Episode Of Variceal Bleeding Research Articles

Primary prevention of variceal haemorrhage: A pharmacological approach

The Royal Free Sheila Sherlock Liver Centre and University Division of Surgery, UCL, and Royal Free Hospital, London NW3 2QG, UKGastro-intestinal bleeding from oesophago-gastric varices or por-tal hypertensive gastropathy due to cirrhosis is a life-threateningcomplication. During the last decades, mortality rates of varicealbleeding in patients with cirrhosis have been falling, but portalhypertensive bleeding continues to be amongst the leadingcauses of death [1].For primary prophylaxis of variceal bleeding, non-selectivebeta blockade (NSBB)and endoscopic band ligation (EBL) are bothused as they are effective therapies [2,3]. Which therapy shouldbe the one of first choice can be considered a controversy. How-ever there are several issues that go beyond the initial assess-ment of differences in survival, for which there are none or firstbleeding, and for which EBL has a statistical advantage overNSBB.The safety of the endoscopic procedure is the first consider-ation. EBL can cause fatal iatrogenic bleeding [4,5], also reportedin the largest trial with the longest follow-up [6].The increasedexpense and need for specialized staff of EBL compared to NSBBis the second consideration. As mortality is not different betweentherapies, the cost-effectiveness could be mainly related to thecost of the extra variceal bleeding episodes in the NSBB treatedpatients versus the equipment and staff costs for EBL. This hasbeen evaluated prospectively in trials comprising patients onliver transplant waiting lists with mixed results, as a US trialfound a NSBB strategy more expensive [7] and a European trialfound the EBL to cost more [8]. Fatal iatrogenic bleeding wasnot ‘‘costed” and it is unclear how it could be evaluated in suchan analysis. The third consideration is that EBL cannot preventbleeding from portal hypertensive gastropathy, which is the casefor NSBB [9]. The fourth consideration is that EBL has only beenevaluated in patients with medium/large varices. Patients withsmall varices and severe liver disease are candidates for primaryprophylaxis [3]. In a single trial based on patients with contrain-dications to NSBB, some of whom also had small varices, fatal iat-rogenic bleeding occurred with EBL and the trial was stoppedprematurely [5]. Conversely NSBB are effective in patients withsmall varices [10] and are effective independent of cause andseverity of cirrhosis, the presence of ascites and variceal size[11]. Despite this long-standing evidence, the common percep-tion amongst endoscopists is that NSBB are less effective inpatients with decompensated cirrhosis. Another common mis-conception is an increased risk of hepatic encephalopathy withadministration of beta-blockers. This has not been documentedin placebo-controlled trials and is not a contraindication toreceiving beta-blockers.A further consideration is that preventative therapy, particu-larly in asymptomatic patients, should be easy to administer,have few and no serious adverse effects, and be effective. NSBBon paper fulfil these criteria better than EBL, but unfortunatelythese aspects have not been evaluated in randomised compara-tive studies. Although a survey on patient preferences in the pro-phylactic setting has been published favouring EBL, the potentialiatrogenic bleeding with EBL was not part of the questionnaire[12].There are 16 randomised trials in patients with medium tohigh risk varices comparing EBL with propranolol [6–8,13–25].In the meta-analysis of the 16 studies, EBL significantly reducedthe risk of first variceal bleeding compared to propranolol (rela-tive risk difference 9.2%, 95% CI 5.2%-13.1%, and POR 0.5, 95% CI0.37–0.68). However, mortality in the same meta-analysis wasnot statistically different (POR 0.94, 95% CI 0.70–1.28). Recentlynadolol and isosorbide mononitrate combined were found tohave similar efficacy to EBL [26]. A summary of the meta-analyt-ical data is set out in Table 1 and Fig. 1A and B. The number ofpatients needing treatment with EBL to save one episode ofbleeding is 11 (95% CI 7–21 by random effects model). It requiresan average of three endoscopic sessions to eradicate varices, sothis means, on average 33 endoscopic procedures discounting fol-low-up endoscopies after eradication. Conversely NSBB remainscheap, as haemodynamic monitoring is not required in this set-ting [27].The important conclusion when considering the merits ofNSBB or EBL for primary prophylaxis against variceal bleedingis that mortality is no different. Survival following variceal bleed-ing, including that of more severely ill patients is improving [28].As several of the randomised trials were undertaken before theuniversal use of antibiotics, which improve survival in acute var-iceal bleeding [3,29], it is likely that mortality from bleeding isalready better and will further improve. Moreover, data is emerg-ing data that NSBB may also have other beneficial therapeuticeffects in patients with cirrhosis, for example by reducing the riskof spontaneous bacterial peritonitis [30]. Improved survival withNSBB compared to EBL has been shown in a long term follow upof a randomised trial of secondary prophylaxis [31,32] leading toJournal of Hepatology 2010 vol. xxx

