Suboptimal Implementation of Evidence-based Therapy for Acute Variceal Hemorrhage: A Systematic Review of Observational Studies.

Abstract

Gastroenterologists should strive to improve the outcomes associated with acute variceal hemorrhage (AVH) by optimizing care delivery and clinician preparedness through training. Unfortunately, data regarding contemporary outcomes and management of AVH are limited. We performed a systematic review of cohort studies examining outcomes and management of AVH from January 1990 to September 2016. We pooled data on mortality and utilization of medical therapy, endoscopic interventions, balloon tamponade (BT), and salvage procedures (portal decompressive surgery or transjugular portosystemic shunt). The pooled 6-week mortality rate after AVH was 17.7% (95% confidence interval [CI], 14.4%-21.7%). Sclerotherapy was used in 18.7% of cases (95% CI, 9.2%-34.3%), and no endoscopic intervention was provided in 14.3% of patients (95% CI, 9.7%-20.6%). The overall rate of BT use was 10.8% (95% CI, 8.2%-14.1%). Salvage procedures were used in 5.7% (95% CI, 3.7%-8.6%), falling to 1.7% (95% CI, 0.7%-3.8%) among patients treated after 2000. Although pooled rates of timely endoscopy and vasoactive medication use were high (85.8% and 83.0%, respectively), only half of patients received prophylactic antibiotics (52.8%; 95% CI, 40.0%-66.2%). In studies that enrolled patients exclusively after 2000, 13.8% of patients (95% CI, 7.0%-25.4%) received sclerotherapy, salvage transjugular portosystemic shunt fell to 1.7% (95% CI, 0.7%-3.8%), BT use fell slightly to 8.7% (95% CI, 6.4%-11.6%), and vasoactive medication and prophylactic antibiotic use rose to 91.4% (95% CI, 86.0%-94.9%) and 62.7% (95% CI, 48.9%-74.9%), respectively. AVH is associated with high mortality rates and suboptimal implementation of evidence-based therapies including prophylactic antibiotics and endoscopic interventions, suggesting a need for quality improvement. In addition, the frequent need for BT and sclerotherapy suggests that specific attention to these procedures in gastroenterology training curricula may be warranted.