Acute Variceal Bleeding In Patients Research Articles

The coagulation changes associated with acute variceal bleeding in patients with HCV-induced cirrhosis as assessed by rotational thromboelastometry

Background and objectivesAlterations of hemostasis in patients with decompensated cirrhosis are complex. Accordingly, standard coagulation tests are not feasible to evaluate bleeding risk in these patients. The aim of this study was to assess the coagulation kinetics in cirrhotic patients with variceal bleeding using rotational thromboelastometry (ROTEM). ROTEM including EXTEM, INTEM, and FIBTEM which represent extrinsic, intrinsic pathways, and fibrinogen activity, respectively, was measured in 60 cirrhotic patients with variceal bleeding who were compared to 60 patients with stable cirrhosis. APTEM was optionally performed to evaluate fibrinolysis.ResultsOverall, cirrhosis patients displayed features of hypofibrinolysis, whereas the state of hypocoagulability was significantly higher in cirrhotic patients with variceal bleeding (61.7% versus 30%, p = 0.001). Values of clot formation time (CFT) by EXTEM and INTEM correlated positively with those of model for end-stage liver disease score (r = 0.529, p = 0.001, and r = 0.595, p < 0.001, respectively). Furthermore, in a multivariate analysis, values of CFT in both assays were significantly associated with increased risk of 1.9 (95% CI = 1.04–2.45, p = 0.02) and of 1.78 (95% CI = 1.02–2.14, p = 0.01), respectively, for occurrence of variceal bleeding.ConclusionCirrhotic patients with variceal bleeding frequently showed a hypocoagulable state that is triggered by thrombocytopenia and/or hypofibrinogenemia. CFT by EXTEM and INTEM seemed to be an extra marker for disease severity and prognosis in cirrhosis patients, in addition to its valuable role in prediction of variceal bleeding in these patients. However, large multicenter studies have yet been required.

Erratum: Timing of endoscopy for acute variceal bleeding in patients with cirrhosis (CHESS1905): A nationwide cohort study.

Erratum: Timing of endoscopy for acute variceal bleeding in patients with cirrhosis (CHESS1905): A nationwide cohort study.

Hepatic Venous Pressure Gradient Predicts Further Decompensation in Cirrhosis Patients with Acute Esophageal Variceal Bleeding.

The role of hepatic venous pressure gradient (HVPG) in predicting further decompensation in cirrhosis patients with acute variceal bleeding (AVB) is not known. We aimed to evaluate the role of HVPG in predicting further decompensation in cirrhosis patients with AVB Methods: In this prospective study, 145 patients with cirrhosis with esophageal or gastric AVB were included. HVPG was measured on the day of the AVB. Decompensating events occurring after 42-days of AVB were considered further decompensation. The median age of the study cohort was 44 years; 88.3% males. The predominant etiology of cirrhosis was alcohol (46.2%). Overall, 40 (27.6%) patients developed further decompensation during median follow-up of 296 days following AVB. Gastro intestinal bleeding n = 27 (18.6%) and new-onset/worsening ascites n = 20 (13.8%) were the most common decompensating events. According to the multivariate model, HVPG was an independent predictor of any further decompensation in esophageal AVB patients but not in gastric variceal bleeding patients. HVPG cut-off of ≥16 mmHg predicted further decompensation in the esophageal AVB. However, HVPG was not an independent predictor of mortality. HVPG measured during an episode of acute variceal hemorrhage from esophageal varices predicts further decompensating events in cirrhosis patients.

An imaging-based machine learning model outperforms clinical risk scores for prognosis of cirrhotic variceal bleeding.

