Esophageal Varices Research Articles

Correlation between the diameter of esophageal varices measured using a virtual ruler under endoscopy and portal pressure gradient

BackgroundEsophageal variceal diameter (EVD) is a crucial factor in determining the risk of esophageal variceal bleeding, which is associated with an increased portal pressure gradient (PPG). However, research into the relationship between EVD and PPG has been limited, primarily because the assessment of EVD depends on visual estimation during endoscopy. Recently, we developed an artificial intelligence (AI)-based method to accurately detect EVD. In this study, we aim to investigate the correlation between EVD and PPG, with the goal of evaluating EVD as a potential non-invasive indicator of PPG.MethodsThis study included both retrospective and prospective data from 128 patients diagnosed with portal hypertension and gastroesophageal varices, gathered from two medical institutions. Clinical data including PPG, biochemical markers, and routine blood tests were collected. In the retrospective phase, EVD was evaluated using an AI-based virtual ruler. In the prospective phase, PPG was measured using radiological intervention methods, and EVD was measured during endoscopy with the aid of AI.ResultsA positive correlation between PPG and EVD was identified (r = 0.521, P < 0.001), which was further supported by multivariate linear regression analysis (b = 6.521, t = 6.872, P < 0.001). When patients were stratified into two groups based on PPG levels (27 patients with PPG < 20 mmHg and 101 patients with PPG ≥ 20 mmHg), a significant difference in EVD was observed between the groups (OR = 29.275, 95% CI 5.590–153.304, P < 0.001), with larger EVD in the higher PPG group. These findings suggest that EVD may serve as a predictor of adverse events associated with elevated PPG levels. In addition, receiver operating characteristic (ROC) curve analysis showed that EVD had an accuracy of 0.814 in diagnosing PPG function (standard error 0.048, 95% CI 0.720-0.908; P < 0.001), indicating that PPG levels are likely to exceed 20 mmHg when the variceal diameter is greater than 1.1 cm.ConclusionEVD demonstrated a positive correlation with PPG and could potentially be used as a predictive marker for assessing PPG levels. These findings provide novel insights for the non-invasive evaluation of PPG in clinical practice.

Relationship between Child-Pough score and late complications in hospital patients with liver cirrhosis

This study aimed to determine the frequency of available complications in patients with liver cirrhosis and any dependence according to the Child-Pough score. A retrospective study of cases with newly diagnosed liver cirrhosis was conducted in the Gastroenterology Clinic of UMBAL Pleven from 2017 to 2021. Of them, 258 (71.5%) were men and 103 (28.5%) were women. The mean age of the studied population was 57.8 years ± 11.4 years. The leading aetiology was alcohol in 244 (67.6%) of them. All cases were classified according to Child-Pough score system into three groups: Child A 98(27%), Child B 141(39%), and Child C 122(34%). Ours findings show that the occurrence of ascites is most common in the studied population at 232 (64.5%). Esophageal varices were found in 164 (62.4%) patients out of 264 who underwent upper gastrointestinal endoscopy. Portal encephalopathy was found in 170 (47.09%), with a predominance of the minimal in 116 (68.23%) of them. Jaundice was found in 124 (34.34%), and more of them were in Child C. In 65 (18%), renal dysfunction was found, such as acute renal dysfunction in 12.4%. In conclusion, the high frequency of available complications is closely related to late diagnosis.

Self-Expanding Metal Stents in the Acute Management of Oesophageal Variceal Bleeding: A Systematic Review

Self-Expanding Metal Stents in the Acute Management of Oesophageal Variceal Bleeding: A Systematic Review

Short-term efficacy and safety of endoscopic injection of low dose of sclerotherapy and cyanoacrylate injection for type GOV1 gastric varices combined with endoscopic variceal ligation for esophageal varices

Short-term efficacy and safety of endoscopic injection of low dose of sclerotherapy and cyanoacrylate injection for type GOV1 gastric varices combined with endoscopic variceal ligation for esophageal varices

Prevalence of Helicobacter Pylori Infection Among Dyspepsia Patients in a Tertiary Care Hospital of Puducherry

