Esophageal Varices Research Articles

Effect of malnutrition on cirrhotic patients with hepatocellular carcinoma: A nationwide study.

e16250 Background: Liver cancer is the sixth most common cancer and the third leading cause of cancer mortality worldwide. There are two main types of primary liver cancers; hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma. HCC accounts for around 80% of primary liver cancer cases. Generally, HCC develops in genetically susceptible individuals with risk factors, especially in the presence of cirrhosis. Cirrhosis is a systemic disease, and malnutrition is a key feature as well as an important complication which can be associated with worse outcomes. In this study, we aim to characterize the potential effects of malnutrition on HCC patients with underlying cirrhosis. Methods: The United States Nationwide Inpatient Sample (NIS) was used to extract hospitalization data of patients admitted between 2016 to 2018. Using ICD10 revision codes, we identified adults with the diagnosis of cirrhosis who have HCC with concomitant malnutrition, including sarcopenia. The control group included cirrhotic HCC patients without malnutrition. The primary outcome was the in-hospital mortality. Secondary outcomes included encephalopathy, ascites, variceal bleed, hepatorenal syndrome (HRS) and length of stay (LOS). Multivariate logistic regression was used to adjust for relevant variables. Results: We identified 423,158 patients admitted with cirrhosis. 20,582 had HCC, and of those, 2560 patients had the diagnosis of malnutrition. In this group of patients, the mean age was 59.85 years. 30% were females and 62% were Caucasians. When adjusted to other relevant variables, malnutrition was associated with increased in-hospital mortality (OR 1.40; P-value 0.000). It was also associated with an increased chance of developing encephalopathy (OR 1.42; P-value 0.000), ascites (OR 1.62; P-value 0.000), and HRS (OR 1.33; P-value 0.000). Moreover, it was associated with increased LOS (OR 1.99; P-value 0.001). Other factors associated with increased in-hospital mortality in cirrhotic HCC patients are described in the table. Conclusions: Malnutrition is a common complication in patients with cirrhosis. If identified, it can be treated efficiently. In this study, cirrhotic HCC patients with malnutrition had an increased chance of mortality. Further, they were at increased risk for cirrhosis decompensation and other in-hospital complications, which in turn can lead to increased LOS and therefore increased financial burden. We recommend that clinicians pay attention to patients with malnutrition and to treat them in order to prevent these complications. [Table: see text]

Intermediate and long-term survival prediction using prognostic scores in patients undergoing salvage TIPS for uncontrolled variceal bleeding

Intermediate and long-term survival prediction using prognostic scores in patients undergoing salvage TIPS for uncontrolled variceal bleeding

Hepatic venous pressure gradient predicts risk of hepatic decompensation and liver-related mortality in patients with MASLD