Non-cirrhotic extrahepatic portal vein thrombosis: a 6-year long case history

In the absence of liver cirrhosis or cancer, splanchnic vein thrombosis is rare. Additional risk factors are neoplasia, abdominal inflammatory disease, and inherited and acquired thrombophilia as reported in chronic myeloproliferative disorders (CMPD), i.e. polycythemia vera and essential thrombocythemia [1, 2]. The Janus kinase-2 somatic mutation (JAK2V617F) represents a risk factor for myeloproliferative diseases and is helpful in laboratory tests for the evaluation of unexplained abdominal vein thrombosis [3–5]. A 47-year-old man was referred (November 2007) to our gastroenterology unit for further investigations regarding complications related to portal hypertension. Extrahepatic portal vein thrombosis (EHPVT) was diagnosed in another Hospital 6 years before (November 2001) after the onset of acute abdominal pain. Basic investigations were performed in order to diagnose liver cirrhosis as the main cause of splanchnic vein thrombosis. Neither ascites nor encephalopathy was present at the time of EHPVT diagnosis. Computed tomography showed thrombosis of the portal, splenic, and mesenteric veins, without alterations in hepatic pattern. Collateral vessels and portal cavernoma, as well as splenomegaly, were also reported. The patient developed significant portal hypertension with portosystemic collaterals that caused a serious episode of esophageal variceal bleeding in June 2007. Further abdominal ultrasound investigations, confirming the EHPVT, showed a significant enlargement of the spleen (16–17 cm) with signs of portal hypertension. The liver appeared to be slightly enlarged with a normal echo-pattern and regular borders. A splenoportography confirmed the presence of spleno-portal axis thrombosis. Liver biopsy excluded cirrhosis and showed mild portal inflammation with fibrosis confined to portal tracts. In November 2007, when he was referred to our gastroenterology unit, and additional causes of non-cirrhotic EHPVT were investigated (Table 1). Liver routine laboratory examinations did not show any significant alteration. However, despite the considerable splenomegaly (18 cm at abdominal US), platelet count was higher than normal (449 9 10/l). The review of previous clinical and laboratory files showed increased platelet counts ranging from 900 to 449 9 10/l from the first (November 2001) to the last investigation. This feature was never highlighted before our case investigation. We suspected that the normal and sometimes increased platelet count might mask CMPD. A search for the molecular marker, JAK2V617F, was performed by means of PCR assay and was positive in our patient. A bone marrow biopsy showed CMPD with prevalence of megakaryocytes, as well as myelofibrosis, consistent with ‘essential thrombocythemia’. The patient started treatment with acetylsalicylic acid (75 mg/day) and hydroxycarbamide (500 mg/day). Non-cirrhotic EHPVT is quite a rare event [1, 2]. In our patient from the EHPVT onset (6 years before) onwards, despite increasing splenomegaly, platelet counts were observed at the upper level of normal range and sometimes higher than normal. However, they were never investigated until the last admission to our hospital. It could be argued that a myeloproliferative disease was already present at the time of EHPVT diagnosis. Bone marrow biopsy showed an G. Ricci (&) F. Pigo V. Alvisi Department of Clinical and Experimental Medicine, Gastroenterology, University of Ferrara, Via Savonarola 9, 44100 Ferrara, Italy e-mail: giorgio.ricci@unife.it

