Faculty of Medicine, Yang-Ming University School of Medicine, Taipei 112, Taiwan.
| | - Chien-Heng Shen
- Division of Gastroenterology, Chang Gung Memorial Hospital, Chia-Yi 613, Taiwan.
| | - Chung-Chi Huang
- Division of Critical Care Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan.
| | - Cheng-Shyong Wu
- Division of Gastroenterology, Chang Gung Memorial Hospital, Chia-Yi 613, Taiwan.
| | - Fa-Yauh Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veteran General Hospital, Faculty of Medicine, Yang-Ming University School of Medicine, Taipei 112, Taiwan.
| |
Collapse
|
35
|
Patel G, Pancholy N, Thomas L, Rai A, Kher A, Peters C, Amin A, Patel TM, Pancholy S. Effect of Chronic Hematologic Malignancies on In-Hospital Outcomes of Patients With ST-Segment Elevation Myocardial Infarction. Am J Cardiol 2019; 124:349-354. [PMID: 31196560 DOI: 10.1016/j.amjcard.2019.04.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/17/2019] [Accepted: 04/25/2019] [Indexed: 11/16/2022]
Abstract
In view of hemorrhagic and prothrombotic tendencies, ST-segment elevation myocardial infarction (STEMI) patients with chronic hematologic malignancies (CHM) are felt to be at a higher risk and hence denied standard reperfusion strategies. In-hospital outcomes of CHM patients presenting with STEMI are unclear. The Nationwide Inpatient Sample data files from 2003 to 2014 were used to extract adult patients who presented with a primary diagnosis of STEMI. Patients who had a diagnosis of CHM defined as chronic myelogenous leukemia, chronic lymphocytic leukemia, essential thrombocythemia, polycythemia vera, chronic monocytic leukemia, and multiple myeloma were identified. The primary study outcome measure was in-hospital mortality. Inverse probability weighting-adjusted binary logistic regression was performed to identify independent predictors of in-hospital mortality. Of 2,715,807 STEMI patients included in the final analyses, 11,974 (0.4%) patients had a diagnosis of CHM. Patients with CHM were significantly older, had a higher prevalence of co-morbidities, and had a significantly higher unadjusted in-hospital mortality (14.9% vs 9.0%; p <0.001). After adjusting for co-morbidities, CHM did not independently predict a higher in-hospital mortality (odds ratio = 1.02, 95% confidence interval = 0.96 to 1.09; p = 0.461). In patients with CHM who presented with STEMI, percutaneous coronary intervention was found to be associated with a significant reduction in in-hospital mortality (odds ratio = 0.22, 95% confidence interval = 0.18 to 0.27; p <0.001) (c-statistic = 0.81). In conclusion, CHM patients presenting with STEMI should be treated with similar treatment strategies as those without CHM, including revascularization if indicated, as there appears to be a sizable outcome advantage with this approach.
Collapse
Affiliation(s)
- Gaurav Patel
- The Wright Center for Graduate Medical Education, Scranton, Pennsylvania
| | - Neha Pancholy
- Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Lisa Thomas
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Anvit Rai
- Albert Einstein College of Medicine, New York, New York
| | - Akhil Kher
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Amit Amin
- Washington University School of Medicine, St. Louis, Missouri
| | | | - Samir Pancholy
- The Wright Center for Graduate Medical Education, Scranton, Pennsylvania.
| |
Collapse
|
36
|
Rout G, Sharma S, Gunjan D, Kedia S, Saraya A, Nayak B, Singh V, Kumar R. Development and Validation of a Novel Model for Outcomes in Patients with Cirrhosis and Acute Variceal Bleeding. Dig Dis Sci 2019; 64:2327-2337. [PMID: 30830520 DOI: 10.1007/s10620-019-05557-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 02/20/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acute variceal bleeding (AVB) in patients with cirrhosis is associated with high mortality, ranging from 12 to 20% at 6 weeks. The existing prognostic models for AVB lack precision and require further validation. AIM In this prospective study, we aimed to develop and validate a new prognostic model for AVB, and compared it with the existing models. METHODS We included 285 patients from March 2017 to November 2017 in the derivation cohort and 238 patients from December 2017 to June 2018 in the validation cohort. Two prognostic models were developed from derivation cohort by logistic regression analysis. Discrimination was assessed using area under the receiver operator characteristic curve (AUROC). RESULTS The 6-week mortality was 22.1% in derivation cohort and 22.3% in validation cohort, P = 0.866. Model for end-stage liver disease (MELD) [odds ratio (OR) 1.106] and encephalopathy (E) (OR 4.658) in one analysis and Child-Pugh score (OR 1.379) and serum creatinine (OR 1.474) in another analysis were significantly associated with 6-week mortality. MELD-E model (AUROC 0.792) was superior to Child-creatinine model (AUROC) in terms of discrimination. The MELD-E model had highest AUROC; as compared to other models-MELD score (AUROC 0.751, P = 0.036), Child-Pugh score (AUROC 0.737, P = 0.037), D'Amico model (AUROC 0.716, P = 0.014) and Augustin model (AUROC 0.739, P = 0.018) in derivation cohort. In validation cohort, the discriminatory performance of MELD-E model (AUROC 0.805) was higher as compared to other models including MELD score (AUROC 0.771, P = 0.048), Child-Pugh score (AUROC 0.746, P = 0.011), Augustin model (AUROC 0.753, P = 0.039) and D'Amico model (AUROC 0.736, P = 0.021). CONCLUSION In cirrhotic patients with AVB, the novel MELD-Encephalopathy model predicts 6 weeks mortality with higher accuracy than the existing prognostic models.