To develop and validate a machine learning model based on contrast-enhanced CT to predict the risk of occurrence of the composite clinical endpoint (hospital-based intervention or death) in cirrhotic patients with acute variceal bleeding (AVB). This retrospective study enrolled 330 cirrhotic patients with AVB between January 2017 and December 2020 from three clinical centers. Contrast-enhanced CT and clinical data were collected. Centers A and B were divided 7:3 into a training set and an internal test set, and center C served as a separate external test set. A well-trained deep learning model was applied to segment the liver and spleen. Then, we extracted 106 original features of the liver and spleen separately based on the Image Biomarker Standardization Initiative (IBSI). We constructed the Liver-Spleen (LS) model based on the selected radiomics features. The performance of LS model was evaluated by receiver operating characteristics and calibration curves. The clinical utility of models was analyzed using decision curve analyses (DCA). The LS model demonstrated the best diagnostic performance in predicting the composite clinical endpoint of AVB in patients with cirrhosis, with an AUC of 0.782 (95% CI 0.650-0.882) and 0.789 (95% CI 0.674-0.878) in the internal test and external test groups, respectively. Calibration curves and DCA indicated the LS model had better performance than traditional clinical scores. A novel machine learning model outperforms previously known clinical risk scores in assessing the prognosis of cirrhotic patients with AVB CLINICAL RELEVANCE STATEMENT: The Liver-Spleen model based on contrast-enhanced CT has proven to be a promising tool to predict the prognosis of cirrhotic patients with acute variceal bleeding, which can facilitate decision-making and personalized therapy in clinical practice. • The Liver-Spleen machine learning model (LS model) showed good performance in assessing the clinical composite endpoint of cirrhotic patients with AVB (AUC ≥ 0.782, sensitivity ≥ 80%). • The LS model outperformed the clinical scores (AUC ≤ 0.730, sensitivity ≤ 70%) in both internal and external test cohorts.

Platelet-albumin-bilirubin score - a risk stratification scoring system to predict outcome of acute variceal bleeding in patients with cirrhosis.

Acute variceal bleed is a common complication of cirrhosis of liver. Up to 25% of patients with newly diagnosed varices will experience bleeding within 2 years. Of patients who have stopped bleeding, approximately one-third will rebleed within the next 6 weeks. Though scores like Child-Turcotte-Pugh (CTP) and Model of End-stage Liver Disease (MELD) predict the survival of upper gastrointestinal bleed, they have certain limitations in this regard. So, there is a need for reliable scoring system to assess the outcome of patients who had acute variceal bleed. To evaluate the platelet-albumin-bilirubin (PALBI) score in predicting outcome of acute variceal bleeding in patients with cirrhosis. A total of 130 patients who presented to our institute with acute variceal bleed over a period of 1 year were analyzed. CTP, MELD Na and PALBI scores were calculated for these patients on admission and the outcome was compared in the form of 90-day rebleeding rates. The areas under the receiver operating characteristic curves (AUROC) were calculated for this purpose. Mean age was 56 years; 80 were male (61.5%), 50 were female (38.5%), 62 CTP-A (47.7%), 53 CTP-B (40.8%), 15 CTP-C (11.5%); 63 PALBI 1 (48.5%), 23 PALBI 2 (17.8%), and 44 PALBI 3 (33.8%). 1 patient died in the due course of the study. The AUROC for predicting rebleeding was 0.732, 0.71 and 0.803 for CTP, MELD Na and PALBI scores, respectively. PALBI score on admission is a good predictor of outcomes in cirrhotics with acute variceal bleed.

Timing of endoscopy for acute variceal bleeding in patients with cirrhosis (CHESS1905): A nationwide cohort study.