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a leading cause of advanced chronic liver disease (ACLD). Portal hypertension drives hepatic decompensation and is best diagnosed by hepatic venous pressure gradient (HVPG) measurement. Here, we investigate the prognostic value of HVPG in MASLD-related compensated ACLD (MASLD-cACLD). This European multicentre study included patients with MASLD-cACLD characterised by HVPG at baseline. Hepatic decompensation (variceal bleeding/ascites/hepatic encephalopathy) and liver-related mortality were considered the primary events of interest. A total of 340 patients with MASLD-cACLD (56.2% male; median age 62 [55-68] years, median MELD 8 [7-9], 71.2% with diabetes) were included. Clinically significant portal hypertension (CSPH: i.e., HVPG ≥10mmHg) was found in 209 patients (61.5%). During a median follow-up of 41.5 (27.5-65.8) months, 65 patients developed hepatic decompensation with a cumulative incidence of 10.0% after 2 years (2Y) and 30.7% after 5 years (5Y) in those with MASLD-cACLD with CSPH, compared to 2.4% after 2Y and 9.4% after 5Y in patients without CSPH. Variceal bleeding did not occur without CSPH. CSPH (subdistribution hazard ratio [SHR] 5.13; p <0.001) was associated with an increased decompensation risk and a higher HVPG remained an independent risk factor in the multivariable model (adjusted SHR per mmHg: 1.12, p <0.001). Liver-related mortality occurred in 37 patients at a cumulative incidence of 3.3% after 2Y and 21.4% after 5Y in CSPH. Without CSPH, the incidence after 5Y was 0.8%. Accordingly, a higher HVPG was also independently associated with a higher risk of liver-related death (adjusted SHR per mmHg: 1.20, p <0.001). HVPG measurement is of high prognostic value in MASLD-cACLD. In patients with MASLD-cACLD without CSPH, the short-term risk of decompensation is very low and liver-related mortality is rare, while the presence of CSPH substantially increases the risk of both. While the incidence of compensated advanced chronic liver disease (cACLD) due to metabolic dysfunction-associated steatotic liver disease (MASLD) is increasing worldwide, insights into the impact of clinically significant portal hypertension (CSPH) on the risk of liver-related events in MASLD-cACLD remain limited. Based on the findings of this European multicentre study including 340 MASLD-cACLD patients, we could show that increasing HVPG values and the presence of CSPH in particular were associated with a significantly higher risk of first hepatic decompensation and liver-related mortality. In contrast, the short-term incidence of decompensation in patients with MASLD-cACLD without CSPH was low and the risk of liver-mortality remained negligible. Thus, HVPG measurements can provide important prognostic information for individualised risk stratification in MASLD-cACLD and may help facilitate the study of novel and promising treatment possibilities for MASLD.

CT guided percutaneous NBCA glue injection of rectal varices for refractory rectal variceal bleed as a bailout

To propose minimally invasive percutaneous approach in the management of refractory rectal variceal bleed. Rectal varices are porto-systemic collaterals that arise as a complication of portal hypertension. Bleeding is less common from rectal varices than from esophageal varices

Sarcopenia is an independent risk factor for short-term mortality in patients undergoing transjugular intrahepatic portosystemic shunt.

Sarcopenia is common in patients with cirrhosis and is a risk factor for increased mortality. Transjugular intrahepatic portosystemic shunt (TIPS) placement has been utilized in cirrhosis patients with decompensation . We investigated the role of sarcopenia in predicting mortality in patients undergoing TIPS. We conducted a single-center retrospective study of 232 patients with cirrhosis who underwent TIPS between January 2010 and December 2015. Sarcopenia was defined by the psoas muscle index (PMI) cutoff value, calculated based on dynamic time-dependent outcomes using X-tile software. Kaplan-Meier analysis demonstrated the difference in survival in the sarcopenia group versus the non-sarcopenia group. . Univariate and multivariate analyses were used to identify the relationship between sarcopenia and post-TIPS mortality during a follow-up period of 1 year. For TIPS indications, 111 (47.84%) patients had refractory ascites, 69 (29.74%) patients had variceal bleeding, 12 (5.17%) patients had ascites, and 40 (17.24%) for other indications. The mean PMI was 4.40 ± 1.55. Sarcopenia was defined as a PMI value of <4.36 in males, and <3.23 in females. Sarcopenia was present in 96 (41.38%) of patients. . Kaplan-Meier analysis showed thatsarcopenia is associated with worse survival (log-rank P < 0.01). Multivariate Cox regression analysis showed that sarcopenia is independently associated with worse survival during the 1-year follow-up period with an hazard ratio of 2.435 (95% CI 1.346-4.403) ( P < 0.01), after adjusting for age, BMI, indications for TIPS, etiology for cirrhosis, and MELD score and stratified by sex. Sarcopenia is an independent risk factor for 1-year mortality in patients undergoing TIPS and should be considered when patients are evaluated as a candidate for TIPS.

Current concepts in the management of non-cirrhotic non-malignant portal vein thrombosis.