Collapse
Affiliation(s)
- Gyanranjan Rout
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Sanchit Sharma
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Baibaswata Nayak
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Vishwajeet Singh
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, 801507, India
| |
Collapse
|
37
|
Brito-Azevedo A. Diuretic window hypothesis in cirrhosis: Changing the point of view. World J Gastroenterol 2019; 25:3283-3290. [PMID: 31341355 PMCID: PMC6639551 DOI: 10.3748/wjg.v25.i26.3283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/09/2019] [Accepted: 06/01/2019] [Indexed: 02/06/2023] Open
Abstract
Since the 1970s, non-selective beta-blockers (NSBB) have been used to prevent variceal upper bleeding in advanced cirrhotic patients. However, several recent studies have raised the doubt about the benefit of NSBB in end-stage cirrhotic patients. In fact, they suggested a detrimental effect in these patients that even reduced survival. All of these studies have been assembled to compose the “window therapy hypothesis”, in which NSBB would have traditional indication to be initiated to prevent variceal upper bleeding; however, treatment should be stopped (or not be initiated) in patients with end-stage cirrhosis. NSBB would reduce the cardiac reserve of these patients, worsening systemic perfusion and prognosis. However, it should be emphasized that these studies present important bias issues, and their results also suggested that diuretic treatment may also be behind the effects observed. In this opinion review, we changed the point of view from NSBB to diuretic treatment, based on a physiopathogenic approach of circulatory parameters of cirrhotic patients studied, and based on diuretic effect in blood pressure lowering and in other hypervolemic disease, as heart failure. We suggest a “diuretic window hypothesis”, composed by an open window in hypervolemic phase, an attention window when patient present in a normal plasma volume phase, and a closed window during the plasma hypovolemic phase.
Collapse
Affiliation(s)
- Anderson Brito-Azevedo
- Liver Transplant Unit, São Lucas Hospital, Rio de Janeiro 22061-080, Brazil
- Liver Transplant Unit, São Francisco na Providência de Deus Hospital, Rio de Janeiro 20520-053, Brazil
- Liver Transplant Unit, Adventist Silvestre Hospital, Rio de Janeiro 22241-280, Brazil
| |
Collapse
|
38
|
Bellido-Caparó Á, Espinoza-Ríos J, Gómez Hinojosa P, Prochazka-Zarate R, Bravo Paredes E, León Rabanal CP, Tagle Arróspide M, Pinto Valdivia JL. [Independent risk factors for severity and mortality in lower gastrointestinal bleeding]. Rev Gastroenterol Peru 2019; 39:229-238. [PMID: 31688846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
UNLABELLED In lower gastrointestinal bleeding (LGIB), it is very important to stratify the risk of LGIB for a proper management. OBJECTIVE Identity the independent risk factors to mortality and severity (require critical care, prolonged hospitalization, reebleding, re hospitalization, politrasfusion, surgery for bleeding control) in LGIB. MATERIALS AND METHODS It is an analytic prospective cohort study, performed between June 2016 and April 2018 in a tertiary care hospital. Independent factors were determined using binomial logistic regression. RESULTS A total of 98 patients were included, of which 13 patients (13,3%) died, and 56 (57,1%) met severity criteria. The independent risk factor for mortality was Glasgow scale under 15, and for severe bleeding were: Systolic blood pressure under 100 mm Hg, albumin lower than 2,8 g/dL. CONCLUSIONS The frequency of mortality and severe LGIB is high in our population, the principal risk factors were systolic blood pressure under than 100 mm Hg, Glasgow score lower than 15, albumin lower than 2,8 g/dL. Identifying these associated factors would improve the management of LGB in the emergency room.
Collapse
Affiliation(s)
| | - Jorge Espinoza-Ríos
- Hospital Cayetano Heredia. Lima, Per ú; Universidad Peruana Cayetano Heredia. Lima, Per ú
| | | | | | - Eduar Bravo Paredes
- Hospital Cayetano Heredia. Lima, Per ú; Universidad Peruana Cayetano Heredia. Lima, Per ú
| | | | | | | |
Collapse
|
39
|
Vadera S, Yong CWK, Gluud LL, Morgan MY. Band ligation versus no intervention for primary prevention of upper gastrointestinal bleeding in adults with cirrhosis and oesophageal varices. Cochrane Database Syst Rev 2019; 6:CD012673. [PMID: 31220333 PMCID: PMC6586251 DOI: 10.1002/14651858.cd012673.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The presence of oesophageal varices is associated with the risk of upper gastrointestinal bleeding. Endoscopic variceal ligation is used to prevent this occurrence but the ligation procedure may be associated with complications. OBJECTIVES To assess the beneficial and harmful effects of band ligation versus no intervention for primary prevention of upper gastrointestinal bleeding in adults with cirrhosis and oesophageal varices. SEARCH METHODS We combined searches in the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, and Science Citation Index with manual searches. The last search update was 9 February 2019. SELECTION CRITERIA We included randomised clinical trials comparing band ligation verus no intervention regardless of publication status, blinding, or language in the analyses of benefits and harms, and observational studies in the assessment of harms. Included participants had cirrhosis and oesophageal varices with no previous history of variceal bleeding. DATA COLLECTION AND ANALYSIS Three review authors extracted data independently. The primary outcome measures were all-cause mortality, upper gastrointestinal bleeding, and serious adverse events. We undertook meta-analyses and presented results using risk ratios (RRs) with 95% confidence intervals (CIs) and I2 values as a marker of heterogeneity. In addition, we calculated the number needed to treat to benefit (NNTTB) for the primary outcomes . We assessed bias control using the Cochrane Hepato-Biliary domains; determined the certainty of the evidence using GRADE; and conducted sensitivity analyses including Trial Sequential Analysis. MAIN RESULTS Six randomised clinical trials involving 637 participants fulfilled our inclusion criteria. One of the trials included an additional small number of participants (< 10% of the total) with