Endoscopy plays an important role in the management of acute variceal bleeding (AVB) in patients with cirrhosis. This study aimed at determining the optimal endoscopy timing for cirrhotic AVB. Patients with cirrhosis with AVB across 34 university hospitals in 30 cities from February 2013 to May 2020 who underwent endoscopy within 24 hours were included in this study. Patients were divided into an urgent endoscopy group (endoscopy <6 h after admission) and an early endoscopy group (endoscopy 6-24 h after admission). Multivariable analysis was performed to identify risk factors for treatment failure. Primary outcome was the incidence of 5-day treatment failure. Secondary outcomes included in-hospital mortality, need for intensive care unit, and length of hospital stay. A propensity score matching analysis was performed. In addition, we performed an analysis, in which we compared the 5-day treatment failure incidence and the in-hospital mortality among patients with endoscopy performed at <12 hours and 12-24 hours. A total of 3319 patients were enrolled: 2383 in the urgent endoscopy group and 936 in the early endoscopy group. After propensity score matching, on multivariable analysis, Child-Pugh class was identified as an independent risk factor for 5-day treatment failure (HR, 1.61; 95% CI: 1.09-2.37). The incidence of 5-day treatment failure was 3.0% in the urgent endoscopy group and 2.9% in the early group ( p = 0.90). The in-hospital mortality was 1.9% in the urgent endoscopy group and 1.2% in the early endoscopy group ( p = 0.26). The incidence of need for intensive care unit was 18.2% in the urgent endoscopy group and 21.4% in the early endoscopy group ( p = 0.11). The mean length of hospital stay was 17.9 days in the urgent endoscopy group and 12.9 days in the early endoscopy group ( p < 0.05). The incidence of 5-day treatment failure in the <12-hour group was 2.3% and 2.2% in the 12-24 hours group ( p = 0.85). The in-hospital mortality was 2.2% in the <12-hour group and 0.5% in the 12-24 hours group ( p < 0.05). The data suggest that performance of endoscopy within 6-12 or within 24 hours of presentation among patients with cirrhosis with AVB led to similar treatment failure outcomes.

Value of Some Scoring Systems for the Prognosis of Rebleeding and In-Hospital Mortality in Liver Cirrhosis with Acute Variceal Bleeding

Background: Upper gastrointestinal (GI) hemorrhage, caused by acute esophageal variceal bleeding, is a common complication and a leading cause of death in patients with cirrhosis. Therefore, predicting the risk in order to employ an active management to prevent rebleeding and death is crucial. Currently, there are many prognostic scoring systems that have been proposed, but research is needed to find a valid score which can be applied in clinical practice in each country and population. Aims: To compare the value of ALBI (Albumin-Bilirubin), PALBI (Platelet Albumin-Bilirubin), AIMS65, model for end-stage liver disease (MELD), and Child–Pugh scores (CPS) approaches in predicting early rebleeding and in-hospital mortality of acute variceal bleeding in patients with cirrhosis. Subjects and methods: We performed a cross-sectional descriptive study on cirrhotic patients with acute variceal bleeding who were being treated at the Department of Gastroenterology, Intensive care unit—Military Hospital 103 and the Institute for Treatment of Digestive Diseases—108 Military Central Hospital from September 2020 to May 2022. We calculated ALBI, PALBI, AIMS65, MELD, Child–Pugh values and compared them with the rates of early rebleeding and in-hospital mortality. Then, determined and compared the prognostic value through an analysis of the area under the curve (AUC). Results: 222 patients with acute esophageal variceal bleeding were eligible for inclusion in the study. The rates of rebleeding and in-hospital mortality were 9.0% and 6.8%, respectively. Regarding the prognosis of early rebleeding, the ALBI and PALBI scores have good prognostic value (AUROC 0.74; 95% CI: 0.63–0.85 and AUROC 0.7; 95% CI: 0.59–0.81; p = 0.004, respectively), while the Child–Pugh, MELD, AIMS65 scores have little prognostic value, with AUROC &lt; 0.70. Regarding prognosis of in-hospital mortality: the ALBI, PALBI, MELD and AIMS65 all have good value in predicting in-hospital mortality, with AUROC of 0.81 (95% CI: 0.68–0.93, respectively; p &lt; 0.001); 0.8 (95% CI: 0.69–0.91; p &lt;0.001); 0.83 (95% CI: 0.72–0.93; p &lt; 0.001); and 0.82 (95% CI: 0.76–0.87, p &lt; 0.001), respectively. While Child–Pugh score only has medium prognostic value, with AUROC 0.79 (95% CI: 0.66–0.92; p &lt; 0.05). However, there was no significant difference between these prognostic scoring systems. Conclusion: the ALBI, PALBI, MELD and AIMS65 scores all had similar good value in predicting in-hospital mortality, but with early rebleeding prognosis, only ALBI and PALBI had good value. CPS does not show prognostic value like other scores, both in predicting early rebleeding and in-hospital mortality.

Sonographic gallbladder wall thickness measurement and the prediction of esophageal varices among cirrhotics.