Non-cirrhotic non-malignant portal vein thrombosis (NCPVT) is an uncommon condition characterised by thrombosis of the portal vein, with or without extension into other mesenteric veins, in the absence of cirrhosis or intra-abdominal malignancy. Complications can include intestinal infarction, variceal bleeding and portal biliopathy. In this article, we address current concepts in the management of NCPVT including identification of risk factors, classification and treatment, and review the latest evidence on medical and interventional management options.

Portal hypertension and its prognostic implications in patients with Wilson's disease.

Wilson's disease may progress to cirrhosis and clinically significant portal hypertension (CSPH). We aimed to assess the prevalence and prognostic impact of CSPH-related features on hepatic decompensation and transplant-free survival in patients with Wilson's disease. About 137 patients with Wilson's disease (Leipzig score ≥4), followed for a median observation period of 9.0 (3.9-17.7) years at the Vienna General Hospital, were included in this retrospective study. Overall, 49 (35.8%) developed features of CSPH: 14 (10.2%) varices, 40 (29.2%) splenomegaly, 20 (14.6%) ascites, 18 (13.1%) hepatic encephalopathy and 3 (2.2%) experienced acute variceal bleeding. Overall, 8 (5.8%) patients died, including three deaths caused by CSPH-related complications. Within 10 years, compensated patients with features of CSPH developed more decompensation events (8.3% vs. 1.5% in patients without CSPH, p = 0.3) and had worse transplant-free-survival (91.7% vs. 98.6%), which further declined in patients with hepatic decompensation (26.7%, log-rank: p < 0.0001). Patients with liver stiffness <15 kPa and normal platelets (≥150 G/L) were less likely to decompensate within 10 years (2.6% vs. 8.4%, p = 0.002) and had a better 10-year transplant-free-survival (97.7% vs. 83.9%, p = 0.006). Patients with Wilson's disease developing features of CSPH are at an increased risk for hepatic decompensation and liver-related mortality, warranting for regular screening and timely initiation of effective CSPH-directed treatments.

A Noninferiority Trial Comparing 2 Days vs 5 Days of Terlipressin and Ceftriaxone in Terms of 5-Day Rebleeding for Patients With Acute Gastroesophageal Variceal Hemorrhage.

This trial was to shorten the duration of both vasoconstrictors and prophylactic antibiotics to only 2 days in the therapy of acute gastroesophageal variceal hemorrhage. After successful endoscopic hemostasis of gastroesophageal variceal hemorrhage, eligible patients were randomized to receive terlipressin infusion 1 mg per 6 hours and ceftriaxone 1 g daily for 5 days (group A) or a similar regimen for 2 days (group B). Primary end points were very early rebleeding at 5 days, and secondary end points included 48-hour hemostasis, 42-day rebleeding, and hospitalization days. Group A comprised 48 patients, and group B comprised 52 patients. Both groups were comparable in the severity of liver disease. Forty-eight-hour initial hemostasis was 95.8% in group A and 100% in group B ( P = 0.13). Very early rebleeding between 3 and 5 days occurred in 1 patient (2.1%) in group A and 2 patients (3.8%) in group B ( P = 0.60). The difference was 1.8% and the 95% confidence interval was -1.31% to 2.08%, which demonstrated noninferiority. Forty-two-day rebleeding occurred in 5 patients (10.4%) in group A and 4 patients (7.7%) in group B ( P = 0.63). The median hospitalization days were 8.5 ± 3.8 days in group A vs 5.6 ± 2.6 days in group B ( P < 0.001). After successful endoscopic hemostasis of acute variceal bleeding, combination of 2-day terlipressin infusion and ceftriaxone therapy was not inferior to the 5-day regimen in terms of very early rebleeding, with the advantage of shortening hospitalization stay.

Mortality, Hepatic Decompensation, and Cardiovascular- and Renal-Related Outcomes in Lean Versus Non-lean Patients Hospitalized With Metabolic Dysfunction-Associated Steatohepatitis (MASH).