Adult to pediatric living donor liver transplantation for portal cavernoma

Portal cavernoma (PC) is an important cause of non-cirrhotic portal hypertension with severe complications, such as variceal hemorrhage in pediatric patients. With the development of new surgical techniques, living donor liver transplantation (LDLT) has recently been recognized as a viable but challenging treatment option for PC. The purpose of the present study was to summarize the efficacy of LDLT in PC patients and to carry out a follow-up study of pediatric recipients. The primary indication for LDLT in our research was PC with severe variceal bleeding and liver function decompensation. Three patients were diagnosed with PC following evaluation with computed tomography angiography and abdominal color Doppler ultrasonography (CDU). Various surgical techniques, including jump bypass grafting for portal vein anastomosis, were carried out according to the range and degree of cavernous transformation within the splenic vein and superior mesenteric vein. Postoperative CDU confirmed the early integrity of the portal vein (PV) in each patient. PV rethrombosis occurred in one patient 7 days after LDLT, despite anticoagulation therapy with coumadin. Two of the three patients had no further episodes of variceal hemorrhage during the 2-year follow-up period. The present study is the first report of the successful use of LDLT to treat pediatric PC patients. We conclude that LDLT is effective for the majority of pediatric patients with PC.

Long‐Term Results of Fundectomy and Periesophagogastric Devascularization in Patients with Gastric Fundal Variceal Bleeding

Gastric variceal bleeding is life-threatening, and occasionally it requires operative intervention, but its treatment is controversial. Based on our experience, we considered that fundectomy and periesophagogastric devascularization (FPD) offers an effective treatment method. Accordingly, this study was undertaken to document postoperative and long-term follow-up results, such as, gastric variceal bleeding recurrence and patient survival. A retrospective analysis was conducted on 41 patients with gastric fundal variceal bleeding who underwent FPD between August 1994 and May 2005. The evaluation included clinical characteristics, operative morbidity, mortality, and long-term follow up results. Operative morbidity and mortality rates were 26.8% and 17.1%, respectively. Child-Pugh classification, number of previous variceal bleeding episodes, success of preoperative intervention, and ongoing active bleeding during surgery were all factors found to have significant effects on postoperative mortality. No recurrent bleeding from gastric varices was encountered over a median follow-up period of 52.1 months. The cumulative 5-year survival rate was 62.0%, and the major causes of death were hepatocellular carcinoma (HCC) and hepatic failure. The operative procedure used in this study resulted in a low rate of recurrent bleeding and good long-term survival. This analysis of results suggests that fundectomy and periesophagogastric devascularization is an effective therapeutic intervention in patients with fundal variceal bleeding.

Sandostatin causing reversible thrombocytopenia

Esophageal variceal bleeding can be serious or life threatening. Drug-induced thrombocytopenia can further complicate such bleeding episodes. Thrombocytopenia because of sandostatin has been reported in the literature only once previously. We describe a case of sandostatin-induced reversible thrombocytopenia with a positive rechallenge. Platelet count decreased during administration of sandostatin and recovered only when the infusion was halted. The proposed mechanism of thrombocytopenia during both episodes is immunologic. Physician awareness of sandostatin-induced thrombocytopenia can prevent unnecessary complication during episodes of esophageal variceal bleeding and is rapidly reversed with discontinuation of the drug.

Valoración del pronóstico a corto y largo plazo de pacientes con cirrosis y hemorragia digestiva por hipertensión portal

to evaluate the efficacy of various indicators in predicting short- and long-term survival in patients with cirrhosis and acute variceal bleeding. prognostic indicators were calculated for a cohort of 201 cirrhotic patients with acute variceal bleeding hospitalized in our center, a third-level teaching hospital. The studied variables were: age, sex, etiology of cirrhosis, endoscopic findings, previous variceal bleeding episodes, human immunodeficiency virus (HIV) infection, hepatocellular carcinoma (HCC), infection during episode, and Child-Turcotte-Pugh (CTP) and Model for End-stage Liver Disease (MELD) scores within 24 hours of bleeding onset. Patients were followed up for at least 6 months until death, liver transplantation, or end of observation. median follow-up was 66.85 weeks (range 0-432.4). The 6-week, 3-month, 12-month and 36-month mortality rates were 22.9, 24.9, 34.3, and 39.8%, respectively. Age >= 65 years, presence of HCC, CTP score >=10, and MELD score >= 18 were the variables associated with mortality in the multivariate analysis. The accuracy of MELD scores as predictors of 6-week, 3-month, 12-month, and 36-month mortality was better than that of CTP scores (c-statistics: 6 week MELD 0.804, CTP 0.762; 3-month MELD 0.794, CTP 0.760; 12-month MELD 0.766, CTP 0.741; 36 month MELD 0.737, CTP 0.717). MELD and CTP scores together with age and a diagnosis of hepatocellular carcinoma are useful indicators to assess the short- and long-term prognosis of patients with acute variceal bleeding.