Background: Dyspepsia is a relatively common clinical condition characterized by chronic / recurrent upper abdominal pain or discomfort. Dyspeptic individuals were found to be infected with H-pylori than asymptomatic individuals. Though most individuals are asymptomatic, H. pylori plays a key role in the etiology of many upper gastrointestinal disorder. Materials and Methods: This cross-sectional prospective analytical study was done in Department of General surgery, IGMCRI Pondicherry from February 2022 to June 2022. Both male and female patients attending surgery OPD of age 20 to 60 years with upper gastrointestinal symptoms like dyspepsia and epigastric pain were subjected to upper gastrointestinal endoscopy and scopy findings noted and a Rapid urease test done for them. Results: The prevalence of H-Pylori was found to be 53%. Gender wise distribution shows more prevalence among females (61%) compared to males (44%). Of the total patients, 72% presented with abdominal pain, 34% presented with associated nausea, vomiting and 50% presented with regurgitation, 47% presented with bloating sensation. 11% present with other associated symptoms like malena and dysphagia. 9 patients with dyspepsia had ulcers in the antral wall and duodenum with 33% RUT positivity. 11 of them presented with pangastritis with 72% RUT positivity, 47 of them had antral gastritis with 66% RUT positivity, and 15 of them were found to have normal endoscopic findings with 33% RUT positivity.47% of the patients with esophageal varices and 20% of the patients with ulceroproliferative growth showed RUT positivity. Conclusion: This study validates that more than half the patients with dyspepsia in our population are H-pylori positive. Early referral for Upper GI endoscopy can help diagnose the same and associated clinical condition and initiate an early anti-H. Pylori regimen to achieve quicker symptom relief in these patients.

Activation of MEK‐ERK‐c‐MYC signaling pathway promotes splenic M2-like macrophage polarization to inhibit PHcH-liver cirrhosis

IntroductionPortal hypertension combined with hypersplenism (PHcH) is the main cause of hypocytosis and esophagogastric variceal hemorrhage in patients with liver cirrhosis. Activated macrophages that destroy excess blood cells are the main cause of hypersplenism, but the activating pathway is not very clear. This study aims to investigate the activation types of splenic macrophages and their activation mechanisms, to provide experimental evidence for the biological treatment of splenomegaly, and to find a strategy to improve liver fibrosis and inflammation by intervening in splenic immune cells. This study revealed the occurrence of M2-like polarization of macrophages and upregulation of c-Myc gene expression in the PH spleen.MethodsRNAseq, protein chip, western blot, and chip-seq were performed on macrophages and the in vitro MEK inhibitor rafametinib was used. Carbon tetrachloride and thioacetamide induced mouse cirrhosis models were separately constructed.Resultsc-Myc gene knockout in splenic macrophages reduced M2-like polarization and exacerbated liver fibrosis inflammation. c-Myc activated the MAPK signaling pathway and upregulated the expression of IL-4 and M2-like related genes in PH hypersplenism through the MEK-ERK-c-Myc axis. In addition, the c-Myc gene exerted anti-inflammatory effects by upregulating IL-4-mediated signal transduction to promote M2-like differentiation and anti-inflammatory cytokine secretion.ConclusionsActivation of MEK‐ERK‐c‐MYC signaling pathway promotes splenic M2-like macrophage polarization to inhibit PHcH-liver cirrhosis. Therefore, the induction of macrophage depolarization might represent a new therapeutic approach in the cure of PH hypersplenism, making c-Myc a potential candidate for macrophage polarization therapy.

The Management of Shunt Dysfunction Caused by Stent Deviation During Transjugular Intrahepatic Portosystemic Shunt (TIPS) Surgery for Esophageal and Gastric Varices Bleeding

The Management of Shunt Dysfunction Caused by Stent Deviation During Transjugular Intrahepatic Portosystemic Shunt (TIPS) Surgery for Esophageal and Gastric Varices Bleeding

Portal Hypertensive Gastropathy and MELD-Na Score Predict Recurrent Gastrointestinal Bleeding After TIPSS: An ALTA Group Study.

