Difference In Rebleeding Rate Research Articles

A Randomized Controlled Trial of Propranolol Use During Ligation Program for Secondary Prophylaxis of Esophageal Variceal Bleeding.

Endoscopic variceal ligation (EVL) plus nonselective β-blockers (NSBB) is the standard of care for secondary prophylaxis of esophageal variceal bleeding (EVB). This trial aimed to compare the rebleeding rates between EVL plus NSBB till eradication of esophageal varices (EEV) and EVL plus long-term NSBB. After control of acute EVB, patients with cirrhosis were randomized into 2 groups, with group A patients receiving EVL plus propranolol till EEV, while group B patients received standard of care with continuation of propranolol. Recurrent varices were ligated at follow-up endoscopy in both groups. The median follow-up period was 23.0 months in group A (n = 106) and 23.6 months in group B (n = 106). Twelve patients (11.3%) in group A and 11 (10.4%) in group B had recurrent EVB. The difference in rebleeding rates and the 95% confidence interval (CI) was 0.9% (-7.5% to 9.3%). The upper 95% CI bound of the difference was within the margin of 13.2%, and the noninferiority of group A to group B was established. Thirty-eight patients (35.8%) in group A and 40 (37.7%) in group B had further decompensation, with the difference (95% CI) of -1.9% (-14.9% to 11.1%). Twenty-four patients (22.6%) in group A and 26 (24.5%) in group B expired, with the difference (95% CI) in mortality rates of -1.9% (-13.3% to 9.5%). EVL plus propranolol till EEV was noninferior to EVL plus continuing propranolol in secondary prophylaxis of EVB, but the impact on further decompensation and transplantation-free survival deserved further investigation.

Lumbar puncture-verified subarachnoid hemorrhage: bleeding sources, need of radiological examination, and functional recovery

BackgroundThe primary aim was to determine the diagnostic yield of vascular work-up, the clinical course during neurointensive care (NIC), and rate of functional recovery for patients with computed tomography (CT)-negative, lumbar puncture (LP)-verified SAH.MethodsIn this retrospective study, 1280 patients with spontaneous SAH, treated at our NIC unit, Uppsala University Hospital, Sweden, between 2008 and 2018, were included. Demography, admission status, radiological examinations (CT angiography (CTA) and digital subtraction angiography (DSA)), treatments, and functional outcome (GOS-E) at 12 months were evaluated.ResultsEighty (6%) out of 1280 SAH patients were computed tomography (CT)-negative, LP-verified cases. Time between ictus and diagnosis was longer for the LP-verified SAH cohort in comparison to the CT-positive patients (median 3 vs 0 days, p < 0.001). One fifth of the LP-verified SAH patients exhibited an underlying vascular pathology (aneurysm/AVM), which was significantly less common than for the CT-verified SAH cohort (19% vs. 76%, p < 0.001). The CTA- and DSA-findings were consistent in all of the LP-verified cases. The LP-verified SAH patients exhibited a lower rate of delayed ischemic neurological deficits, but no difference in rebleeding rate, compared to the CT-verified cohort. At 1-year post-ictus, 89% of the LP-verified SAH patients had recovered favorably, but 45% of the cases did not reach good recovery. Having an underlying vascular pathology and an external ventricular drainage were associated with worse functional recovery (p = 0.02) in this cohort.ConclusionsLP-verified SAH constituted a small proportion of the entire SAH population. Having an underlying vascular pathology was less frequent in this cohort, but still occurred in one out of five patients. Despite the small initial bleeding in the LP-verified cohort, many of these patients did not reach good recovery at 1 year, this calls for more attentive follow-up and rehabilitation in this cohort.

Comparing the predictive ability of portoatrial and portocaval gradient after transjugular intrahepatic portosystemic shunt creation for variceal rebleeding.