non-cirrhotic portal hypertension/portal vein block. We classified one trial as at low risk of bias for the outcome, mortality and high risk of bias for the remaining outcomes; the five remaining trials were at high risk of bias for all outcomes. We downgraded the evidence to moderate certainty due to the bias risk. We gathered data on all primary outcomes from all trials. Seventy-one of 320 participants allocated to band ligation compared to 129 of 317 participants allocated to no intervention died (RR 0.55, 95% CI 0.43 to 0.70; I2 = 0%; NNTTB = 6 persons). In addition, band ligation was associated with reduced risks of upper gastrointestinal bleeding (RR 0.44, 95% CI 0.28 to 0.72; 6 trials, 637 participants; I2 = 61%; NNTTB = 5 persons), serious adverse events (RR 0.55, 95% CI 0.43 to 0.70; 6 trials, 637 participants; I2 = 44%; NNTTB = 4 persons), and variceal bleeding (RR 0.43, 95% CI 0.27 to 0.69; 6 trials, 637 participants; I² = 56%; NNTTB = 5 persons). The non-serious adverse events reported in association with band ligation included oesophageal ulceration, dysphagia, odynophagia, retrosternal and throat pain, heartburn, and fever, and in the one trial involving participants with either small or large varices, the incidence of non-serious side effects in the banding group was much higher in those with small varices, namely ulcers: small versus large varices 30.5% versus 8.7%; heartburn 39.2% versus 17.4%. No trials reported on health-related quality of life.Two trials did not receive support from pharmaceutical companies; the remaining four trials did not provide information on this issue. AUTHORS' CONCLUSIONS This review found moderate-certainty evidence that, in patients with cirrhosis, band ligation of oesophageal varices reduces mortality, upper gastrointestinal bleeding, variceal bleeding, and serious adverse events compared to no intervention. It is unlikely that further trials of band ligation versus no intervention would be considered ethical.
Collapse
Affiliation(s)
- Sonam Vadera
- Division of Medicine, Royal Free Campus, University College LondonUCL Institute for Liver & Digestive HealthRowland Hill StreetHampsteadLondonUKNW3 2PF
| | - Charles Wei Kit Yong
- Division of Medicine, Royal Free Campus, University College LondonUCL Institute for Liver & Digestive HealthRowland Hill StreetHampsteadLondonUKNW3 2PF
| | - Lise Lotte Gluud
- Copenhagen University Hospital HvidovreGastrounit, Medical DivisionKettegaards Alle 30HvidovreDenmark2650
| | - Marsha Y Morgan
- Division of Medicine, Royal Free Campus, University College LondonUCL Institute for Liver & Digestive HealthRowland Hill StreetHampsteadLondonUKNW3 2PF
| | | |
Collapse
|
40
|
Orman ES, Roberts A, Ghabril M, Nephew L, Desai A, Patidar K, Chalasani N. Trends in Characteristics, Mortality, and Other Outcomes of Patients With Newly Diagnosed Cirrhosis. JAMA Netw Open 2019; 2:e196412. [PMID: 31251379 PMCID: PMC6604080 DOI: 10.1001/jamanetworkopen.2019.6412] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Changes in the characteristics of patients with cirrhosis are likely to affect future outcomes and are important to understand in planning for the care of this population. OBJECTIVE To identify changes in demographic and clinical characteristics and outcomes in patients with newly diagnosed cirrhosis. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of patients with a new diagnosis of cirrhosis was conducted using the Indiana Network for Patient Care, a large statewide regional health information exchange, between 2004 and 2014. Patients with at least 1 year of continuous follow-up before the cirrhosis diagnosis were followed up through August 1, 2015. The analysis was conducted from December 2018 to January 2019. EXPOSURES Age, cause of cirrhosis, and year of diagnosis. MAIN OUTCOMES AND MEASURES Overall rates for mortality, liver transplant, hepatocellular carcinoma, and hepatic decompensation (composite of ascites, hepatic encephalopathy, or variceal bleeding). RESULTS A total of 9261 patients with newly diagnosed cirrhosis were identified (mean [SD] age, 57.9 [12.6] years; 5109 [55.2%] male). A 69% increase in new diagnoses occurred over the course of the study period (620 in 2004 vs 1045 in 2014). The proportion of those younger than 40 years increased by 0.20% per year (95% CI, 0.04% to 0.36%; P for trend = .02), and the proportion of those aged 65 years and older increased by 0.81% per year (95% CI, 0.51% to 1.11%; P for trend < .001). The proportion of patients with alcoholic cirrhosis increased by 0.80% per year (95% CI, 0.49% to 1.12%), and the proportion with nonalcoholic steatohepatitis increased by 0.59% per year (95% CI, 0.30% to 0.87%), whereas the proportion with viral hepatitis decreased by 1.36% per year (95% CI, -1.68% to -1.03%) (P < .001 for all). In patients younger than 40 years, 40 to 64 years, and 65 years and older, mortality rates were 6.4 (95% CI, 5.4 to 7.6), 9.9 (95% CI, 9.5 to 10.4), and 16.2 (95% CI, 15.2 to 17.2) per 100 person-years, respectively (P < .001). Mortality rates decreased during the study period (11.9 [95% CI, 10.7-13.1] per 100 person-years in 2004 vs 10.0 [95% CI, 8.1-12.2] per 100 person-years in 2014; annual adjusted hazard ratio, 0.87 [95% CI, 0.86 to 0.88]) and were lower in those with alcoholic cirrhosis compared with patients with viral hepatitis (adjusted hazard ratio, 0.89 [95% CI, 0.80 to 0.98]). Rates of hepatocellular carcinoma were low in patients younger than 40 years (0.5 [95% CI, 0.2 to 0.9] per 100 person-years). Liver transplant rates were low throughout the study period (0.3 [95% CI, 0.3-0.4] per 100 person-years). In patients with compensated cirrhosis, rates of hepatic decompensation were lower in patients younger than 40 years (adjusted subhazard ratio 0.78; 95% CI, 0.62 to 0.99) and in patients with nonalcoholic steatohepatitis (adjusted subhazard ratio, 0.51; 95% CI, 0.43 to 0.60). CONCLUSIONS AND RELEVANCE The population of patients with newly diagnosed cirrhosis in Indiana has experienced changes in the age distribution and cause of cirrhosis, with decreasing mortality rates. These findings support investment in the prevention and treatment of alcoholic liver disease and nonalcoholic steatohepatitis, particularly in younger and older patients. Additional study is needed to identify the reasons for decreasing mortality rates.