Model for end stage of liver disease (MELD) is better than the Child-Pugh score for predicting in-hospital mortality related to esophageal variceal bleeding

Aim: The Child Pugh and MELD are good methods for predicting mortality in patients with chronic liver disease. We investigated their performance as risk factors for failure to control bleeding, in-hospital overall mortality and death related to esophageal variceal bleeding episodes. Methods: From a previous collected database, 212 cirrhotic patients with variceal bleeding admitted to our hospital were studied. The predictive capability of Child Pugh and MELD scores were compared using c statistics. Results: The Child-Pugh and MELD scores showed marginal capability for predicting failure to control bleeding (the area under receiver operating characteristics curve (AUROC) values were < 0.70 for both). The AUROC values for predicting inhospital overall mortality of Child-Pugh and MELD score were similar: 0.809 (CI 95%, 0.710 - 0.907) and 0.88 (CI 95% 0.77-0.99,) respectively. There was no significant difference between them (p > 0.05). The AU-ROC value of MELD for predicting mortality related to variceal bleeding was higher than the Child-Pugh score: 0.905 (CI 95% 0.801-1.00) vs 0.794 (CI 95% 0.676 - 0.913) respectively (p < 0.05). Conclusions: MELD and Child-Pugh were not efficacious scores for predicting failure to control bleeding. The Child-Pugh and MELD scores had similar capability for predicting in-hospital overall mortality. Nevertheless, MELD was significantly better than Child-Pugh score for predicting in-hospital mortality related to variceal bleeding.

Prevention of recurrent variceal bleeding

Patients surviving a first episode of variceal bleeding have a risk of over 60% of experiencing recurrent haemorrhages within 1 year from the index episode. Because of this, all patients surviving a variceal bleeding should receive active treatments for the prevention of rebleeding. β-Blockers ± isosorbide-5-mononitrate and band ligation are effective in preventing recurrent bleeding and both can be used. Combination of β-blockers ± isosorbide-5-mononitrate and band ligation may be the best treatment to prevent rebleeding but more studies are needed to confirm this issue. In patients with recurrent variceal bleeding despite appropriate medical and endoscopic treatment, transjugular intrahepatic porto-systemic shunt is highly effective in controlling bleeding. The efficacy is not significantly different from that of shunt surgery (distal splenorenal shunt or 8 mm H-graft shunt), especially since the introduction of polytetrafluoroethylene-covered stents. Therefore, in this situation, transjugular intrahepatic porto-systemic shunt using polytetrafluoroethylene stents should be the treatment of choice.

Duplex sonography study in schistosomiasis portal hypertension: characterization of patients with and without a history of variceal bleeding

Presinusoidal portal hypertension with frequent episodes of upper gastrointestinal variceal bleeding are hallmarks of hepatosplenic Mansons schistosomiasis; a clinical form that affects about 5% of Brazilians who are infected by Schistosoma mansoni. To evaluate duplex sonography findings in patients with hepatosplenic Mansons schistosomiasis with and without upper gastrointestinal variceal hemorrhage. A cross-sectional study was performed whereby 27 consecutive patients with hepatosplenic Mansons schistosomiasis were divided into two groups: group I (six men and six women; mean age 48.7 years) with a past history of bleeding and group II (four men and eight women; mean age 44.7 years) without a past history of upper gastrointestinal bleeding, underwent duplex sonography examination. All patients underwent the same upper gastrointestinal endoscopy and laboratory examinations. Those with signs of mixed chronic liver disease or portal vein thrombosis (three cases) were excluded. Group I showed significantly higher mean portal vein flow velocity than group II (26.36 cm/s vs 17.15 cm/sec). Although, as a whole it was not significant in all forms of collateral vessels (83% vs 100%), there was a significantly higher frequency of splenorenal collateral circulation type in group II compared with group I (17% vs 67%). The congestion index of the portal vein was significantly lower in group I than in group II (0.057 cm vs 0.073 cm/sec). Our duplex sonography findings in hepatosplenic Mansons schistosomiasis support the idea that schistosomotic portal hypertension is strongly influenced by overflow status, and that collateral circulation seems to play an important role in hemodynamic behavior.