Measuring the portal pressure gradient from the portal vein (PV) to the inferior vena cava (IVC) or to the right atrium (RA) remains controversial. The aim of our study was to compare the predictive ability of portoatrial gradient (PAG) and portocaval gradient (PCG) for variceal rebleeding. The data of 285 cirrhotic patients with variceal bleeding undergoing elective transjugular intrahepatic portosystemic shunt (TIPS) in our hospital were analyzed retrospectively. The variceal rebleeding rates were compared between groups categorized by established or modified thresholds. The median follow-up time was 30.0months. After TIPS, PAG was equal to (n = 115) or more than (n = 170) PCG. The pressure of IVC was defined as an independent predictor for a PAG-PCG difference of ≥ 2mmHg (p < 0.001, OR 1.23, 95% CI 1.10-1.37). Using a threshold of 12mmHg, PAG (p = 0.081, HR 0.63, 95% CI 0.37-1.06) could not predict variceal rebleeding but PCG could (p = 0.003, HR 0.45, 95% CI 0.26-0.77). This pattern was unchanged when a ≥ 50% reduction from baseline was also considered as a threshold (PAG/PCG: p = 0.114 and 0.001). Subgroup analyses showed that only in patients with post-TIPS IVC pressure < 9mmHg (p = 0.018), PAG could predict variceal rebleeding. Because PAG was on average 1.4mmHg higher than PCG, patients were classified by a PAG of 14mmHg, and there was no difference in rebleeding rates between these two groups (p = 0.574). For patients with variceal bleeding, the predictive ability of PAG is limited. The portal pressure gradient should be measured between the PV and IVC.

Comparison of intermittent and continuous proton pump inhibitor infusions in patients with non-variceal upper gastrointestinal bleeding at King Abdulaziz University Hospital, Jeddah, Saudi Arabia: A retrospective study.

To compare the effectiveness of intermittent and continuous proton pump inhibitors (PPIs) infusion on the outcomes of patients with nonvariceal upper gastrointestinal bleeding (NVUGIB). The study was a single-centred retrospective study in adult patients with active upper gastrointestinal bleeding who received intermittent or continuous PPI infusion at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, from January 2013 to October 2019. The outcomes assessed were rebleeding, length of hospital stays and mortality within 30 days of admission, and were compared between the treatment groups. A statistically significant p-value was set at 0.05. The study involved 97 patients with NVUGIB treated with intermittent (n=56) and continuous (n=41) PPI infusions, with mean (±SD) ages of 66.0±16.1 and 58.0±19.5 years, respectively. The baseline and clinical characteristics between the 2 treatment groups; age (p=0.116), gender (p=0.345) and comorbidities (p=0.401), were comparable. There were no significant differences in rebleeding rates within 30 days (5 [8.9%] versus 1 [2.4%], p=0.396), length of hospital stays (4 vs 5, p=0.067), and mortality rate (1 [1.7%] vs 3 [7.3%], p=0.308) between the 2 groups. The management of NVUGIB with intermittent and continuous PPI infusions demonstrated comparable outcomes in reducing rebleeding rate, length of hospital stays, and mortality rate among patients attending the university hospital in Saudi Arabia.

Efficacy of radiotherapy for gastric bleeding associated with advanced gastric cancer

BackgroundGastric bleeding negatively impacts the quality of life of patients with unresectable advanced gastric cancer and is frequently lethal. We investigated the efficacy of RT for palliation of gastric bleeding from gastric cancer and identified an optimal radiotherapy (RT) strategy.MethodsThe study analyzed 57 patients submitted to palliative RT for gastric bleeding associated with gastric cancer between January 2009 and February 2019. Changes in hemoglobin (Hb) levels were analyzed based on measurements taken before and immediately, 1 month, and 2 months after RT. Re-bleeding after RT was identified as either Hb level dropping to < 7.0 g/dL or the administration of a blood transfusion after RT.ResultsThe median biologically effective dose (α/β = 10) was 37.5 Gy (range 23.6–58.5). The most common regimen was 25 Gy in five fractions. The mean Hb levels before, immediately after, 1 month, and 2 months after RT (6.6, 9.7, 10.3, and 9.7 g/dL, respectively) were significantly higher than that before RT (all p < 0.001). No significant differences in re-bleeding rates were observed according to total dose, fractional dose, and fraction number. Gastric tumor response evaluated by computed tomography within 2 months after RT showed partial responses were more frequent in patients achieving bleeding control (25.0% vs. 10.8%, p = 0.023) and overall survival was significantly improved for bleeding control within 3 months after RT (median, 15.4 vs. 10.0 weeks, p = 0.048).ConclusionsRT was an effective modality for gastric bleeding control in gastric cancer, which can be achieved with a short course scheme with five fractions.