Metabolic dysfunction-associated steatohepatitis (MASH) is an important cause of cirrhosis and end-stage liver disease. In addition, there have been reports of worse extrahepatic outcomes, especially cardiovascular events, in patients with lean patients' fatty liver disease compared to the non-lean group.There is limited data on hepatic, cardiac, and renal outcomes in lean compared to non-lean patients with MASH. This study aims to evaluate the cardiovascular, renal, and hepatic outcomes in hospitalized US adults with MASH, focusing on a comprehensive comparison between lean and non-lean patients. The National Inpatient Sample (NIS) database was queried from 2016 to 2020 to identify hospitalizations with MASH. Hospitalizations with a history of overweight and obesity (lean body mass index (BMI) <25 vs. lean BMI >25) were also identified. The primary outcome was in-hospital mortality. Secondary outcomes were major adverse cardiovascular outcomes (MACE: a composite of acute myocardial infarction, cardiac arrest, stroke, heart failure, and atrial fibrillation); major adverse kidney outcome (MAKE: a composite outcome of acute kidney injury (AKI), renal replacement therapy, and renal cancer), and hepatic decompensation (esophageal varices with bleeding, ascites, spontaneous bacterial peritonitis (SBP), hepatic encephalopathy, and hepatorenal syndrome) Multivariate logistic regression analysis was used to derive risk ratios for clinical outcomes. We included 539,275 MASH patients in our sample; 324,330 (60%) were lean. The included patients were mostly female (61%), the mean age was 64 years, and 76% were White. At baseline, non-lean patients had a higher prevalence of heart failure, hypertension, and hyperlipidemia. There was no difference in the prevalence of smoking among both groups.In a multivariate analysis, with adjustment for age, sex, race, sarcopenia, cardiometabolic risk factors, hospital characteristics, admission type, socioeconomic factors, and all comorbidities (including 31 Elixhauser comorbidities), lean status was associated with a 40% increased risk of mortality(adjusted odds ratio (aOR) 1.40, confidence interval (CI) 1.29-1.53), 19% increased risk of MACE (aOR 1.19; 95% CI 1.14-1.24), 20% increased risk of renal decompensation (aOR 1.25; 95% CI 1.20-1.30), and 33% increased risk of hepatic decompensation (aOR 1.33 CI 1.28-1.38). Lean patients with MASH are at higher risk of cardiovascular and renal outcomes and may benefit from enhanced screening for early identification and treatment to improve outcomes.

Management of Portal Hypertension in the Older Patient.

Aging is a process of physiological slowing, reduced regenerative capacity and inability to maintain cellular homeostasis. World Health Organisation declared the commencement of population aging globally, largely attributed to improvement in the healthcare system with early diagnosis and effective clinical management. Liver ages similar to other organs, with reduction in size and blood flow. In this review we aim to evaluate the effect of aging in liver disease. Aging causes dysregulation of major carbohydrate, fat and protein metabolism in the liver. Age is a major risk factor for liver fibrosis accelerated by sinusoidal endothelial dysfunction and immunological disharmony. Age plays a major role in patients with liver cirrhosis and influence outcomes in patients with portal hypertension. Transient elastography may be an useful tool in the assessment of portal hypertension. Hepatic structural distortion, increased vascular resistance, state of chronic inflammation, associated comorbidities, lack of physiological reserve in the older population may aggravate portal hypertension in patients with liver cirrhosis and may result in pronounced variceal bleed. Cut-offs for other non-invasive markers of fibrosis may differ in the elderly population. Non-selective beta blockers initiated at lower dose followed by escalation are the first line of therapy in elderly patients with cirrhosis and portal hypertension, unless contraindicated. Acute variceal bleed in the elderly cirrhotic patients can be life threatening and may cause rapid exsanguination due to poor reserve and associated comorbidities. Vasoactive drugs may be associated with more adverse reactions. Early endoscopy may be warranted in the elderly patients with acute variceal bleed. Role of TIPS in the elderly cirrhotics discussed. Management of portal hypertension in the older population may pose significant challenges to the treating clinician.