Acute variceal bleeding in patients with liver cirrhosis and portal hypertension (PHT) is the most serious emergency complication among those patients and could have catastrophic ‎outcomes if not timely managed. ‎Early screening by esophago-gastro-duodenoscopy (EGD) for the presence of esophageal varices (EVs) is ‎‎currently recommended by the practice guidelines for all cirrhotic patients. Meanwhile, EGD is not readily accepted or preferred by many patients. The literature is rich in ‎studies to investigate and validate ‎ non-invasive markers of EVs prediction aiming at reducing the unneeded endoscopic procedures. Gallbladder (GB) wall thickness (GBWT) ‎measurement has been found promising in many published research ‎articles. We aim to highlight the validity of sonographic GBWT measurement in the ‎prediction of EVs based on the available evidence.‎ We searched databases including Cochrane library, PubMed, Web of Science and many others for relevant articles. GBWT is associated with the presence of EVs in cirrhotic patients with PHT of different etiologies. The cut-off of GBWT that can predict the presence of EVs varied in the literature and ranges from 3.1 mm to 4.35 mm with variable sensitivities of 46%-90.9% and lower cut-offs in viral cirrhosis compared to non-viral, however GBWT > 4 mm in many studies is associated with acceptable sensitivity up to 90%. Furthermore, a relation was also noticed with the degree of varices and portal hypertensive gastropathy. Among cirrhotics, GBWT > 3.5 mm predicts the presence of advanced (grade III-IV) EVs with a sensitivity of 45%, the sensitivity increased to 92% when a cut-off ≥ 3.95 mm was used in another cohort. Analysis of these results should carefully be revised in the context of ascites, hypoalbuminemia and other intrinsic GB diseases among cirrhotic patients. The sensitivity for prediction of EVs improved upon combining GBWT measurement with other non-invasive predictors, e.g., platelets/GBWT.

Compare Between Endoscopic Variceal Band Ligation and Injection Sclerotherapy Treatment Among Acute Variceal Bleeding Patients MSI Bleeding Center, Khartoum State, Sudan, 2018

This study was carried out in MSI bleeding center, Ibn Sina teaching hospital in Khartoum State, Sudan, with in the period from June to October 2018. The Objectives: Of this study to compare between endoscopic variceal band ligation and injection sclerotherapy treatment among acute variceal bleeding patients. The study also aimed to assess the outcome of the treatment in term of the occurrence of post treatment re-bleeding within the first and sixth weeks after the treatment, and to assess if the type of the treatment used is associated with a difference in the outcome (occurrence of re-bleeding). The study covered all patients diagnosed with acute variceal bleeding attend the study area with in the study time period. 100 cases have been selected. A questionnaire used to collect data, which was computed and statistically analyzed by using SPSS version 25.0. The result of study found that participants were 83% male and 17 females, age of 40 – 60 years old (51%) followed by age group 20 to 40 years (25%) and 24% for the age group of more than 60 years old. 44% of the study group were from Aljazeera state, followed by Khartoum state which was 32% of the study group, and 23% from other states. 32% of participants were diagnosed by liver cirrhosis, while 67% of the study group diagnosed by schistosomiasis. 51% had EVL, and 49% had EIS. 4% of patients who had EVL, experienced rebleeding within six weeks, while 8% of the of patients who had EIS experienced rebleeding (4% within one week and 4% within six weeks). Mortality was not associated with type of treatment of acute variceal bleeding.The study Conclude that the recurrent bleeding was more associated with EIS than EVL, treatment by EVL is more effective than EIS in the matter of timing of rebleeding.

Pre-emptive TIPSS in Acute Variceal Bleeding: Current Status, Controversies, and Future Directions.

Acute variceal bleeding (AVB) is associated with significant short-term morbidity and mortality. Pre-emptive transjugular intrahepatic portosystemic shunt (p-TIPSS) is recommended to prevent rebleeding in AVB patients with a high risk of rebleeding. Despite the benefit of preventing rebleeding and de-novo ascites, the uptake of p-TIPSS remains low because logistic challenges in the real-world setting. In this review, we summarize the current evidence and controversies on p-TIPSS including patient selection for p-TIPSS, particularly in the setting of NASH cirrhosis and acute-on-chronic liver failure, the role of sarcopenia, renal impairment in the setting of p-TIPSS. Finally, we summarize both pharmacological and nonpharmacological strategies to optimize outcomes in patients undergoing p-TIPSS.