Clinical Outcomes between P1 and P0 Lesions for Obscure Gastrointestinal Bleeding with Negative Computed Tomography and Capsule Endoscopy.

Background: A simple classification for the relevance of lesions (P0, P1, and P2; no bleeding potential, less likely to bleed, and more likely to bleed, respectively) based on capsule endoscopy (CE) findings has been used. This study aimed at investigating rebleeding rates and predictive factors of P0 and P1 lesions after obtaining negative findings in both, CE and computed tomography (CT), for patients with obscure gastrointestinal bleeding (OGIB). Methods: Among 193 patients resulted in negative CE findings defined as P0 or P1 lesions, 84 patients with negative results on CT images were enrolled in this study. The rebleeding rates and predictive factors were assessed in the P0 and P1 groups. Results: Overall rebleeding rate in patients with negative CT and CE was 17.9%; 18.4% in the P0 group; 17.4% in the P1 group within a median follow-up duration of 18.5 months. In the P0 and P1 groups, the cumulative rebleeding rates were 9.2%, 25.4%, and 25.4%, and 6.9%, 11.8%, and 18.6% at 12, 24, and 60 months, respectively (p = 0.97). There were no independent rebleeding associated factors in the P0 group, whereas Charlson comorbidity index (CCI) (hazard ratio (HR) = 2.019, 95% confidence interval (CI): 1.158–3.519, p = 0.013), and initial low hemoglobin (Hb) level (<8 g/dL) (HR = 15.085, 95% CI: 1.182–192.514, p = 0.037) were independent predictive factors responsible for rebleeding in the P1 group. Conclusions: Despite having negative findings on CT and CE, patients with OGIB have a significant potential rebleeding risk. Although there was no significant difference in rebleeding rates between the P0 and P1 groups on CE, the P1 group, with CCI or low initial Hb level, should be cautiously observed after the first bleeding episode.

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

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

Transjugular intrahepatic portosystemic shunt is effective in patients with chronic portal vein thrombosis and variceal bleeding

BackgroundStudies about treatment of patients with chronic portal vein thrombosis (CPVT) are still limited, especially in different types of CPVT. This study aimed to evaluate the effect of transjugular intrahepatic portosystemic shunt (TIPS) in all types of CPVT with variceal bleeding. MethodsPatients with CPVT who received TIPS treatment between January 2011 and June 2019 were divided into four types according to the extent of thrombosis. All patients had a history of variceal bleeding. The characteristics and clinical parameters were collected and recorded. Data on procedure success rate, variation in portal vein pressure, rebleeding, hepatic encephalopathy (HE), stent stenosis, and overall mortality were analyzed. ResultsA total of 189 patients were included in this study (39 in type 1, 84 in type 2, 48 in type 3, 18 in type 4). The TIPS procedure success rate was 86.2%. The success rate was significantly different among the four types (89.7% vs. 88.1% vs. 83.3% vs. 77.8%, P = 0.001). In the TIPS success group, portal vein pressure was significantly reduced from 27.15 ± 6.59 to 19.74 ± 6.73 mmHg after the procedure (P < 0.001) and the rebleeding rate was significantly lower than that of the fail group (14.7% vs. 30.8%, P = 0.017). In addition, there were no significant differences in HE rate (30.7% vs. 26.9%, P = 0.912) or overall mortality (12.9% vs. 19.2%, P = 0.403) between the TIPS success group and the fail group. In the TIPS success group, we found that the occurrence of HE was significantly different (P = 0.020) among the four types, while there were no significant differences in rebleeding rate (P = 0.669), stent stenosis rate (P = 0.056), or overall mortality (P = 0.690). ConclusionsTIPS was safe and effective in decreasing portal vein pressure and rebleeding rate in patients with CPVT.

Selective Esophagogastric Devascularization in the Modified Sugiura Procedure for Patients with Cirrhotic Hemorrhagic Portal Hypertension: A Randomized Controlled Trial.