Transjugular intrahepatic portosystemic shunt (TIPSS) is highly effective for treatment of variceal bleeding; however, factors contributing to rebleeding complications remain unclear. In this study, we aim to determine risk factors for recurrent portal hypertensive gastrointestinal bleeding following TIPSS. Utilising the Advancing Liver Therapeutic Approaches multicentre database, we retrospectively identified adult patients who underwent TIPSS for secondary prophylaxis of variceal bleeding and had a gastrointestinal rebleeding event within 1 year. We developed multivariable logistic regression models to identify clinical/procedural characteristics associated with rebleeding. We identified 476 patients, predominately middle-aged (mean age 57), male (62%) and White (65%), with mean MELD-Na 16. 16% (n = 77) had a rebleeding event; these patients were more likely to be male (p = 0.016), with higher serum creatinine (p = 0.005), MELD-Na (p = 0.0002), portal hypertensive gastropathy on pre-TIPSS upper endoscopy (p = 0.000) and with higher incidence of TIPSS revision (p = 0.000). There were no significant differences in type of TIPSS endoprosthesis, concurrent embolotherapy, and post-TIPSS pressure gradients between those who experienced rebleeding and those who did not. After adjusting for TIPSS revision, multivariable analysis revealed MELD-Na and presence of portal hypertensive gastropathy on pre-TIPSS endoscopy were independently associated with rebleeding. In this retrospective analysis of a multicentre, nationally representative database, we found that apart from TIPSS-related factors, high MELD-Na and portal hypertensive gastropathy on pre-TIPSS endoscopy were independent predictors of rebleeding within 1 year following TIPSS. These variables may be used to identify high-risk patients who may require additional monitoring following TIPSS.

Clinical Outcomes of Transjugular Intrahepatic Portosystemic Shunt Among Cirrhosis Patients With Recurrent Esophageal Variceal Bleeding

Clinical Outcomes of Transjugular Intrahepatic Portosystemic Shunt Among Cirrhosis Patients With Recurrent Esophageal Variceal Bleeding

ICG-r15 predicts esophageal varices in compensated liver cirrhosis: a noninvasive approach

ObjectiveThe aim of our study was to evaluate the indocyanine green (ICG) retention test as a noninvasive marker of esophageal varices(EV).MethodsThe clinical data of patients diagnosed with compensated liver cirrhosis in Tianjin Second People’s Hospital between January 2018 and January 2021 were analysed with SPSS 23.0.ResultA total of 144 patients (88 M/56 F, 51.7 ± 11.06 years) were enrolled. The ICG retention at 15 min(ICG-r15), PVD, TBIL, Cholinesterase(CHE), AST to ALT ratio(ARR), APRI, splenic area, Lok index, Park index and liver stiffness measurement in the absent or small EV group were lower than those in the medium or large EV group, while the ICG disappareance rate(ICG-K), Effective hepatic blood flow(EHBF), ALB, PLT, and Platelet to Spleen Diameter Ratio(PSDR) were higher, and the differences were significant (P < 0.05). ICG-r15, splenic area, APRI and PLT were independent predictors for medium or large esophageal varices (OR = 1.115, 1.025, 0.281, and 0.987, respectively,P < 0.05). The predictive value of ICG-r15 for medium or large varices was 17.95%, the specificity was 0.849, and the sensitivity was 0.662, the AUROC was 0.815. The cut-off value of PLT for M/L EV was 113.5, and the specificity and sensitivity were 0.616 and 0.887, the AUROC was 0.759. The AUROC of ICG-r15 combined with PLT was 0.866, which was more superior than others.ConclusionAlthough we are far from the replacement of endoscopy, ICG-r15 combined with PLT seems to be able to identify patients with medium or large EV in patients with compensated liver cirrhosis.

Addition of neutrophil-to-lymphocyte ratio to Pre-DAA FIB-4 does not increase prediction value for de novo liver complications in hepatitis C