Effect of thrombocytopenia and platelet transfusion on outcomes of acute variceal bleeding in patients with chronic liver disease.

BACKGROUNDPlatelet transfusion in acute variceal bleeding (AVB) is recommended by few guidelines and is common in routine clinical practice, even though the effect of thrombocytopenia and platelet transfusion on the outcomes of AVB is unclear.AIMTo determine how platelet counts, platelets transfusions, and fresh frozen plasma transfusions affect the outcomes of AVB in cirrhosis patients in terms of bleeding control, rebleeding, and mortality.METHODSProspectively maintained database was used to analyze the outcomes of cirrhosis patients who presented with AVB. The outcomes were assessed as the risk of rebleeding at days 5 and 42, and risk of death at day 42, considering the platelet counts and platelet transfusion. Propensity score matching (PSM) was used to compare the outcomes in those who received platelet transfusion. Statistical comparisons were done using Kaplan-Meier curves with log-rank tests and Cox-proportional hazard model for rebleeding and for 42-d mortality.RESULTSThe study included 913 patients, with 83.5% men, median age 45 years, and Model for End-stage Liver Disease score 14.7. Platelet count < 20 × 109/L, 20-50 × 109/L, and > 50 × 109/L were found in 23 (2.5%), 168 (18.4%), and 722 (79.1%) patients, respectively. Rebleeding rates were similar between the three platelet groups on days 5 and 42 (13%, 6.5%, and 4.7%, respectively, on days 5, P = 0.150; and 21.7%, 17.3%, and 14.4%, respectively, on days 42, P = 0.433). At day 42, the mortality rates for the three platelet groups were also similar (13.0%, 23.2%, and 17.2%, respectively, P = 0.153). On PSM analysis patients receiving platelets transfusions (n = 89) had significantly higher rebleeding rates on day 5 (14.6% vs 4.5%; P = 0.039) and day 42 (32.6% vs 15.7%; P = 0.014), compared to those who didn't. The mortality rates were also higher among patients receiving platelets (25.8% vs 23.6%; P = 0.862), although the difference was not significant. On multivariate analysis, platelet transfusion and not platelet count, was independently associated with 42-d rebleeding. Hepatic encephalopathy was independently associated with 42-d mortality. CONCLUSIONThrombocytopenia had no effect on rebleeding rates or mortality in cirrhosis patients with AVB; however, platelet transfusion increased rebleeding on days 5 and 42, with a higher but non-significant effect on mortality.

Acute variceal bleeding portends poor outcomes in patients with acute-on-chronic liver failure: a propensity score matched study from the APASL ACLF Research Consortium (AARC).

Limited data exist regarding outcomes of acute variceal bleeding (AVB) in patients with acute-on-chronic liver failure (ACLF), especially in those with hepatic failure. We evaluated the outcomes of AVB in patients with ACLF in a multinational cohort of APASL ACLF Research Consortium (AARC). Prospectively maintained data from AARC database on patients with ACLF who developed AVB (ACLF-AVB) was analysed. This data included demographic profile, severity of liver disease, and rebleeding and mortality in 6 weeks. These outcomes were compared with a propensity score matched (PSM) cohort of ACLF matched for severity of liver disease (MELD, AARC score) without AVB (ACLF without AVB). Of the 4434 ACLF patients, the outcomes in ACLF-AVB (n = 72) [mean age-46 ± 10.4years, 93% males, 66% with alcoholic liver disease, 65% with alcoholic hepatitis, AARC score: 10.1 ± 2.2, MELD score: 34 (IQR: 27-40)] were compared with a PSM cohort selected in a ratio of 1:2 (n = 143) [mean age-44.9 ± 12.5years, 82.5% males, 48% alcoholic liver disease, 55.7% alcoholic hepatitis, AARC score: 9.4 ± 1.5, MELD score: 32 (IQR: 24-40)] of ACLF-without AVB. Despite PSM, ACLF patients with AVB had a higher baseline HVPG than without AVB (25.00 [IQR: 23.00-28.00] vs. 17.00 [15.00-21.75] mmHg; p = 0.045). The 6-week mortality in ACLF patients with or without AVB was 70.8% and 53.8%, respectively (p = 0.025). The 6-week rebleeding rate was 23% in ACLF-AVB. Presence of ascites [hazard ratio (HR) 2.2 (95% CI 1.03-9.8), p = 0.026], AVB [HR 1.9 (95% CI 1.2-2.5, p = 0.03)], and MELD score [HR 1.7 (95% CI 1.1-2.1), p = 0.001] independently predicted mortality in the overall ACLF cohort. Development of AVB confers poor outcomes in patients with ACLF with a high 6-week mortality. Elevated HVPG at baseline represents a potential risk factor for future AVB in ACLF.