Collapse
Affiliation(s)
- Eric S. Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | - Anna Roberts
- Regenstrief Institute, Inc, Indianapolis, Indiana
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | - Lauren Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | - Archita Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | - Kavish Patidar
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| |
Collapse
|
41
|
Lu M, Sun G, Huang H, Zhang X, Xu Y, Chen S, Song Y, Li X, Lv B, Ren J, Chen X, Zhang H, Mo C, Wang Y, Yang Y. Comparison of the Glasgow-Blatchford and Rockall Scores for prediction of nonvariceal upper gastrointestinal bleeding outcomes in Chinese patients. Medicine (Baltimore) 2019; 98:e15716. [PMID: 31124950 PMCID: PMC6571241 DOI: 10.1097/md.0000000000015716] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The Glasgow-Blatchford scores (GBS) and Rockall scores (RS) are commonly used for stratifying patients with nonvariceal upper gastrointestinal hemorrhage (NVUGIH). Although predictive value of these scoring methods has been extensively validated, their clinical effectiveness remains unclear. The following study evaluated the GBS and RS scoring system with reference to bleeding, needs for further surgery, endoscopic intervention and death, in order to verify their effectiveness and accuracy in clinical application.Patients who presented with NVUGIH, or who were consequently diagnosed with the disease (by endoscopy examination) between January 1, 2008, and December 31, 2012 were enrolled in the study. GBS and RS scores were compared to predict bleeding, the needs for further surgery, endoscopic intervention, death by ROC curves and AUC value.Among 2977 patients, the pre-endoscopic RS and complete RS score (CRS) were superior to the GBS score (AUC: 0.842 vs 0.804 vs 0.622, respectively) for predicting the mortality risk in patients. The pre-endoscopic RS score predicting re-bleeding was significantly higher than the CRS and the GBS score (AUC: 0.658 vs 0.548 vs 0.528, respectively). In addition, the 3 scoring systems revealed to be poor predictors of surgical operation effectiveness (AUC: 0.589 vs 0.547 vs 0.504, respectively).Our data demonstrated that the GBS and RS scoring systems could be used to predict outcomes in patients with nonvariceal upper gastrointestinal bleeding.
Collapse
Affiliation(s)
- Mingliang Lu
- Department of Gastroenterology, The Second Affiliated Hospital, Kunming Medical University, Kunming
| | - Gang Sun
- Institute of Digestive Diseases, Chinese PLA General Hospital
| | - Hua Huang
- Department of Gastroenterology, The Second Affiliated Hospital, Kunming Medical University, Kunming
| | - Xiaomei Zhang
- Institute of Digestive Diseases, Chinese PLA General Hospital
| | - Youqing Xu
- Department of Gastroenterology, Beijing Tian Tan Hospital, Beijing
| | - Shiyao Chen
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai
| | - Ying Song
- Department of Gastroenterology, Xi’an Central Hospital, Xi’an
| | - Xueliang Li
- Department of Gastroenterology, First Affiliated Hospital, Nanjing Medical University, Nanjing
| | - Bin Lv
- Department of Gastroenterology, First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou
| | - Jianlin Ren
- Department of Gastroenterology, Zhongshan Hospital, Xiamen University, Xiamen
| | - Xueqing Chen
- Department of Gastroenterology, First People's Hospital of Foshan, Foshan, China
| | - Hui Zhang
- Department of Gastroenterology, Beijing Tian Tan Hospital, Beijing
| | - Chen Mo
- Institute of Digestive Diseases, Chinese PLA General Hospital
| | - Yanzhi Wang
- Institute of Digestive Diseases, Chinese PLA General Hospital
| | - Yunsheng Yang
- Institute of Digestive Diseases, Chinese PLA General Hospital
| |
Collapse
|
42
|
Maimone S, Saffioti F, Filomia R, Alibrandi A, Isgrò G, Calvaruso V, Xirouchakis E, Guerrini GP, Burroughs AK, Tsochatzis E, Patch D. Predictors of Re-bleeding and Mortality Among Patients with Refractory Variceal Bleeding Undergoing Salvage Transjugular Intrahepatic Portosystemic Shunt (TIPS). Dig Dis Sci 2019; 64:1335-1345. [PMID: 30560334 DOI: 10.1007/s10620-018-5412-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 12/03/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) has proven clinical efficacy as rescue therapy for cirrhotic patients with acute portal hypertensive bleeding who fail endoscopic treatment. AIMS To investigate predictive factors of 6-week and 1-year mortality in patients undergoing salvage TIPS for refractory portal hypertensive bleeding. METHODS A total of 144 consecutive patients were retrospectively evaluated. Three logistic regression multivariate models were estimated to individualize prognostic factors for 6-week and 12-month mortality. Log-rank test was used to evaluate survival according to Child-Pugh classes and Bureau's criteria. RESULTS Mean age 51 ± 10 years, 66% male, mean MELD 18.5 ± 8.3, Child-Pugh A/B/C 8%/38%/54%. TIPS failure occurred in 23(16%) patients and was associated with pre-TIPS portal pressure gradient and pre-TIPS intensive care unit stay. Six-week and 12-month mortality was 36% and 42%, respectively. Pre-TIPS intensive care unit stay, MELD, and Child-Pugh score were independently associated with mortality at 6 weeks. Independent predictors of mortality at 12 months were pre-TIPS intensive care unit stay and Child-Pugh score. CONCLUSIONS In this large cohort of patients undergoing salvage TIPS, MELD and Child-Pugh scores were predictive of short- and long-term mortality, respectively. Pre-TIPS intensive care unit stay was independently associated with TIPS failure and mortality at 6 weeks and 12 months. Salvage TIPS is futile in patients with Child-Pugh score of 14-15.