Optimizing Acute Variceal Bleeding Management: Abbreviated Therapy With Terlipressin and Antibiotics

Optimizing Acute Variceal Bleeding Management: Abbreviated Therapy With Terlipressin and Antibiotics

Reinforcing the management of type 1 gastric esophageal varices.

Variceal bleed represents an important complication of cirrhosis, with its presence reflecting the severity of liver disease. Gastric varices, though less frequently seen than esophageal varices, present a distinct clinical challenge due to its higher intensity of bleeding and associated mortality. Based upon the Sarin classification, GOV1 is the most common subtype of gastric varices seen in clinical practice.

Frequency of Different Causes of Upper GI Bleed Using Endoscopic Procedure

Background: Upper gastrointestinal (GI) bleeding is a significant clinical emergency that necessitates swift and precise diagnostic and therapeutic interventions. Due to its diverse etiologies, ranging from peptic ulcers to variceal bleeding, understanding these causes is crucial for effective management. Objective: To evaluate the prevalence of various causes of upper GI bleeding through endoscopic examination. Methods: This descriptive cross-sectional study was conducted at the Department of Gastroenterology, Asian Institute of Medical Sciences (AIMS), Hyderabad, involving 150 hemodynamically stable patients who had fasted for 6 to 8 hours. A comprehensive physical examination and detailed medical history preceded the endoscopic procedures. Data were captured on a structured proforma and analyzed using SPSS software, version 26.0. Results: The cohort's mean age was 50.35 years (range 18-85 years), with a male predominance of 72%. Variceal bleeding was the most common finding (64.7%), followed by peptic ulcers (24%), Mallory-Weiss tears (12.7%), vascular anomalies (13.3%), gastric ulcers (7.3%), duodenal ulcers (6%), erosive gastritis (3.3%), and esophagitis (2.7%). Conclusion: Upper GI bleeding predominantly affects older adult males, with variceal bleeding accounting for about two-thirds of cases. The diversity of underlying causes highlights the need for accurate diagnostics and tailored treatments for high-risk groups.

Endoscopic ultrasound‐guided portal pressure gradient identifies patients with previously undiagnosed clinically significant portal hypertension

AbstractAimsPortal hypertension (PH) is a complication of cirrhosis that leads to hepatic decompensation. Assessing the portal pressure gradient (PPG) provides valuable information for disease assessment, staging, and prognosis. In this study, we aimed to report the utilization of endoscopic ultrasound (EUS)‐guided PPG (EUS‐PPG) measurements in a real‐world setting.MethodsThis retrospective analysis included patients at a tertiary care center who underwent EUS‐PPG between February 2021 and May 2022. The most common indication was to establish or exclude the diagnosis of cirrhosis, followed by an assessment of surgical risk in the setting of suspected cirrhosis. Extensive demographic and clinical data were collected, and statistical analysis was performed using the Student's t test.ResultsEighteen patients underwent EUS‐PPG. Technical success was achieved in 17 of the 18 patients. No complications were observed. The mean scores of Child‐Pugh, Model for End‐Stage Liver Disease‐Sodium, and Fibrosis‐4 scores were 5.1 ± 0.5, 9.0 ± 3.0, and 3.7 ± 4.5, respectively. Of the 18 patients, two presented with esophageal varices and six with portal hypertensive gastropathy. The mean PPG was 5.8 ± 4.5 mmHg, and five patients exhibited clinically significant PH (CSPH). Of the 18 patients, 15 underwent concurrent EUS‐liver biopsy, which was 100% successful and provided diagnostic histology for all patients. The PPG data led to changes in the clinical management of 17 patients.ConclusionsEUS‐PPG is safe and technically feasible. The Child‐Pugh score did not correlate well with the presence of CSPH; however, PPG measurements resulted in changes in the management of almost all patients. Larger studies correlating EUS‐PPG with other assessments of liver diseases are required.