Aim Portal hypertension is a series of syndrome commonly seen with advanced cirrhosis, which seriously affects patient's quality of life and survival. This study was designed to access the efficacy and safety of selective esophagogastric devascularization in the modified Sugiura procedure for patients with cirrhotic hemorrhagic portal hypertension. Methods Sixty patients with hepatitis B cirrhotic hemorrhagic portal hypertension and meeting the inclusion criteria were selected and randomly divided by using computer into the selective modified Sugiura group (sMSP group, n = 30) and the modified Sugiura group (MSP group, n = 30). The primary endpoint measurement is the postoperative rebleeding rate. Secondary endpoint measurements included free portal venous pressure, liver Child–Pugh score, liver volume, portal vein width and blood flow velocity, survival rate, quality of life, and dysphagia as well as other complications one year postoperatively. This trial is registered with ChiCTR, number ChiCTR2000033468. Results There was no statistically significant difference in rebleeding rates within one year after surgery between patients in the sMSP and MSP groups (χ = 0.11, p=0.73). In comparison with the MSP group, the Child–Pugh score of liver function in the sMSP group significantly increased (χ = 6.4, p=0.04) and the incidence of dysphagia was significantly reduced (χ = 6.23, p=0.01) one year after surgery. There was a statistically significant difference in the quality of life between the two groups. However, there were no statistically significant differences in free portal venous pressure (MD = −3.44, 95% CI: −7.87 to 0.98, p=0.12), postoperative liver volume (3 months: MD = -258.81, 95% CI: −723.21 to 205.57, p=0.24; 1 year: MD = −320.12, 95% CI: −438.43 to 102.78, p=0.16), postoperative portal vein width (3 months: MD = −0.06, p=0.50; 1 year: MD = 0.17, p=0.21), portal vein flow velocity (3 months: MD = 1.64, p=0.21; 1 year: MD = −1.19, p=0.57), 1-year survival rate (χ = 1.01, p=0.31), and other complications between the two groups. Conclusions Selective esophagogastric devascularization in the modified Sugiura procedure may not lower the incidence of rebleeding in the short term based on our findings. However, it may significantly improve quality of life of patients with cirrhotic hemorrhagic portal hypertension, improve liver function, and reduce postoperative dysphagia.

Treatment outcomes after splenectomy with gastric devascularization or balloon-occluded retrograde transvenous obliteration for gastric varices: a propensity score-weighted analysis from a single institution.

BackgroundAlthough balloon-occluded retrograde transvenous obliteration (BRTO) is often selected to treat gastric varices caused by portal hypertension, data comparing BRTO and splenectomy with gastric devascularization (Sp + Dev) are limited.MethodsFrom January 2009 to February 2018, 100 patients with gastric varices caused by portal hypertension who underwent Sp + Dev (n = 45) or BRTO (n = 55) were included. Overall survival (OS) and the rebleeding rate were calculated using the inverse probability of a treatment weighting-adjusted log-rank test. Independent risk factors were identified by Cox regression analysis. Changes in liver function and adverse events after the procedures were analyzed.ResultsPatients in the Sp + Dev group tended to have lower platelet counts than those in the BRTO group, but liver function did not differ between these groups. The 5-year OS rates for the Sp + Dev and BRTO groups were 73.4 and 50.0% (p = 0.005), respectively. There were no significant differences in rebleeding rates between the two groups. Multivariate analysis showed that serum albumin level ≤3.6 g/dL, prothrombin time% activity (PT%) ≤80%, and serum creatinine level ≥0.84 mg/dL were poor prognostic factors. Although the Sp + Dev group had more short-term complications after procedures, Sp + Dev tended to be more effective in improving liver function than BRTO.ConclusionsSp + Dev showed better OS and improvement of liver function compared with BRTO for the treatment of gastric varices caused by portal hypertension.Electronic supplementary materialThe online version of this article (10.1007/s00535-020-01693-9) contains supplementary material, which is available to authorized users.

Effect of baseline characteristics on response to proton pump inhibitors in patients with peptic ulcer bleeding.