Collapse
Affiliation(s)
- Sergio Maimone
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK.
- Division of Clinical and Molecular Hepatology, Department of Internal Medicine, University Hospital of Messina, Messina, Italy.
| | - Francesca Saffioti
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Roberto Filomia
- Division of Clinical and Molecular Hepatology, Department of Internal Medicine, University Hospital of Messina, Messina, Italy
| | - Angela Alibrandi
- Department of Economics, Unit of Statistical and Mathematical Sciences, University of Messina, Messina, Italy
| | - Grazia Isgrò
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
| | - Vincenza Calvaruso
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
- Gastroenterology and Hepatology Unit, Di.Bi.M.I.S., University of Palermo, Palermo, Italy
| | - Elias Xirouchakis
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
- Gastroenterology and Hepatology Department, Athens Medical P. Faliron Hospital, Athens, Greece
| | - Gian Piero Guerrini
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
- Department of Surgery, Ravenna Hospital, Ravenna, Italy
| | - Andrew K Burroughs
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
| | - Emmanuel Tsochatzis
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
| | - David Patch
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
| |
Collapse
|
43
|
Zhang K, Sun X, Wang G, Zhang M, Wu Z, Tian X, Zhang C. Treatment outcomes of percutaneous transhepatic variceal embolization versus transjugular intrahepatic portosystemic shunt for gastric variceal bleeding. Medicine (Baltimore) 2019; 98:e15464. [PMID: 31045824 PMCID: PMC6504295 DOI: 10.1097/md.0000000000015464] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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
There have been few studies comparing percutaneous transhepatic variceal embolization (PTVE) and transjugular intrahepatic portosystemic shunt (TIPS) for the prevention of recurrent gastric variceal bleeding (GVB).Compare the outcomes of these 2 procedures in patients with GVB.A total of 74 cirrhosis patients with GVB who underwent TIPS and modified PTVE were enrolled. The rebleeding and mortality rates, portal vein pressure (PVP) variation, and rates of hepatic encephalopathy (HE) were compared between the 2 groups.A total of 43 PTVE and 31 TIPS patients were enrolled in this study. The difference of rebleeding rate in the 2 groups was not statistically significant (P = .190). The difference of early rebleeding rates and cumulative rebleeding-free rates were all not statistically significant (P = .256, P = .200). The difference of mortality rates in the 2 groups was not statistically significant (χ = 1.206, P = .272). The rate of HE in TIPS group was statistically higher than that in PTVE group (P < .0001).Both PTVE and TIPS were effective for preventing rebleeding of GVs. There were no significant differences in rebleeding and mortality rates. The incidence of HE after TIPS was higher than PTVE.
Collapse
Affiliation(s)
- Kai Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Xiaoyan Sun
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Guangchuan Wang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Mingyan Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Zhe Wu
- Department of Gastroenterology, Ningbo Medical Center Lihuili Hospital, Ningbo, China
| | - Xiangguo Tian
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| |
Collapse
|
44
|
Sharma M, Singh S, Desai V, Shah VH, Kamath PS, Murad MH, Simonetto DA. Comparison of Therapies for Primary Prevention of Esophageal Variceal Bleeding: A Systematic Review and Network Meta-analysis. Hepatology 2019; 69:1657-1675. [PMID: 30125369 DOI: 10.1002/hep.30220] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 08/15/2018] [Indexed: 12/14/2022]
Abstract
We performed a systematic review with network meta-analysis (NMA) to compare the efficacy of different approaches in primary prevention of esophageal variceal bleeding and overall survival in patients with cirrhosis with large varices. Thirty-two randomized clinical trials (RCTs) with 3,362 adults with cirrhosis with large esophageal varices and no prior history of bleeding, with a minimum of 12 months of follow-up, were included. Nonselective beta-blockers (NSBB), isosorbide-mononitrate (ISMN), carvedilol, and variceal band ligation (VBL), alone or in combination, were compared with each other or placebo. Primary outcomes were reduction of all-cause mortality and prevention of esophageal variceal bleeding. Random-effects NMA was performed and summary estimates were expressed as odds ratio and 95% confidence intervals (OR; CI). Quality of evidence was critically appraised using the Grading of Recommendations, Assessment, Development and Evaluation approach. Moderate quality evidence supports NSBB monotherapy (0.70; 0.49-1.00) or in combination with VBL (0.49; 0.23-1.02) or ISMN (0.44; 0.21-0.93) for decreasing mortality in patients with cirrhosis with large esophageal varices and no prior history of bleeding. Moderate-quality evidence supports carvedilol (0.21; 0.08-0.56) and VBL monotherapy (0.33; 0.19-0.55) or in combination with NSBB (0.34; 0.14-0.86), and low-quality evidence supports NSBB monotherapy (0.64; 0.38-1.07) for primary prevention of variceal bleeding. VBL carries a higher risk of serious adverse events compared with NSBB. Conclusion: NSBB monotherapy may decrease all-cause mortality and the risk of first variceal bleeding in patients with cirrhosis with large esophageal varices. Additionally, NSBB carries a lower risk of serious complications compared with VBL. Therefore, NSBB may be the preferred initial approach for primary prophylaxis of esophageal variceal bleeding.