Computed tomography for the diagnosis of gastroesophageal varices and risk assessment in patients with cirrhosis: a systematic review and meta-analysis

This meta-analysis aimed to evaluate the diagnostic accuracy of computed tomography (CT) for detecting gastroesophageal varices (GEVs) and identify high-risk GEVs in patients with cirrhosis. A comprehensive search of databases identified 28 studies reporting on CT-based diagnosis for GEVs confirmed via endoscopy. Meta-analyses were conducted to calculate pooled sensitivity (SEN) and pooled specificity (SPE), positive likelihood ratio (PLR) and negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and the area under the curve (AUC). Based on the number of patients (or varices), the pooled SEN, SPE, PLR, NLR, DOR, and AUC of CT-based diagnosis were estimated at 0.91 (0.92), 0.81 (0.45), 4.82 (1.67), 0.11 (0.17), 42.47 (10.26), and 0.93 (0.94), respectively, for any GEV and at 0.89 (0.89), 0.90 (0.79), 8.86 (4.28), 0.12 (0.14), 75.71 (30.19), and 0.95 (0.85), respectively, for high-risk GEVs. Subgroup analyses indicated that CT had a higher diagnostic accuracy for esophageal varices compared with gastric varices (AUC: 0.93 vs. 0.89, P < 0.05), and the 64-slice CT yielded superior SEN compared with 16-slice and <16-slice CT (AUC: 0.97 vs. 0.92 and 0.82, respectively, P < 0.05). Prospective studies demonstrated higher diagnostic accuracy than retrospective studies (AUC: 0.95 vs. 0.90, P < 0.05). Regarding variceal size, a cut-off of 3 mm and 5 mm discriminated between low- and high-risk individuals, respectively, with high diagnostic accuracy (AUC: 0.992 vs. 0.997, P > 0.05). CT demonstrates promising diagnostic accuracy for identifying gastroesophageal varices and distinguishing high-risk GEVs in patients with cirrhosis. Further research to validate optimal variceal size cut-offs is warranted to enhance clinical utility. Such a high diagnostic accuracy of CT scans for predicting varices is clinically meaningful for patients with cirrhosis accompanied by portal hypertension. If high-risk varices are identified at CT scans, early intervention would be helpful to reduce the risk of variceal bleeding.

Treatment of portal hypertension complicated by variceal bleeding

Background. Mortality in variceal bleeding (VB) on the background of portal hypertension (PH) is highest among patients with gastrointestinal bleeding. The treatment of PH complicated by VB is a complex problem that is far from being solved, especially in case of Child-Pugh class B and C decompensation. The aim of the study was to determine the causes of PH complicated by VB, features of conservative and interventional therapy, indications and nature of surgical procedures, treatment efficacy, as well as causes of complications and mortality. Materials and methods. We analyzed treatment outcomes of 923 inpatients with PH complicated by VB who were treated in the clinic of the Department of Surgery of the Faculty of Dentistry of Bogomolets National Medical University on the basis of the Kyiv City Clinical Emergency Hospital from 2012 to 2023. It was possible to talk about the cause of PH based on anamnestic data in 61 % of cases. In 711 (77 %) patients, the source of bleeding was detected endoscopically within 30–60 minutes from the moment of admission to the clinic. Conservative therapy included the administration of hemostatic and agents lowering pressure in the portal system, as well as vasoconstrictors that reduce portal blood flow. For the failure of conservative therapy, unstable hemostasis, and repeated previous bleedings, 59 (6.4 %) patients were operated. The methodology of the research analysis consisted in the fact that the arithmetic mean and standard error (M ± m) were determined as the characteristics of the groups for features with a distribution corresponding to the Gaussian law. This reference method of descriptive statistics was applied to evaluate surgical treatment in comparison with conservative therapy and interventional measures. Results. Endoscopic hemostasis by the ligature method was achieved in 97 (10.5 %) patients. Repeated endoscopy due to VB recurrence was done in 276 (29.9 %) participants. In cases of unsatisfactory endoscopic hemostasis, as well as recurrent VB, a Sengstaken-Blakemore probe was installed. In case of right-sided PH, the formation of varices in the esophagus is caused by the discharge of blood mainly through the coronary vein, which required its transection during еsophagogastric devascularization. In compliance with this rule, the patients underwent esophagogastric devascularization, circular transection of the esophagus, which provided portoazygous disconnection. The total mortality rate was 43.1 %, among operated people — 8.5 %, and among non-operated ones — 42.1 %. Conclusions. PH complicated by VB is evidence of decompensated processes in the liver parenchyma or obstruction in the portal system. Conservative therapy and interventional measures make it possible to stop bleeding and prepare the patient for elective surgery, if necessary. An operation that stops blood flow through dilated veins of the esophagus or stomach is an effective method of treating bleeding in portal hypertension.