The Treatment of Acute Variceal Bleeding

Bleeding from gastroesophageal varices is a frequent and often deadly complication of cirrhosis. Although mortality from an episode of variceal bleeding has decreased in the last 2 decades it is still around 20%. This paper reviews the most recent advancements in the general management and hemostatic treatments of acute variceal bleeding.

Efficacy of the combination of long-acting release octreotide and tamoxifen in patients with advanced hepatocellular carcinoma: a randomised multicentre phase III study

To assess the efficacy of the combination of long-acting release (LAR) octreotide and tamoxifen (TMX) for the treatment of advanced hepatocellular carcinoma (HCC). A total of 109 patients with advanced HCC were randomised to receive octreotide LAR combined with TMX (n=56) (experimental treatment group) or TMX alone (n=53; control group). The clinical, biological and tumoural parameters were recorded every 3 months until death. Primary end point was patient survival; secondary end points were the impact of therapy on tumour response, quality of life and variceal bleeding episodes. Univariate and multivariate analyses were performed for assessment of specific prognostic factors. The median survival was 3 months (95% CI 1.4–4.6) for the experimental treatment group and 6 months (CI 95% 2–10) for the control group (P=0.609). There was no difference in terms of α-foetoprotein (α-FP) decrease, tumour regression, improvement of quality of life and prevention of variceal bleeding between the two groups. Variables associated with a better survival in the multivariate analysis were: presence of cirrhosis, α-FP level <400 ng ml−1 and Okuda stage I. The combination of octreotide LAR and TMX does not influence survival, tumour progression or quality of life in patients with advanced HCC.

Prevalence and Predictors of Esophageal Varices in Patients With Primary Biliary Cirrhosis

Esophageal varices and bleeding are among the most feared complications of primary biliary cirrhosis (PBC). We aimed to determine the prevalence of esophageal varices in patients with PBC, to evaluate noninvasive markers of esophageal varices in this population, and to validate the results in an independent set of patients. Data were collected on all patients with PBC seen for the first time at the University of Florida (study group) and at Case Western Reserve University hospitals (cross-validation group) during 7 consecutive years. Logistic regression analysis was used to identify independent predictors of esophageal varices. The best cut-off values were calculated based on receiver operating characteristic curves. The diagnostic accuracy of the independent predictors of esophageal varices identified in the study group were retested in the cross-validation group. Of 210 patients with PBC seen at the University of Florida, 113 had an endoscopy and 49.6% (56 of 113) were found to have esophageal varices. After excluding 22 patients with a history of variceal bleeding, data on 91 patients were analyzed. Thirty-four patients had esophageal varices (37%). Multivariate analysis revealed that a platelet count of less than 140,000 (odds ratio, 7.6; 95% confidence interval, 1.6-37) and a Mayo risk score of 4.5 or greater (odds ratio, 10.6; 95% confidence interval, 1.8-62) were independent predictors of esophageal varices. The diagnostic accuracy of these predictors was confirmed in an independent set of patients. Among patients with PBC, a platelet count of less than 140,000 and/or a Mayo risk score of 4.5 or greater appears to identify those patients more likely to benefit from a screening endoscopy.

Efficacy of endoscopic variceal ligation and sclerotheraphy in treatment of acute variceal bleeding