The rate of rebleeding from peptic ulcers could differ between Asian and Western populations. This study aimed to determine whether the observed twofold difference in rebleeding rates in two similarly designed clinical trials (one in Hong Kong [n = 240], the other in a predominantly Western population [n = 764, ClinicalTrials.gov identifier: NCT00251979]) can be explained by differences in baseline patient characteristics. Two-factor and multifactor analyses (adjusted by demographics, established risk factors for peptic ulcer and peptic ulcer bleeding, and disease severity variables) were performed using pooled data from the two studies. Cox regression analysis was used to predict the rebleeding risk at 3 days. In the two-factor analysis (placebo vs esomeprazole/omeprazole and Western study vs Hong Kong study), data trended towards a reduced risk of rebleeding in the Western study (hazard ratio [HR] 0.69, 95% confidence interval [CI] 0.44-1.07, P = 0.094). The risk of rebleeding was similar in both studies after adjusted for multiple factors (HR 1.10, 95% CI 0.60-1.99, P = 0.767). The strongest predictor of rebleeding (apart from study drug) was a classification of American Society of Anesthesiologists (ASA) grade IV (HR 4.15, 95% CI 1.49-11.56, P = 0.006). When such patients were excluded, the difference in rebleeding rates between the studies reduced. The difference in rebleeding rates between the two studies is explained by the factors in our analysis, most importantly a classification of ASA grade IV, suggesting that other differences, including ethnicity, did not influence the rebleeding rate.

Randomized pragmatic trial of nasogastric tube placement in patients with upper gastrointestinal tract bleeding

The value of nasogastric (NG) tube placement in patients with upper gastrointestinal tract bleeding (UGIB) is unclear. We therefore aimed to determine the usefulness of NG tube placement in patients...

Are higher doses of proton pump inhibitors better in acute peptic bleeding?

Although there is broad consensus about the benefits of proton pump inhibitors in acute upper peptic bleeding, there is still controversy over their optimal dosing. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified six systematic reviews including 27 randomized trials addressing this question. We combined the evidence using meta-analysis and generated a summary of findings table following the GRADE approach. We concluded high-dose proton pump inhibitors probably result in little or no difference in re-bleeding rate or mortality. The risk/benefit and cost/benefit balance probably favor use of low-doses.

Risk factors for re-bleeding events in obscure gastrointestinal bleeding patients with negative findings in capsule endoscopy

To investigate the frequency of and risk factors for re-bleeding in obscure gastrointestinal bleeding (OGIB) patients who had negative findings in capsule endoscopy (CE). Patients with OGIB referred for CE to the First Affiliated Hospital of Zhengzhou University between January 2011 and December 2012 were identified.Follow-up data were obtained via medical records review, telephone interviews or follow-up clinic visits in order to establish the rate of re-bleeding and identify the risk factors associated with re-bleeding among patients with negative CE findings. A total of 198 patients were included in this study, of whom 196 patients completed the follow-up, with a mean (±SD) follow-up of (16.1±5.3) months. In the 196 patients, 94 had negative CE findings and did not receive any further specific treatment for OGIB. Re-bleeding episodes were observed in 32 of the 94 patients (34.0%), and the cumulative re-bleeding rates at 6, 12, 18, and 24 months in follow-up were 3.2%, 6.4%, 20.2%, 34.0%, respectively. There was no statistically significant difference in re-bleeding rate between patients with positive CE findings and patients with negative CE findings (23.7% vs 34.0%, P=0.246). Diabetes mellitus (HR=3.250, 95%CI: 1.296-8.154, P=0.012), minimum hemoglobin levels ≤80 g/L before CE (HR=0.397, 95%CI: 0.172-0.917, P=0.031), and continued use of aspirin after CE (HR=4.915, 95%CI: 1.887-12.800, P=0.001) were independent risk factors for re-bleeding among OGIB patients with negative CE findings. Considering the high risk of re-bleeding, close follow-ups are needed for OGIB patients with negative CE findings.Repeated CE or other investigations (enteroscopy and CT enterography) within 12-24 months are recommended for the OGIB patients with negative findings in initial CE investigation who have risk factors for re-bleeding.