Can laparoscopic splenectomy and azygoportal disconnection be safely performed in patients presenting with cirrhosis, hypersplenism and gastroesophageal variceal bleeding? How to do it, tips and tricks (with videos)

BackgroundThe minimally invasive splenectomy and azygoportal disconnection procedure has evolved into an established treatment option for patients with cirrhosis, hypersplenism and gastroesophageal variceal bleeding. However, it remains technically challenging, particularly in patients presenting with splenomegaly. This study provides a comprehensive description of the laparoscopic splenectomy and azygoportal disconnection (LSD) technique for managing hypersplenism and gastroesophageal variceal bleeding, emphasising crucial strategies to overcome technical challenges and optimise surgical outcomes. MethodsThis retrospective observational study includes consecutive patients undergoing LSD by a single surgeon. The attachment includes video showcasing the surgical techniques. ResultsIn this study, 30 patients undergo LSD successfully. The mean operative time is 150.75 ± 25.81 min, and the mean blood loss is 119.62 ± 70.94 mL. The average length of postoperative hospital stay is 10.43 ± 1.97 days. Allogeneic blood transfusion was administered to two patients only. No conversions occurred. Haemoglobin, white blood cell and platelet counts on the seventh postoperative day are significantly higher than those on the day of admission. ConclusionThis study provides the results of the LSD technique performed in patients with hypersplenism and gastroesophageal variceal bleeding by a highly experienced surgeon. It offers tips and tricks for successfully performing the LSD technique, which can contribute to quick patient rehabilitation and optimal postoperative results.

Octreotide versus Terlipressin as Adjuvant to Endoscopic Variceal Band Ligation in Bleeding Oesophageal Varices: A Systematic Review and Meta-Analysis

Background: Acute variceal bleeding (AVB) is a critical complication of portal hypertension, contributing significantly to mortality worldwide. Pharmacological interventions, including terlipressin and octreotide, have evolved to manage AVB, yet consensus on their comparative effectiveness remains elusive. This study conducts a comprehensive systematic review and meta-analysis of randomized control trials (RCTs) comparing terlipressin and octreotide in the management of AVB, aiming to provide insights into their relative benefits. Methods: This study included RCTs with head-to-head comparisons of terlipressin and octreotide. The search strategy covered PubMed, Scopus, and Cinahl databases, and the included studies involved adult patients with confirmed AVB undergoing endoscopic variceal band ligation (EVBL). Results: Seven RCTs meeting inclusion criteria were included in the meta-analysis. The assessed outcomes were: achieving haemostasis within 24 h, rebleeding rate, and mortality rate. The pooled analysis revealed no statistically significant differences between terlipressin and octreotide in achieving haemostasis (OR: 1.30, p = 0.23), rebleeding rates at 5 days (OR: 0.7, p = 0.23), and mortality at 42 days (OR: 0.9, p &gt; 0.5). Conclusion: This meta-analysis suggests that terlipressin and octreotide exhibit similar efficacy in reducing bleeding, rebleeding rates, and mortality when used as adjuvants to EVBL in AVB. Clinicians are encouraged to consider individual patient characteristics and the broader clinical context when choosing between these agents. Future research should focus on addressing existing evidence gaps and enhancing understanding of variables influencing EVBL outcomes.

