Thrombin Is an Effective and Safe Therapy in the Management of Bleeding Gastric Varices. A Real-World Experience.

Sarah-Louise Gillespie,Alexander Robertson,Norma C Mcavoy,Peter C Hayes,Diana E Yung,John N Plevris

doi:10.3390/jcm10040785

Sarah-Louise Gillespie, Alexander Robertson + Show 4 more

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https://doi.org/10.3390/jcm10040785

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Abstract

Variceal haemorrhage is a severe complication of liver disease with high mortality. Human recombinant thrombin has gained popularity in the management of variceal haemorrhage. We report on the use of thrombin for gastric and ectopic varices at a regional tertiary care centre. This was a retrospective observational study. Patients with portal hypertension who received endoscopic injection of recombinant thrombin were identified and data collected on haemostasis and rebleeding rates, complications and mortality. Patients were grouped by indication for thrombin injection: gastric/oesophageal/ectopic varices and endoscopic band ligation (EBL)-induced ulceration. 155 patients (96M/59F, mean age 58.3 years) received endoscopic thrombin injection. Mean volume of thrombin injected at index endoscopy was 9.5 ml/2375IU. Initial haemostasis was achieved in 144 patients (92.9%). Rebleeding occurred in a total of 53 patients (36.8%) divided as follows: early rebleeding (<5 days from index endoscopy)—26 patients (18%); rebleeding within 30 days—42 patients (29.1%); delayed rebleeding (> 30 days)—11 patients (7.6%). There was statistically significant difference in rate of initial haemostasis between Child-Pugh A/B patients vs Child-Pugh C (p = 0.046). There was no significant difference in rebleeding rates between different indication groups (p = 0.78), by presence of cirrhosis or by Child-Pugh Score. All-cause mortality at 6 weeks was 18.7%; 1-year mortality 37.4% (median follow-up 48 months). There was no significant difference in mortality between groups (p = 0.37). No significant adverse events or complications were reported. Thrombin is effective and safe for gastric varices and other portal-hypertension-related bleeding including oesophageal varices, ulcers secondary to EBL and ectopic varices.

Highlights

Variceal haemorrhage is a severe complication of liver disease with high morbidity and mortality
The causes of index bleed were not significantly different between the three groups there was a statistically significant difference in whether initial haemostasis was achieved between patients who were Child-Pugh A, B
There was no significant difference between the percentages of patients in each group who re-bled following initial haemostasis and no significant difference in timing or cause of re-bleed

Summary

Introduction

Variceal haemorrhage is a severe complication of liver disease with high morbidity and mortality. Bleeding from gastric varices is less common compared with oesophageal varices, this tends to be more severe with higher mortality [1,3,4]. Compared with the extensive research into the management of bleeding oesophageal varices, evidence for the best way to treat gastric and ectopic varices is much more limited. Current British Society of Gastroenterology (BSG) guidelines recommend intra-variceal injection of either N-butyl-cyanoacrylate (glue) or thrombin for the endoscopic management of acute gastric variceal haemorrhage. The other main approach to acutely bleeding gastric varices is interventional radiology (IR), primarily transjugular portosystemic stent-shunt (TIPSS); this is generally reserved for bleeding refractory to endoscopic therapy or for secondary prevention of rebleeding [8]

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