Introduction: Variceal bleeding is a major complication of portal hypertension contributing substantially to morbidity and mortality in this group of patients (pts). Endoscopic sclerothrapy (Scl) and variceal ligation (EVL) are established therapeutic modalities of acute variceal bleeding. Whether one of these treatment options is superior, compared to the other in the setting of acute variceal bleeding is under debate. The aim of this retrospective study is to evaluate the efficacy of EVL and Scl in pts with their first variceal bleeding episode. Patients and methods: During one year (2006), 26 pts with alcoholic cirrhosis presented with their first variceal bleeding episode. All pts underwent upper endoscopy and Scl (n=17) or EVL (n=9). Both procedures were done with standard methods. The age (63ys), the distribution gender (57%male), Child-class (A: 19%, B: 61%, C: 19%) and grade of varices (I.:0%, II: 11%, III: 42%, IV: 46%) were virtually identical in both treatment groups. Outcome measures as the rates of in-hospital mortality, rebleeding and units of blood transfusion required were compared between the two groups. Results: There was no significant difference in mortality rates (EVL: 11% vs. Scl: 17.6%, OR=1.17 95%CI (0.61–2.25) and rates of rebleeding episodes (EVL: 11% vs. Scl: 23.5%, OR=1.29 95%CI (0.74–2.24). Patients treated with Scl required significantly more units of transfusion as compared to EVL group (2.35±0.42 vs. 0.55±0.29, p=0.013). Conclusions: Based on our results, Scl and EVL seems to have similar efficacy in control of acute variceal hemorrhage. Transfusion requirements are higher in pts treated by Scl.

Acute Variceal Hemorrhage

Variceal bleeding is a frequent and life-threatening complication of portal hypertension. The first episode of variceal bleeding is associated not only with a high mortality, but also with a high recurrence rate in those who survive. Therefore, management should focus on different therapeutic strategies aiming to prevent the first episode of variceal bleeding (primary prophylaxis), to control hemorrhage during the acute bleeding episode (emergency treatment), and to prevent rebleeding (secondary prophylaxis). These strategies involve pharmacological, endoscopic, surgical, and interventional radiological modalities. This article reviews management of acute variceal bleeding.

Meta-Analysis: Pharmacotherapy Is As Effective As Endoscopic Therapy in the Secondary Prevention of Esophageal Variceal Bleeding

Introduction: Gastroesophageal variceal bleeding recurs in 70% of patients, leading to death in 20- 35% of them. Endoscopic sclerotherapy (ES), variceal ligation (EVL) and medications are all effective in reducing this rebleeding rate and death. Clinical trials comparing endoscopic procedures and drug therapy or the combination of the two are ongoing and have yielded mixed results. Although previous meta-analyses have summarized the results of these studies comparing ES with medications alone or combined with ES, there are none comparing medications with EVL. We analyzed the data from these studies to investigate if medications were as effective as ES or EVL and if adding medications to these interventions improved their efficacy. Materials and Methods: We performed a systematic literature search using Pubmed, Embase and Cochrane Central databases for English articles. Randomized clinical trials that compared Medications (beta-blockers ± nitrates) with or without ES to ES and those that compared Medications with or without EVL to EVL in patients who had at least one prior episode of gastroesophageal variceal bleeding were included. Studies that evaluated at least 1 of the following outcomes: overall mortality, mortality due to gastroesophageal bleeding, recurrence of bleeding or recurrence of bleeding from esophageal varices were included. Data was extracted on an intention-to-treat basis. Heterogeneity of the studies was analyzed by the Cochran's Q statistics. The Mantel-Haenszel fixed-effect model was used to calculate combined relative risks for those outcomes where the studies were homogenous and the random effect model when the studies were heterogenic. Results:Twenty six studies representing a total of 2268 patients fulfilled inclusion criteria. Medications were non inferior to endoscopic therapy in all outcomes. Serious adverse events were not significantly different between any two groups compared. The results are summarized in the table below: Conclusion:Beta Blockers ± nitrates are at least as effective as endoscopic therapy in reducing rebleeding rates and all cause mortality and can potentially reduce cost. They are more effective than endoscopic interventions alone when added to them. Tabled 1Results Treatment groups Rebleeding OR(95% CI) Rebleeding from varices OR(95% CI) All cause mortality OR(95% CI) Death from bleeding OR(95% CI) Meds vs ES 1.09 (0.84-1.42) 1.12 (0.66-1.90) 1.17 (0.91-1.51) 1.42 (0.92-2.19) Meds vs EVL 1.04 (0.64-1.71) 1.20 (0.55-2.63) 0.78 (0.57-1.05) 0.13 (0.06-0.29) Meds vs all endoscopic therapy 1.07 (0.86-1.32) 1.14 (0.79-1.65) 0.98 (0.82-1.18) 1.16 (0.82-1.63) Meds + ES vs ES 0.66 (0.54-0.80) 0.67 (0.47-0.96) 0.81 (0.58-1.14) 0.99 (0.50-1.95) Meds + EVL vs EVL 0.48 (0.33-0.71) 0.38 (0.19-0.75) 0.69 (0.38-1.27) 0.43 (0.15-1.25) Meds + all endoscopic therapy vs all endoscopic therapy 0.62 (0.52-0.74) 0.60 (0.44-0.82) 0.78 (0.58-1.05) 0.78 (0.44-1.38) EVL- Endoscopic variceal ligation ES- Endoscopic sclerotherapy Open table in a new tab EVL- Endoscopic variceal ligation ES- Endoscopic sclerotherapy