Background and aimsDirect-acting antiviral agents (DAAs) achieve high sustained virologic response (SVR) in chronic hepatitis C patients; yet a proportion of patients still experience de novo liver complications after SVR. Identification of risk factors is clinically important. FIB-4 index is a useful noninvasive tool to assess fibrosis, while neutrophil-to-lymphocyte ratio (NLR) is a biomarker for systemic inflammation. Our study aimed to investigate whether the addition of NLR can increase the prediction power of pre-DAA FIB-4 for de novo liver complications after SVR. MethodsWe recruited patients via The Taiwan HCV Registry (TACR) and National Health Insurance Registry Database. The inclusion criteria were patients who achieved SVR12 after DAA and were followed for at least 24 months after SVR12. Liver complications included ascites, hepatic encephalopathy, variceal bleeding, and HCC. ResultsTotally 7657 patients were recruited from 2013 to 2018. Among them, 3674 patients (48.0%) had a FIB-4 value > 3.25 and 491 patients (6.4%) had a NLR >4 before DAA. After two-year of follow-up after SVR 12, 214 patients (2.8%) developed de novo liver complications. Factors associated with liver complications included male gender, diabetes mellitus, hyperlipidemia, chronic kidney disease, and pre-DAA FIB-4 >3.25 in multivariate analyses. Addition of NLR slightly did not increase the power of predicting liver complications. ConclusionsThe overall incidence of de novo liver complications after SVR is low during short-term follow-up. Elevated pre-DAA FIB-4 is associated with de novo liver complications after SVR, whereas the addition of pre-DAA NLR does not increase the prediction power.

A case study of consecutive pregnancies in a woman with liver cirrhosis and portal hypertension

Pregnancy in women with liver cirrhosis is a high-risk one that requires multidisciplinary care. Variceal bleeding occurs in up to half of women having associated portal hypertension and confers the greatest risk. Despite advances made in the management of such cases, maternal morbidity remains high. Pregnancy is rare in women with liver cirrhosis due to reduced natural fertility rates. We report a case of two consecutive pregnancies in a woman with liver cirrhosis. A 29-year-old primipara with hepatitis B-related liver cirrhosis with portal hypertension who had been on tenofovir for the past seven years. The first pregnancy was spontaneously conceived but the second was by assisted conception. Both pregnancies were complicated by recurrent episodes of variceal bleeding that necessitated multiple endoscopic variceal band ligation (EVBL) during pregnancy. Medical advancement has enabled women with cirrhosis to have more pregnancies with reduced maternal and perinatal morbidities. Multidisciplinary management is vital to achieving favourable pregnancy outcomes.

Long-term Effect of the HCV Elimination With Direct-acting Antivirals on the Progression of Gastroesophageal Varices.

Gastroesophageal varices (GEV) hemorrhage is a serious complication that can lead to unfavorable outcomes in cirrhotic patients. However, the clinical impact of HCV elimination [sustained viral response (SVR)] by direct-acting antivirals (DAAs), particularly on the long-term effects on the endoscopic findings of GEV have not been sufficiently evaluated. This study aimed to investigate whether HCV elimination with DAA treatment suppresses the progression of GEV. The clinical courses of the endoscopic findings of GEV were retrospectively compared between patients without an SVR (non-SVR group: n=71) and those who achieved an SVR with DAAs (DAA-SVR group: n=38). At 1, 3, 5, and 7 years, the cumulative GEV progression rates were 8.7%, 32.8%, 45.6%, and 66.2%, respectively. At 3 years, the cumulative GEV progression rate in the DAA-SVR group was similar to that in the non-SVR group. Beyond 3 years, cases with GEV progression were found in the non-SVR group, but not in the DAA-SVR group. At 7 years, the cumulative GEV progression rate in the DAA-SVR group was significantly lower than that in the non-SVR group (p<0.05, log-rank test). Variceal hemorrhage occurred in eight patients in the non-SVR group, while no bleeding events were observed in the DAA-SVR group during the observational period [8/71 (11.3%) vs. 0/38 (0.0%), p<0.05]. DAA treatment suppresses the progression of GEV over the long term.

Coronary heart disease: leading cause of cardiovascular death from analysis of autopsies in a central european university centre