Collapse
Affiliation(s)
- Mayank Sharma
- Mayo Clinic Gastroenterology and Hepatology, Rochester, MN
| | - Siddharth Singh
- University of California San Diego Gastroenterology and Hepatology, San Diego, CA
| | - Vivek Desai
- Mayo Clinic Gastroenterology and Hepatology, Rochester, MN
| | - Vijay H Shah
- Mayo Clinic Gastroenterology and Hepatology, Rochester, MN
| | | | | | | |
Collapse
|
45
|
Chandnani S, Rathi P, Sonthalia N, Udgirkar S, Jain S, Contractor Q, Jain S, Singh AK. Comparison of risk scores in upper gastrointestinal bleeding in western India: A prospective analysis. Indian J Gastroenterol 2019; 38:117-127. [PMID: 31124017 DOI: 10.1007/s12664-019-00951-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 02/28/2019] [Indexed: 02/04/2023]
Abstract
AIM To study the upper gastrointestinal bleeding (UGIB) characteristics and to validate the Rockall and Glasgow-Blatchford scores (GBS), Progetto Nazionale Emorragica Digestiva (PNED) and albumin, international normalized ratio (INR), mental status, systolic blood pressure, and age > 65 (AIMS65) risk scores in predicting outcomes in patients with UGIB. METHODS Three hundred subjects with hematemesis and/or melena were prospectively enrolled and followed up for 30 days. All patients were assessed by hematological investigations, imaging, and endoscopy and risk scores were calculated. RESULTS The mean age was 43.5 ± 17.2 years, and 207 (69%) were males. Hematemesis was the most common presentation (94%). Variceal bleeding was the most common etiology (47.7%). Thirty patients died (10%) and 50 had rebleeding (16.7%). On univariate analysis, serum albumin ≤ 2.7 gm% (p = 0.008), Glasgow Coma scale ≤ 13.9 (p = 0.001), serum bilirubin > 3 mg/dL (p = 0.004), serum bicarbonate ≤ 15.7 mEq/L (p = 0.001), systolic blood pressure < 90 mmHg (p = 0.004), and arterial pH ≤ 7.3 (p = 0.003) were found to be the predictors of mortality. No variable was found significant on multivariate analysis. All four scores were significant in predicting mortality, but Rockall (area under receiver operating characteristic [AUROC] 0.728) was better than others. Rebleeding was better predicted by PNED (modified) (AUROC 0.705). In predicting the need for transfusion and surgical or radiological intervention, GBS score > 0 was significant while score of < 2 classified patients into low risk for mortality with high negative predictive value. CONCLUSION Our study showed that the variceal bleeding was the commonest cause of UGIB. Rockall score was more significant in predicting mortality while PNED for rebleeding. Low risk for mortality, need for blood transfusion, or interventions were accurately predicted by GBS.
Collapse
Affiliation(s)
- Sanjay Chandnani
- Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Charitable Hospital, Dr Anandrao Laxman Nair Marg, Mumbai, 400 008, India.
| | - Pravin Rathi
- Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Charitable Hospital, Dr Anandrao Laxman Nair Marg, Mumbai, 400 008, India
| | - Nikhil Sonthalia
- Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Charitable Hospital, Dr Anandrao Laxman Nair Marg, Mumbai, 400 008, India
| | - Suhas Udgirkar
- Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Charitable Hospital, Dr Anandrao Laxman Nair Marg, Mumbai, 400 008, India
| | - Shubham Jain
- Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Charitable Hospital, Dr Anandrao Laxman Nair Marg, Mumbai, 400 008, India
| | - Qais Contractor
- Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Charitable Hospital, Dr Anandrao Laxman Nair Marg, Mumbai, 400 008, India
| | - Samit Jain
- Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Charitable Hospital, Dr Anandrao Laxman Nair Marg, Mumbai, 400 008, India
| | - Anupam Kumar Singh
- Department of Medicine, Santosh Medical College, Ghaziabad, 201 009, India
| |
Collapse
|
46
|
Lenti MV, Pasina L, Cococcia S, Cortesi L, Miceli E, Caccia Dominioni C, Pisati M, Mengoli C, Perticone F, Nobili A, Di Sabatino A, Corazza GR. Mortality rate and risk factors for gastrointestinal bleeding in elderly patients. Eur J Intern Med 2019; 61:54-61. [PMID: 30522789 DOI: 10.1016/j.ejim.2018.11.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) is burdened by high mortality rate that increases with aging. Elderly patients may be exposed to multiple risk factors for GIB. We aimed at defining the impact of GIB in elderly patients. METHODS Since 2008, samples of elderly patients (age ≥ 65 years) with multimorbidity admitted to 101 internal medicine wards across Italy have been prospectively enrolled and followed-up (REPOSI registry). Diagnoses of GIB, length of stay (LOS), mortality rate, and possible risk factors, including drugs, index of comorbidity (Cumulative Illness Rating Scale [CIRS]), polypharmacy, and chronic diseases were assessed. Adjusted multivariate logistic regression models were computed. RESULTS 3872 patients were included (mean age 79 ± 7.5 years, F:M ratio 1.1:1). GIB was reported in 120 patients (mean age 79.6 ± 7.3 years, F:M 0.9:1), with a crude prevalence of 3.1%. Upper GIB occurred in 72 patients (mean age 79.3 ± 7.6 years, F:M 0.8:1), lower GIB in 51 patients (mean age 79.4 ± 7.1 years, F:M 0.9:1), and both upper/lower GIB in 3 patients. Hemorrhagic gastritis/duodenitis and colonic diverticular disease were the most common causes. The LOS of patients with GIB was 11.7 ± 8.1 days, with a 3.3% in-hospital and a 9.4% 3-month mortality rates. Liver cirrhosis (OR 5.64; CI 2.51-12.65), non-ASA antiplatelet agents (OR 2.70; CI 1.23-5.90), and CIRS index of comorbidity >3 (OR 2.41; CI 1.16-4.98) were associated with GIB (p < 0.05). CONCLUSIONS A high index of comorbidity is associated with high odds of GIB in elderly patients. The use of non-ASA antiplatelet agents should be discussed in patients with multimorbidity.
