A predictive model for failure to control bleeding during acute variceal haemorrhage

Abstract

Background/Aims: Variceal bleeding is a frequent complication of cirrhosis and is associated with a high risk of early rebleeding. In patients with peptic ulcers, continued bleeding or early rebleeding are risk factors for mortality and can be predicted by statistical models; however, no such models exist for acute variceal bleeding. Methods: We prospectively evaluated failure to control bleeding in 695 consecutive patients with cirrhosis, admitted for haematemesis and/or melaena. Criteria were defined for failure to control bleeding, which comprised both continued bleeding or early rebleeding within 5 days of admission. There were 2 sequential groups of patients: (i) those with variceal bleeding initially treated with blood transfusion and vasoactive drugs, and if these failed followed by sclerotherapy ( n=385); (ii) those with variceal bleeding treated with injection sclerotherapy at diagnostic endoscopy ( n=144). The third group was those with bleeding from other sources related to portal hypertension ( n=166). Results: Failure to control bleeding was noted in 169 (44%) patients in group 1, 55 (38%) in group 2 and 44 (25%) in group 3. Twenty variables that were evaluable within 6 h of admission, pertaining to severity of bleeding, severity of type of liver disease, mode of admission, and time of diagnostic endoscopy, were entered into a multivariate Cox model. Independent predictors of early rebleeding in group 1 were: active bleeding at endoscopy (irrespective of interval from admission) ( p<0.0001), encephalopathy ( p=0.007), platelet count ( p=0.002), history of alcoholism ( p=0.002), presentation with haematemesis ( p=0.02), log urea ( p=0.03) and (shorter) interval to admission ( p=0.007). The variables predictive of 30-day mortality were: early bleeding ( p<0.0007), bilirubin ( p=0.0006), encephalopathy ( p<0.0001), (shorter) interval to admission ( p<0.0001), and log urea ( p=0.004); a model based on these variables was also a good predictor of mortality in the other 2 groups. However, the model derived from group 1 for failure to control variceal bleeding was different in group 2, despite similar patient characteristics and a similar failure rate (following a single injection). This could suggest that sclerotherapy may induce bleeding in some patients independently of the baseline risk for failure to control bleeding. Conclusions: In cirrhotic patients who present with haematemesis or melaena, active variceal bleeding at diagnostic endoscopy is predictive of failure to control bleeding (continued bleeding or early rebleeding within 5 days of admission), and this failure is predictive of 30-day mortality.