Abstract Introduction Cardiovascular diseases (CVD) are the most common cause of death globally including in developed countries. Data from autopsies may provide additional and up-to-date information. Purpose 1. To determine the proportion of deaths due to cardiovascular causes in the cohort of deceased persons who underwent autopsies 2. To describe the most frequent causes of cardiovascular death and record differences concerning age and gender. Methods A set of autopsies performed in the 6-year period (2017–2022) in a tertiary referral centre located in a Central European country were analyzed. The causes of death were classified as cardiovascular and non-cardiovascular. The division was performed based on the autopsy diagnosis according to the International Classification of Diseases (ICD)-10. Subsequently, cardiovascular causes of death were categorized by age (under 50 years, over 50 years) and gender (male, female). Results The total number of autopsies performed in the monitored period was 8651 (eight thousand six hundred and fifty-one) of which 4400 cases (50.9%) were classified by cardiovascular cause of death. Of those, coronary heart disease (CHD) was the most frequent cause of death (2340 cases; 50.9%). The vast majority of CHD patients were over 50 years of age (2083 cases, 92.2%), and males predominated (n=1569, 75.3%) over females (n=514, 24.7%). In the patients younger than 50 years of age, 155 deaths from CHD were recorded, males predominated nearly 6 times (132 males, 23 females, M:F ratio 5.74). Heart failure (HF) represented the second most common cause of cardiovascular death with 1191 cases (27.1%), again with dominance of patients over 50 years of age (684 male, 418 female, M:F ratio 1:64) In the patients under 50 years of age, the HF frequency was lower (89 cases), with a predominance of male patients (n=64) over females (n=25); M:F ratio 2.56. Pulmonary embolism accounted for the third highest share of deaths from cardiovascular reasons (370 cases; 8.4%), 330 patients were over 50 years of age and there was no significant gender difference observed (168 male, 162 female, M:F ratio 1.04). Other less frequent common diagnoses as causes of cardiovascular death observed in our cohort were as follows: hemorrhagic stroke (142 cases, 3.2%), aneurysm ruptures (107 cases; 2.4%), and esophageal varices (58 cases; 1.3%). Conclusions Death from cardiovascular causes accounted for more than half of the causes of death in the recent cohort of autopsied patients of a substantial size from a Central European country with coronary heart disease being the most common diagnosis accountable for half of the deaths from cardiovascular causes. Importantly, heart failure represented more than a quarter of deaths from cardiovascular causes. In both CHD and HF, the most vulnerable group was males over 50 years of age.

Evaluation of Patients with Hepatic Cirrhosis due to Etiology for the Complication

Objectives: Hepatic cirrhosis is a disease with high mortality. The leading causes of morbidity and mortality in patients with hepatic cirrhosis are disease-associated complications. We aimed to describe the association between the difference in laboratory parameters, complications, and commonly known causes of cirrhosis, such as hepatitis B, hepatitis C, alcoholic liver disease (NASH), and autoimmune hepatitis. Methods: We investigated 541 patients with different etiologies of cirrhosis who applied to a gastroenterology clinic from 2009 to 2018 in Florance Nightingale Hospital. All patients were divided into five groups according to the etiology of cirrhosis, such as hepatitis B, hepatitis C, alcoholic liver disease (ALD), NASH, and autoimmune hepatitis. Biochemical and metabolic parameters were evaluated between five groups. Results: 83 patients with alcoholic liver disease, 242 patients with hepatitis B-associated cirrhosis, 112 patients with hepatitis C-associated cirrhosis, 77 patients with NASH, and 27 patients with autoimmune hepatitis were enrolled. Laboratory parameters due to the etiology of hepatic cirrhosis are shown in Table 2. Ascites and hepatic encephalopathy were statistically higher in alcoholic liver disease, hepatitis B, and NASH cirrhosis, while esophageal variceal bleeding was higher in NASH and autoimmune hepatitis. Spontaneous bacterial peritonitis was statistically higher only in cirrhosis due to autoimmune hepatitis. Conclusion: It is very important to assign complications that may develop in liver cirrhosis and manage them by etiology.

Predicting Portal Pressure Gradient in Patients with Decompensated Cirrhosis: A Non-invasive Deep Learning Model.