Mo1485 Comparison of Direct Endoscopic Injection (DEI) and EUS-Guided Fine Needle Injection (EUS-FNI) of 2-Octyl-Cyanoacrylate for Treatment of Gastric Varices

Mo1485 Comparison of Direct Endoscopic Injection (DEI) and EUS-Guided Fine Needle Injection (EUS-FNI) of 2-Octyl-Cyanoacrylate for Treatment of Gastric Varices

Mo1486 The Diagnostic Utility of Endoscopic Ultrasonography in Assessing the Depth of Tumor Invasion in Early Gastric Cancer

Mo1486 The Diagnostic Utility of Endoscopic Ultrasonography in Assessing the Depth of Tumor Invasion in Early Gastric Cancer

Is topical corticosteroid necessary in traumatic hyphema?

To compare the outcomes in the management of traumatic hyphema treated with topical corticosteroid plus supportive therapy versus only supportive therapy. In this retrospective study, 206 patients were divided into two groups; group I, 98 eyes were treated with topical corticosteroid 12 × 1 and supportive therapy including bed rest, keeping the head elevated (45 degrees), and hydration. In group II, 108 eyes were treated with only supportive therapy. Hyphema size, initial and final visual acuities and intraocular pressure, time to hyphema clearance, and incidence of rebleeding were evaluated. The time needed for hyphema resorption in the two groups were 60.25 ± 33.9 and 62.3 ± 28.9 hours respectively (P=0.62). There was no significant difference in rebleeding rate between the topical corticosteroid group (4.01%) and non-steroid group (6.48%) (P=0.67). The initial and final visual acuities were similar in the two groups (P=0.86). In Groups I and II, the average intraocular pressures were 19.7 ± 8.01 and 14.2 ± 10.2 mmHg respectively. The difference between the two groups was statistically significant (P=0.04). Patients who were treated with topical corticosteroids were no less likely to experience a rebleed or a poor visual outcome than those treated with supportive therapy alone. Supportive therapy alone may be convenient and cost-effective management strategy in uncomplicated traumatic hyphema.

Commentary: what is the optimal PPI dosing following endoscopic haemostasis in acute ulcer bleeding?

We commend Chen et al. on a well-reported randomised controlled trial (RCT) addressing a persistent controversy in the management of ulcer bleeding.1 The trial avoided two main limitations of most previous RCTs: the authors excluded patients exhibiting low-risk endoscopic stigmata, and adopted efficacious endoscopic therapy.2, 3 Unfortunately methodological shortcomings remain. Was the method of blinding adequate, and how was it implemented? This aspect is critical when assessing risk of bias and RCT validity. The comparator dose used was very low but may be adequate in this population.4 The main limitation is the lack of statistical power. Indeed, the observed difference in re-bleeding rates of 1% carries wide 95% confidence intervals (–5.6% to +7.6%), compatible with clinically important differences in either direction. A recent Cochrane systematic review (13 studies, 1727 patients), comparing ‘high-dose’ PPI to other regimens, found no statistically significant differences in clinical outcomes.5 However, as the overall quality of evidence ranged from ‘very low’ to ‘low’, mainly due to high risk of bias and imprecision, even these better powered summary results are inconclusive, and do not provide evidence for therapeutic equivalence.2, 3 Such considerations motivated the recent recommendations by an international consensus group, favouring a high-dose intravenous PPI regimen in patients with high-risk endoscopic stigmata after endoscopic haemostatic therapy until better quality data come to light,6 especially when considering the risk-benefit ratio of PPIs for this indication, and the demonstrated cost-effectiveness of the high-dose approach compared to not using a PPI acutely.7-9 The suggestion that H. pylori presence may be associated with decreased re-bleeding is biologically plausible and requires confirmation. In conclusion, this study unfortunately does not provide decisive data, but may be useful when included in future meta-analyses to determine the optimal PPI dosing when managing patients with ulcer bleeding. Declaration of personal interests: Alan Barkun is a consultant for AstraZeneca, Takeda Canada, Boston Scientific Inc. and Olympus Canada, and received research funding from Boston Scientific Inc. and Cook. Grigorios I. Leontiadis has received research funding from AstraZeneca. Declaration of funding interests: None.