Midodrine plus propranolol versus propranolol alone in preventing first bleed in patients with cirrhosis and severe ascites: a randomized controlled trial.

Propranolol, a non-selective beta-blocker, commonly used to prevent variceal bleed, but might precipitate circulatory dysfunction in severe ascites. Midodrine, an alpha-1 adrenergic agonist improves renal perfusion and systemic hemodynamics. Addition of midodrine might facilitate higher maximum tolerated dose (MTD) of propranolol, thereby less risk of variceal bleed in cirrhosis patients with severe ascites. 140 patients with cirrhosis and severe/refractory ascites were randomized- propranolol and midodrine (Gr.A,n = 70) or propranolol alone (Gr.B,n = 70). Primary outcome was incidence of bleed at 1year. Secondary outcomes included ascites control, achievement of target heart rate (THR), HVPG response and adverse effects. Baseline characteristics were comparable between two groups. Cumulative incidence of bleed at 1year was lower in Gr.A than B (8.5%vs.27.1%,p-0.043). The MTD of propranolol was higher in Gr.A (96.67 ± 36.6mg vs. 76.52 ± 24.4mg; p-0.01) and more patients achieved THR (84.2%vs.55.7%,p-0.034). Significantly higher proportion of patients in Gr.A had complete resolution of ascites [17.1%vs.11.4%,p-0.014), diuretic tolerance (80%vs.60%,p-0.047) at higher doses(p-0.02) and lesser need for paracentesis. Patients in Gr.A also had greater reduction in variceal grade (75.7%vs.55.7%;p-0.01), plasma renin activity (54.4% from baseline) (p = 0.02). Mean HVPG reduction was greater in Gr.A than B [4.38 ± 2.81mmHg(23.5%) vs. 2.61 ± 2.87mmHg(14.5%),p-0.045]. Complications like post-paracentesis circulatory dysfunction and spontaneous bacterial peritonitis on follow-up were higher in Gr.B than A (22.8%vs.51.4%,p = 0.013 and 10%vs.15.7%, p = 0.03, respectively). Addition of midodrine facilitates effective use of propranolol in higher doses and greater HVPG reduction, thereby preventing first variceal bleed, reduced paracentesis requirements with fewer ascites- related complications in patients with cirrhosis with severe/refractory ascites.

Clinical Presentations and Risk Factors of Gastrointestinal Bleeding in the Emergency Department: A Multicenter Retrospective Study.

Gastrointestinal bleeding is a major healthcare burden and is associated with significant morbidity and mortality. This study aimed to assess the prevalence, clinical presentation, and risk factors of patients presenting with gastrointestinal bleeding in the emergency department. This retrospective study was conducted in two tertiary care hospitals in Riyadh, Saudi Arabia. The medical records of patients who presented to the emergency department with gastrointestinal bleeding between January 2010 and January 2020 were reviewed. Patients aged 18 years or older, with gastrointestinal bleeding (upper or lower) regardless of underlying cause, lifestyle, location of bleeding, health status, or medication use, were included. Demographic characteristics, initial vital signs, medical history, physical examination findings, comorbidities, medications, laboratory and radiological investigations, cause and stage of liver disease, management, and complications were recorded. Endoscopic findings and management of the bleeding site were collected according to the presenting symptoms. A total of 760 patients were included. The mean age was 62.7 ± 17.8 years, and 61.4% were males. The most common comorbidities at presentation were hypertension (54.1%), diabetes mellitus (51.2%), and ischemic heart disease (18.2%). The origins of the bleeding were lower gastrointestinal in 52%and upper gastrointestinal in 48% of patients. Lower gastrointestinal bleeding was found to be more common than upper gastrointestinal bleeding. Hemorrhoids, polyps, diverticular disease, and colonic ulcers were the major risk factors for lower gastrointestinal bleeding. In contrast, upper gastrointestinal bleeding was predominantly caused by esophageal varices, gastritis, and peptic ulcers.