A high portal pressure gradient (PPG) is associated with an increased risk of failure to control esophagogastric variceal hemorrhage and refractory ascites in patients with decompensated cirrhosis. However, direct measurement of PPG is invasive, limiting its routine use in clinical practice. Consequently, there is an urgent need for non-invasive techniques to assess PPG. To develop and validate a deep learning model that predicts PPG values for patients with decompensated cirrhosis and identifies those with high-risk portal hypertension (HRPH), who may benefit from early transjugular intrahepatic portosystemic shunt (TIPS) intervention. Data of 520 decompensated cirrhosis patients who underwent TIPS between June 2014 and December 2022 were retrospectively analyzed. Laboratory and imaging parameters were used to develop an artificial neural network model for predicting PPG, with feature selection via recursive feature elimination for comparison experiments. The best performing model was tested by external validation. After excluding 92 patients, 428 were included in the final analysis. A series of comparison experiments demonstrated that a three-parameter (3P) model, which includes the international normalized ratio, portal vein diameter, and white blood cell count, achieved the highest accuracy of 87.5%. In two distinct external datasets, the model attained accuracy rates of 85.40% and 90.80%, respectively. It also showed notable ability to distinguish HRPH with an AUROC of 0.842 in external validation. The developed 3P model could predict PPG values for decompensated cirrhosis patients and could effectively distinguish HRPH.

Extra-Hepatic Portal Venous Obstruction in Pregnant Women of South-Asian Descent: A Case Series

Liver diseases complicate approximately 3% of pregnancies worldwide, and require specialized care to ensure optimal pregnancy outcomes. Extra-hepatic portal venous obstruction (EHPVO), even though asymptomatic in a majority of the cases, has a higher risk of variceal bleeding in pregnancy and adverse pregnancy outcomes. In this series, we describe five cases of EHPVO presenting during pregnancy at our tertiary care hospital, their antenatal management, and delivery outcomes. In our case series on EHPVO in pregnancy, a majority of the women were diagnosed during childhood and adequately asymptomatic before pregnancy. Two women underwent Endoscopic band ligation for esophageal varices and one woman underwent splenectomy before pregnancy for disease control. One woman was Anti-nuclear antibody (ANA) positive and another was Anti-phospholipid antibody (APLA) positive, while the other three did not have pre-existing thrombotic tendencies. One patient required Endoscopic band ligation during pregnancy. Pregnancy complicated by hypertension was noted in two of the five women (40%). Four of the five women (80%) had thrombocytopenia requiring blood products during delivery. Two women underwent preterm vaginal delivery, and one woman underwent preterm Caesarean section because of placental abruption. Three women had a post-partum hemorrhage, which was effectively managed with uterotonics and blood products. All five women and their neonates were discharged in good health. Multi-disciplinary approach with standardized antenatal care can give positive pregnancy outcomes in women with EHPVO.

Comparison of outcomes for transjugular intrahepatic portosystemic shunt creation: Viatorr versus Fluency versus a bare stent/Fluency stent combination

PurposeTo compare clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) created with the single covered-uncovered stent (Viatorr TIPS Endoprosthesis) versus covered stent (Fluency) versus a combination of covered and uncovered stent.Materials and methodsFrom May 2016 and July 2019, a total of 180 liver cirrhosis patients with recurrent variceal bleeding underwent TIPS creation with single covered-uncovered stent (n = 63) or covered stent (n = 41) or a covered and uncovered stent combination (n = 76). Shunt dysfunction, rebleeding, overt hepatic encephalopathy and mortality was estimated using the Kaplan–Meier method and compared with the log-rank test.ResultsThe difference of baseline characteristics among these three groups were not significant. The included patients had a median age of 51 years (IQR 43–61), and 101 (56.1%) were men. The 1-year and 2-year shunt dysfunction rates were 1.6% and 3.2% in the single covered-uncovered stent group, 7.3% and 7.3% in the covered stent group and 5.3% and 6.6% in the combination group, respectively. There was no significant difference among groups [Hazard Ratio (HR) (95%CI): 1 vs 2.29 (0.38 − 13.72) vs 2.10 (0.41 − 10.83); P = 0.913]. No significant differences in the incidence of all-cause rebleeding were observed between the groups at 1 year (Viatorr vs Fluency vs combination: 11.1% vs 17.1% vs 10.5%) as well as 2 years (15.9% vs 17.1% vs 11.8%), with the HR (95%CI) being 1 vs 1.27 (0.5—3.21) vs 0.74 (0.30–1.82); P = 0.475). The 1-year and 2-year incidence of overt hepatic encephalopathy were 30.2% and 30.2% in the single covered-uncovered stent group, 22.0% and 22.0% in the covered stent group and 25.0% and 25.0% in the combination group, respectively. However, there was no significant difference among these three groups (P = 0.402). In addition, there was no significant difference in the 1-year and 2-year mortality (6.3% and 7.9% vs. 4.9% and 9.8% vs. 6.6% and 9.2%, P = 0.606).ConclusionNo significant difference was observed among different stent groups. Fluency covered stent and the generic bare stent/Fluency covered stent was not an unreasonable alternative to the Viatorr stent for TIPS creation.