FRI534 - Impact of early nasogastric tube feeding after endotherapy for acute variceal bleeding in patients with cirrhosis : a randomized controlled trial

FRI534 - Impact of early nasogastric tube feeding after endotherapy for acute variceal bleeding in patients with cirrhosis : a randomized controlled trial

Prognostic Relevance of Active Bleeding Seen During Endoscopy on Outcomes in Patients with Child-A Cirrhosis with Acute Variceal Bleeding: A Prospective Observational Study

Background: While relevant in deciding the outcomes in patients with advanced(Child-B/C) cirrhosis, the prognostic significance of active bleeding seen on esophago- gastroduodenoscopy(EGD) in acute variceal bleeding(AVB) in patients with Child-A cirrhosis is inadequately explored. Aim: To study the relevance of active bleed on EGD in determining the prognosis of AVB in patients with Child-A cirrhosis. Methods: In this prospective study, patients with Child-A cirrhosis with no baseline infection presenting with AVB with available clinical, laboratory parameters, endoscopic findings were assessed for relevant 6-week outcomes such as mortality, early rebleeding (within 5 days), need for rescue treatment and incidence of infections. The outcomes described were compared in patients stratified by active bleeding on EGD. Active bleeding on EGD was defined as the presence of ooze/spurt from varices or presence of stigmata of recent haemorrhage in the variceal column with fresh blood in the lumen. Results: Patients with Child-A cirrhosis(n=131) presenting with AVB(mean age:44±11 years, 80% males) of alcoholic liver disease(49%), non-alcoholic steatohepatitis(21.3%), viral cirrhosis(10%) and other etiologies(19.7%) were included and analysed for outcomes. Overall, the 6-week mortality, early rebleeding and infection rates during AVB episode were 4.5%, 12.2% and 10.6%, respectively. Twenty-five out of 131 patients(19%) had active bleed on EGD. Patients with active bleed had a shorter door to scope time(12±4 hrs vs 17±9 hrs, P=0.001), higher serum lactate(3.5mmol/L vs 1.9mmol/L, P=0.002), lower serum albumin (3.1g/dL vs 3.6g/dL, P=0.002) and a higher INR(1.35 vs 1.27, P=0.04) at baseline. Other baseline characteristics and types of variceal bleeding were comparable between two groups. Patients with active bleed had a higher 6-week mortality(17.4% vs 2%, P=0.01), higher early rebleeding(48% vs 3.8%, P<0.001) and increased incidence of bacterial infections(28% vs 6.6%, P=0.006) compared to those without active bleed on EGD. Conclusion: Active bleeding on EGD portends poorer outcomes in AVB even in patients with Child-A cirrhosis.

S3300 Is it Necessary to Transfuse FFP and Platelets Before Esophageal Variceal Band Ligation in Acute Variceal Bleeding Patients? Southeast Asia Experience. RIP FFP and Platelets Transfusion!

S3300 Is it Necessary to Transfuse FFP and Platelets Before Esophageal Variceal Band Ligation in Acute Variceal Bleeding Patients? Southeast Asia Experience. RIP FFP and Platelets Transfusion!