Collapse
Affiliation(s)
- Marco Vincenzo Lenti
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy.
| | - Luca Pasina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Sara Cococcia
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Laura Cortesi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Emanuela Miceli
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Costanza Caccia Dominioni
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Martina Pisati
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Caterina Mengoli
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Francesco Perticone
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | | | - Antonio Di Sabatino
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Gino Roberto Corazza
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| |
Collapse
|
47
|
Abstract
Objective The aim of this study was to identify patients with a high risk of early mortality after acute esophageal variceal bleeding by measuring the C-reactive protein (CRP) level. Methods We retrospectively evaluated 154 consecutive cirrhotic patients admitted with acute esophageal variceal bleeding. Differences between categorical variables were assessed by the chi-square test. Continuous variables were compared using the Mann-Whitney U-test. Multivariate logistic regression analyses consisting of clinical laboratory parameters were performed to identify risk factors associated with the 6-week mortality. The discriminative ability and the best cut-off value were assessed by a receiver-operating characteristic (ROC) curve analysis. Results Child-Pugh C patients showed a significantly higher 6-week mortality than Child-Pugh A or B patients (38% vs. 6%, p<0.0001). The 6-week mortality in Child-Pugh C patients was associated with the age (p<0.0001), etiology of cirrhosis (p=0.003), hepatocellular carcinoma (p=0.0003), portal vein thrombosis (p=0.005), baseline creatinine (p=0.0001), albumin (p=0.001), white blood cell count (p=0.038), baseline CRP [p=0.0004; area under the ROC (AUROC)=0.765; optimum cut-off value at 1.30 mg/dL] and bacterial infection (p=0.019). We determined that CRP ≥1.30 mg/dL was an independent predictor for 6-week mortality in Child-Pugh C patients [odds ratio (OR)=8.789; 95% confidence interval (CI): 2.080-47.496; p=0.003], along with a creatinine level of 0.71 mg/dL (OR=17.628; 95% CI: 2.349-384.426; p=0.004) (73% mortality if CRP ≥1.30 mg/dL vs. 19% if CRP<1.30 mg/dL, p<0.0001). Conclusion In Child-Pugh C patients with esophageal variceal bleeding, a baseline CRP ≥1.30 mg/dL can help identify patients with an increased risk of mortality.
Collapse
Affiliation(s)
- Takeshi Ichikawa
- Department of Gastroenterology and Hepatology, Nippon Koukan Hospital, Japan
- Department of Gastroenterology and Hepatology, Itabashi Chuo Medical Center, Japan
| | - Nobuaki Machida
- Department of Gastroenterology and Hepatology, Itabashi Chuo Medical Center, Japan
| | - Hiroaki Kaneko
- Department of Gastroenterology and Hepatology, Itabashi Chuo Medical Center, Japan
| | - Itaru Oi
- Department of Gastroenterology and Hepatology, Itabashi Chuo Medical Center, Japan
| | - Masayuki A Fujino
- Department of Gastroenterology and Hepatology, Itabashi Chuo Medical Center, Japan
- Department of Internal Medicine, Hasune Royal Clinic, Japan
| |
Collapse
|
48
|
Schmidt MS, Preisler L, Fabricius R, Svenningsen P, Hillingsø J, Svendsen LB, Sillesen M. Effect of hospital-admission volume on outcomes following acute non-variceal upper gastrointestinal bleeding. Dan Med J 2019; 66:A5531. [PMID: 30722826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Treatment-requiring acute non-variceal upper gastrointestinal bleeding (NVUGIB) is a common, potentially life-threatening emergency. This study investigated whether hospital admittance volume of patients with NVUGIB was associated with reduced mortality, reduced lasting failure of haemostatic procedures defined as rate of re-endoscopy with repeated haemostasis intervention (ReWHI), transfusion requirements and conversion to surgery. METHODS Data on Danish nationwide admissions of patients with acute NVUGIB from 2011-2013 were analysed to estimate 30-day mortality, re-bleeding (ReWHI), transfusion rates and rates of conversion to surgery. Data were analysed by regression modelling while controlling for confounders including age, admission haemoglobin, the American College of Anesthesiologists score, comorbidities and the Forrest classification. RESULTS A total of 3,537 patients with acute non-variceal upper gastrointestinal bleeding were included in the study. The hospital admission volume of patients with NVUGIB was positively associated with a significant increase in ReWHI with an odds ratio of 1.27; p = 1.91 × 10-6. There was no significant association between admission volume and conversion to surgery, 30-day mortality or transfusion rates. CONCLUSIONS A positive association between admission volumes of patients with NVUGIB and ReWHI was identified. No association between admission volumes and 30-day mortality or other failure of haemostasis events could be identified. FUNDING none. TRIAL REGISTRATION not applicable.