Effectiveness of Adjunctive Drug Therapy to Endoscopic Stenting in Liver Cirrhosis Complicated by Refractory Variceal Bleeding

AIM OF THE STUDY. Comparative clinical analysis of the efficacy of terlipressin and octreotide as additional drug therapy to mechanical hemostasis with nitinol stent in patients with liver cirrhosis complicated by bleeding from esophageal varices refractory to endoscopic treatment.MATERIAL AND METHODS. Thirty-one patients with liver cirrhosis complicated by esophageal variceal bleeding refractory to endoscopic treatment , in whose complex treatment program, as a first-line life­saving measure, hemostasis with a self-expanding hemostasis was performed nitinol stent were randomly assigned to two groups. In group A, 20 patients were treated with terlipressin as an adjuvant to mechanical hemostasis, and in group B, 11 patients were treated with octreotide. Unpaired Student’s t-test was used for statistical analysis of the results. Graphs for assessing the survival function of patients for 8 weeks after the end of treatment were constructed using the Kaplan-Meier method.RESULTS. In the acute observation period terlipressin and octreotide were equally effective in treating refractory variceal bleeding. In the subacute observation period, the administration of octreotide was generally accompanied by a greater number of side effects (54.5%) than terlipressin (30.0%) (p=0.453). In the remote observation period, 8-week survival in the group of patients receiving terlipressin was higher than in the group of patients receiving octreotide.CONCLUSION. Terlipressin is as effective as octreotide as an adjunct to endoscopic stenting in drug therapy for liver cirrhosis complicated by esophageal variceal bleeding refractory to endoscopic treatment. At the same time, terlipressin has a greater effect than octreotide on reducing 8-week mortality, which approaches statistical significance. In this regard, terlipressin may be the vasoactive drug of choice in acute refractory variceal bleeding.

Preemptive Transjugular Intrahepatic Portosystemic Shunt in Variceal Bleeding: A Real-World Study in a Tertiary Hospital

Introduction: Several studies have highlighted the potential benefits of early prophylactic transjugular intrahepatic portosystemic shunt (preemptive TIPS) placement in reducing morbidity and mortality following variceal bleeding (VB). Baveno VII recommends its placement less than 72 h after VB (Child-Pugh class C <14 or class B >7 plus active bleeding). This study aimed to evaluate the effectiveness of preemptive TIPS compared to a control group in a referral center. Methods: The control group included cirrhotic patients with VB and Child-Pugh class C or B with active bleeding, retrospectively selected between 2016 and 2022 and divided into 2 subgroups: those that never underwent TIPS placement during the course of their illness (subgroup A) and those submitted to TIPS placement due to rebleeding (subgroup B). Additionally, patients who received preemptive TIPS placement between August 2022 and January 2024 were prospectively included into the preemptive transjugular intrahepatic portosystemic shunt (pTIPS) group. Results: A total of 47 patients were included, 19 (40.4%) in the pTIPS group and 28 (59.6%) in control group (17 in subgroup A). There were no differences in baseline characteristics between the groups, except hepatic encephalopathy that was significantly higher in the control group when compared to the pTIPS group: 19 (67.9%) versus 6 (31.6%), p = 0.014. Early rebleeding rates were significantly lower in the pTIPS group: 1 (5.3%) versus 13 (46.4%) (p = 0.002). There were no significant differences in 6-week survival between the groups: 25 (89.3%) versus 17 (89.5%), p = 0.683. Regarding hepatic encephalopathy, no significant differences were observed between the control and the pTIPS group: 6 (21.4%) versus 4 (21.1%), p = 0.632, even when comparing subgroup A (4, 23.5%) with the pTIPS group (p = 0.432). Conclusion: This real-world study highlights the potential benefits of preemptive TIPS placement in reducing early relapse of VB, thereby lowering morbidity and complications. The findings advocate for the proactive incorporation of preemptive TIPS into clinical practice to optimize patient outcomes following VB.