Acute variceal bleeding and out-of-hours endoscopy: Evaluation of an emergency care setting according to Baveno VI guidelines adherence

BackgroundThe extent to which patients with acute variceal bleeding (AVB) receive recommended care is largely unknown. Aimto evaluate the adherence of the 4 major Baveno VI recommendations [vasoactive agents, prophylactic antibiotic, esophagogastroduodenoscopy (EGD) within 12 hours, endoscopic variceal ligation (EVL)] as a marker of quality of an emergency model. MethodsRetrospective evaluation of AVB admissions to a tertiary centre in which endoscopy was available 24hours-a-day, with a regional out-of-hours service at night (the furthest hospital is 200Km away). Patients were divided in directly admitted or transferred from other centres. Results210 AVB patients were included; 101 (48.1%) were directly admitted. The majority of patients were submitted to vasoactive agents (85.7%) and prophylactic antibiotics (79%) before EGD. In 178 patients (84.8%) endoscopy was performed within 12h and EVL was the procedure of choice in 116 (74.8%) (only oesophageal varices). No significant differences were observed between directly admitted and transferred patients in adherence rates. Overall rebleeding rate was 8.6%, in-hospital mortality 11.4% and 6-week mortality 20%. ConclusionAdherence to quality metrics was high which might have played a vital role for reported outcomes. These results suggest that this model of care, provides accessibility and equity in access to urgent endoscopy.

Clinical Outcomes of Upper Gastrointestinal Bleeding in Egyptian Patients with Decompensated Liver Cirrhosis, Does the Bleeding Source Matter?

Background: Upper gastrointestinal bleeding (UGIB) is a prevalent emergency and mortality cause in cirrhotic patients. It prolongs the hospital length of stay (LOS) and increases hospital readmission. Objectives: We investigated the clinical outcomes of acute variceal bleeding (AVB) and non-variceal bleeding (NVB) in patients with decompensated cirrhosis and the possible risk factors for prolonged hospital LOS. Patients and Methods: All patients with decompensated liver cirrhosis and UGIB (AVB & NVB) hospitalized from August 2018 to March 2019 were enrolled in this study. We assessed mortality rate, the hospital LOS and hospital readmission rate along with the probable risk factors associated with prolonged hospital LOS. Results: Our study included 582 patients with decompensated liver cirrhosis, 367 patients had AVB and 215 patients had NVB. There was no significant difference in mortality rate between both groups (11.4% vs. 9.3%, P= 0.43). The hospital LOS in AVB patients was longer than that in NVB group (5.8 ± 2.2 vs. 4.3 ± 1.8, p=0.001). Rate of hospital re-admission within 30 days was significantly higher in the AVB group (27%) compared to NVB group (18%). Inhospital re-bleeding and the need for repeated endoscopy were also higher in AVB patients (20%) than in NVB patients (12%). Risk factors for prolonged hospital LOS were development of hepatic encephalopathy, spontaneous bacterial peritonitis (SBP), in-hospital re-bleeding, Child C score and higher Model for end-stage liver disease (MELD) score. Conclusion: Patients with decompensated cirrhosis and AVB have longer hospital LOS and re-hospitalization rate than those with NVB with no significant difference in mortality rate between both groups.

Platelet-albumin-bilirubin score - a predictor of outcome of acute variceal bleeding in patients with cirrhosis.

BACKGROUNDThe albumin-bilirubin (ALBI) score was validated as a prognostic indicator in patients with liver disease and hepatocellular carcinoma. Incorporating platelet count in the platelet-albumin-bilirubin (PALBI) score improved validity in predicting outcome of patients undergoing resection and ablation.AIMTo evaluate the PALBI score in predicting outcome of acute variceal bleeding in patients with cirrhosis.METHODSThe data of 1517 patients with cirrhosis presenting with variceal bleeding were analyzed. Child Turcotte Pugh (CTP) class, Model of End-stage Liver Disease (MELD), ALBI and PALBI scores were calculated on admission, and were correlated to the outcome of variceal bleeding. Areas under the receiving-operator characteristic curve (AUROC) were calculated for survival and rebleeding.RESULTSMean age was 52.6 years; 1176 were male (77.5%), 69 CTP-A (4.5%), 434 CTP-B (29.2%), 1014 CTP-C (66.8%); 306 PALBI-1 (20.2%), 285 PALBI-2 (18.8%), and 926 PALBI-3 (61.1%). Three hundred and thirty-two patients died during hospitalization (21.9%). Bleeding-related mortality occurred in 11% of CTP-B, 28% of CTP-C, in 21.8% of PALBI-2 and 34.4% of PALBI-3 patients. The AUROC for predicting survival of acute variceal bleeding was 0.668, 0.689, 0.803 and 0.871 for CTP, MELD, ALBI and PALBI scores, respectively. For predicting rebleeding the AUROC was 0.681, 0.74, 0.766 and 0.794 for CTP, MELD, ALBI and PALBI scores, respectively.CONCLUSIONPALBI score on admission is a good prognostic indicator for patients with acute variceal bleeding and predicts early mortality and rebleeding.