Collapse
|
49
|
Tarasov EE, Bagin VA, Nishnevich EV, Astafyeva MN, Rudnov VA, Prudkov MI. [Epidemiology and risk factors of adverse outcome in nonvariceal upper gastrointestinal bleeding]. Khirurgiia (Mosk) 2019:31-37. [PMID: 31169816 DOI: 10.17116/hirurgia201905131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
AIM To identify risk factors of adverse outcomes in patients with nonvariceal upper gastrointestinal bleeding. MATERIAL AND METHODS Epidemiological observational analytical longitudinal retrospective cohort study included 312 patients who were hospitalized in the Clinical Hospital #40 of Yekaterinburg in 2014-2016. The main inclusion criterion was nonvariceal upper gastrointestinal bleeding. RESULTS In-hospital mortality was 31 (9.9%) of 312 patients. Multivariate analysis confirmed the following risk factors of mortality: severity of blood loss (OR 22.70, 95% CI 5.08-102.00); open surgery (OR 15.20, 95% CI 2.71-74.80); M. Charlson comorbidity index (OR 2.15, 95% CI 1.34-3.43); risk of recurrent bleeding according to T. Rockall scale (OR 1.76, 95% CI 1.18-2.64). CONCLUSION Independent risk factors of adverse outcomes in patients with nonvariceal upper gastrointestinal bleeding are severe hemorrhagic shock, open surgery, high M. Charlson comorbidity index and risk of recurrent bleeding according to T. Rockall scale.
Collapse
Affiliation(s)
- E E Tarasov
- City Clinical Hospital #40, Yekaterinburg, Russian Federation
| | - V A Bagin
- City Clinical Hospital #40, Yekaterinburg, Russian Federation
| | - E V Nishnevich
- City Clinical Hospital #40, Yekaterinburg, Russian Federation; Ural state medical university, Ministry of health of the Russian Federation, Yekaterinburg, Russian Federation
| | - M N Astafyeva
- City Clinical Hospital #40, Yekaterinburg, Russian Federation
| | - V A Rudnov
- City Clinical Hospital #40, Yekaterinburg, Russian Federation; Ural state medical university, Ministry of health of the Russian Federation, Yekaterinburg, Russian Federation
| | - M I Prudkov
- Ural state medical university, Ministry of health of the Russian Federation, Yekaterinburg, Russian Federation
| |
Collapse
|
50
|
Yoo JJ, Chang Y, Cho EJ, Moon JE, Kim SG, Kim YS, Lee YB, Lee JH, Yu SJ, Kim YJ, Yoon JH. Timing of upper gastrointestinal endoscopy does not influence short-term outcomes in patients with acute variceal bleeding. World J Gastroenterol 2018; 24:5025-5033. [PMID: 30510377 PMCID: PMC6262253 DOI: 10.3748/wjg.v24.i44.5025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/15/2018] [Accepted: 11/13/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To examine the association between the timing of endoscopy and the short-term outcomes of acute variceal bleeding in cirrhotic patients.
METHODS This retrospective study included 274 consecutive patients admitted with acute esophageal variceal bleeding of two tertiary hospitals in Korea. We adjusted confounding factors using the Cox proportional hazards model and the inverse probability weighting (IPW) method. The primary outcome was the mortality of patients within 6 wk.
RESULTS A total of 173 patients received urgent endoscopy (i.e., ≤ 12 h after admission), and 101 patients received non-urgent endoscopy (> 12 h after admission). The 6-wk mortality rate was 22.5% in the urgent endoscopy group and 29.7% in the non-urgent endoscopy group, and there was no significant difference between the two groups before (P = 0.266) and after IPW (P = 0.639). The length of hospital stay was statistically different between the urgent group and non-urgent group (P = 0.033); however, there was no significant difference in the in-hospital mortality rate between the two groups (8.1% vs 7.9%, P = 0.960). In multivariate analyses, timing of endoscopy was not associated with 6-wk mortality (hazard ratio, 1.297; 95% confidence interval, 0.806-2.089; P = 0.284).
CONCLUSION In cirrhotic patients with acute variceal bleeding, the timing of endoscopy may be independent of short-term mortality.
Collapse
Affiliation(s)
- Jeong-Ju Yoo
- Department of Gastroenterology and Hepatology, Soonchunhyang University school of Medicine, Bucheon 14584, South Korea
| | - Young Chang
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Eun Ju Cho
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Ji Eun Moon
- Department of Biostatistics, Clinical Trial Center, Soonchunhyang University Bucheon Hospital, Bucheon 14584, South Korea
| | - Sang Gyune Kim
- Department of Gastroenterology and Hepatology, Soonchunhyang University school of Medicine, Bucheon 14584, South Korea
| | - Young Seok Kim
- Department of Gastroenterology and Hepatology, Soonchunhyang University school of Medicine, Bucheon 14584, South Korea
| | - Yun Bin Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Su Jong Yu
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Yoon Jun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Jung-Hwan Yoon
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, South Korea
| |
Collapse
|