Effects of craniopuncture and drainage of intracerebral hemorrhage on brain edema and neurological outcome

Objective To investigate the effects of craniopuncture and drainage for the treatment of intracerebral hemorrhage on brain edema and neurological outcome. Methods A total of 62 hypertensive patients with basal ganglia hematoma were selected. These patients were randomly divided into minimally invasive group (n = 32) and medical treatment group (n = 30). Patients of minimally invasive group were treated by craniopuncture and drainage through frontal approach. After surgery patients were given basic treatment: hemostatic agents, antibiotics, dehydration, hypertensive control and nutritive support. Patients of medical treatment group were only treated with medicine. An image process software was used to measure the volume of hematoma and brain edema. The difference in rebleeding rate, time course of complete clot absorption, brain edema volume on the first day and the third day and neurological outcome were compared between the 2 groups. Drainage time, percentage of clot removal and surgery complications were recorded to evaluate the safety of minimally invasive surgery. Results There was no rebleeding case in the 2 groups. Clot evacuation by craniectomy was performed on 6 patients (20%) in medical treatment group for severe brain edema and cerebral herniation in the first 3 d. Time course of complete clot absorption in minimally invasive group [(7.41 ± 5.84) d] was significantly lower than the medical treatment group [(23.15 ± 8.49) d; t = 9.897, P = 0.000]. On the third day edema volume in medical treatment group [(58.42 ± 11.56) ml] was significantly higher than the minimally invasive group [(8.47 ± 7.76) ml; t = 20.242, P = 0.000]. No cases of puncture⁃related bleeding, infection and death were found in the minimally invasive group. The favorable outcome rate in minimally invasive group was 93.75% (30/32), significantly higher than 66.67% (20/30) in the medical treatment group at 6 months later (P = 0.007). Conclusion The craniopuncture and drainage of intracerebral hematoma could reduce the degree of brain edema after intracerebral hemorrhage and improve neurological outcome. DOI：10.3969/j.issn.1672-6731.2011.02.021

T1006 Poor Adherence to Guidelines for Prevention of Recurrent Variceal Bleeding Among Veterans

Background: Variceal hemorrhage is the most lethal complication of cirrhosis, with 20% mortality rate within the first 6 weeks. When untreated, the risk of rebleeding is as high as 60% within 2 years. Guidelines have been proposed by the AASLD to prevent recurrence of variceal hemorrhage. We hypothesize that adherence to these guidelines is suboptimal at this Veterans Affairs Hospital. Aims: (1) To determine the proportion of patients who adhered to current AASLD guidelines for secondary prophylaxis of variceal bleeding, (2) to identify barriers to adherence and (3) to compare outcomes between patients who were compliant and those non-compliant with the guidelines. Methods: All cirrhotic patients presenting to the NF/SGVHS with an index episode of esophageal variceal bleeding between 1/1/2000 and 12/31/ 2008 were identified. Individual charts were reviewed. Primary endpoints were rebleeding or death. Statistical analyzes were performed as appropriate. Results: 67 male patients were included, mean age 59 years old (range 35-81), and followed for a mean of 18.7 months (range 0-85). Beta-blockers were initiated prior to discharge in 55 patients (82%). After index EVL, GI recommended repeat EGD in 46/67 (69%), EGD was ordered prior to discharge in 37/67 (55%), and performed within the guideline recommended 7-14 days in only 4/67 (6%). 18/67 (27%) had EVL within 30 days. Reasons for nonadherence were: MD did not order EGD in 16/32 (50%), patient cancelled in 13/32 (41%) and clinic cancelled in 3/32 (9%). Regardless of the interval between EGDs, 26 patients achieved eradication of varices, and only 9 (13.4%) had follow-up EGD for confirmation of eradication. In all, 26 patients (38.8%) suffered a rebleeding episode, and 51 (76%) were deceased by the end of the study period. Rebleeding rate was 25% of those re-scoped within 2 weeks, 35.7% of those re-scoped within 15-30 days, and 40% of the remaining patients (p=NS). There was also no difference in rebleeding rate according to eradication status. However, mortality was higher among patients who did not achieve eradication (55% vs. 21%, p= 0.0011). Conclusion: Only a negligible proportion of patients undergo appropriate secondary prophylaxis for esophageal variceal bleeding and this poor adherence is associated with increased mortality. Further efforts should be directed toward strategies to provide guideline concordant care should be targeted towards educating providers and identifying patient centered barriers to adherence. One strategy we are exploring is the creation of an order set for EGD scheduling prior to discharge.