Treatment Outcomes and Prognostic Factors of Acute Variceal Bleeding in Patients with Hepatocellular Carcinoma.

Background/AimsThe treatment outcomes and prognostic markers of acute variceal bleeding (AVB) in hepatocellular carcinoma (HCC) patients remain unclear. Therefore, we evaluated the clinical outcomes and prognostic factors of AVB in HCC patients.MethodsCirrhotic patients with endoscopically confirmed AVB between 2007 and 2013 were enrolled in this prospective study. Prognostic factors were identified by multivariate Cox proportional hazards regression analysis.ResultsAmong the 329 enrolled patients, 125 patients (38.0%) were diagnosed with HCC. The 6-week mortality rates of all enrolled AVB patients and the HCC subgroup were 14.9% and 26.4%. The 5-day treatment failure, 6-week mortality, cirrhosis-related complications, and duration of hospitalization were greater in HCC patients than in non-HCC patients (all p<0.05). In the HCC subgroup, the Model for End-Stage Liver Disease (MELD) score (hazard ratio [HR], 1.145; p=0.001) and Barcelona Clinic Liver Cancer (BCLC) stage (C–D vs 0–B) (HR, 3.096; p=0.019) were independent predictors of 6-week mortality. Our study revealed that 85% of HCC patients with both a MELD score ≥15.5 and BCLC stage C–D died within 6 weeks, and the 6-week mortality risk was 21-fold higher in this group than in the group with a lower MELD score and earlier HCC stage (p<0.001).ConclusionsThe 5-day treatment failure and 6-week mortality rates were significantly higher among AVB patients with HCC than those without HCC. The MELD score and the presence and stage of HCC are strong predictors of 6-week mortality in patients with AVB.

Efficacy of endoscopic treatments for acute esophageal variceal bleeding in cirrhotic patients: systematic review and meta-analysis.

Background and aim Guidelines recommend use of ligation and vasoactive drugs as first-line therapy and as grade A evidence for acute variceal bleeding (AVB), although Western studies about this issue are lacking. Methods We performed a systematic review and meta-analysis of randomized controlled trials (RCT) to evaluate the efficacy of endoscopic treatments for AVB in patients with cirrhosis. Trials that included patients with hepatocellular carcinoma, use of portocaval shunts or esophageal resection, balloon tamponade as first bleeding control measure, or that received placebo or elective treatment in one study arm were excluded. Results A total of 8382 publications were searched, of which 36 RCTs with 3593 patients were included. Ligation was associated with a significant improvement in bleeding control (relative risk [RR] 1.08; 95 % confidence interval [CI] 1.02 – 1.15) when compared to sclerotherapy. Sclerotherapy combined with vasoactive drugs showed higher efficacy in active bleeding control compared to sclerotherapy alone (RR 1.17; 95 % CI 1.10 – 1.25). The combination of ligation and vasoactive drugs was not superior to ligation alone in terms of overall rebleeding (RR 2.21; 95 %CI 0.55 – 8.92) and in-hospital mortality (RR 1.97; 95 %CI 0.78 – 4.97). Other treatments did not generate meta-analysis. Conclusions This study showed that ligation is superior to sclerotherapy, although with moderate heterogeneity. The combination of sclerotherapy and vasoactive drugs was more effective than sclerotherapy alone. Although current guidelines recommend combined use of ligation with vasoactive drugs in treatment of esophageal variceal bleeding, this study failed to demonstrate the superiority of this combined treatment.