Risk and causes of gastroesophageal bleeding in patients with liver cirrhosis

Variceal bleeding is the most life-threating complication in liver cirrhosis. The aim of this study was to analyze the sources of gastroesophageal bleeding in patients with liver cirrhosis and to ascertain the risk factors of bleeding from esophageal varices. This prospective study included 52 patients with liver cirrhosis and portal hypertension. Severity of liver dysfunction according to Child's classification, coagulation parameters, and endoscopic findings were analyzed. In patients with varices we analyzed the size, color, location of varices, and the presence of red signs. The varices were classified as small, medium and large. Esophageal varices were found in 76.9% of the patients. Isolated varices were present in 36.6%, and associated with other findings in 40.3%. Small varices were present in 10%, medium in 25% and large in 65% patients. Of them 55% had variceal bleeding. Variceal bleeding was present in 50% of the patients with medium and in 65.38% of the patients with large varices. There was no bleeding in the patients with small varices. Endoscopy revealed red signs before bleeding in 85% of the patients with large varices. There was a higher incidence of variceal bleeding in the Child's group B. There were no significant differences (p > 0.05) in the coagulation parameters in patients with and without variceal bleeding. Rebleeding was present in 86.36% of the patients. Most of them (52.63%) were rebleeding between 7 weeks and 12 months after the first episode of variceal bleeding. In the patients with the most severe hepatocellular dysfunction (Child's group C) the period between the first bleeding and rebleeding was the shortest (mean, 20.8 days). Our study revealed that esophageal varices are the most frequent sources of bleeding in the patients with liver cirrhosis. There is the association between the first bleeding and large varices and the red signs. Coagulation disorders and hepatic dysfunction were not related to the initial episode of variceal bleeding. The risk of early rebleeding was higher in the patients with severe hepatic dysfunction (Child's class C).

Unusual Antibody Reactions in a 55-Year-Old Man

2. Our patient’s anti-C was formed as an immunological response to a previous allogeneic RBC transfusion, which may have been received during his back surgeries or variceal bleeding episodes. The presence of multiple antibodies in his plasma on day 4 of his hospitalization is most likely an anamnestic response of antibodies that were not detectable prior to the current transfusion episode. The decreasing hemoglobin levels accompanied by a post-transfusion rise in serum total bilirubin and LDH levels are indicative of RBC hemolysis resulting from an immune response, commonly known as a delayed hemolytic transfusion reaction (DHTR). The patient’s low haptoglobin level on day 5 could have been caused by the release of free hemoglobin into Clinical History Patient 55-year-old Caucasian man.

Improved survival of patients presenting with acute variceal bleeding: Prognostic indicators of short- and long-term mortality

Background and aim Variceal bleeding is a severe complication of portal hypertension with a mortality rate between 30% and 60% in previous studies. During the last two decades the treatment of these patients has been improved. The aim of this study was to investigate the clinical outcome of patients after an episode of acute variceal bleeding and to identify risk factors for early and late mortality in these patients. Materials and methods All patients with acute variceal bleeding hospitalised at two large hospitals between January 1, 1999 and June 30, 2004, were retrospectively enrolled in this study. After discharge, patients were followed until death or study closure date, on June 30, 2005. Bleeding related mortality, 6-week, 1-year and overall mortality were evaluated as well as factors related to early and late mortality. Results One hundred and forty one patients were included (114 men, 27 women) with a mean age of 60.5 ± 13.5 years. In hospital, 6-week, 1-year and overall mortality were 12.1%, 18.4%, 32.6% and 48.2%, respectively. The mean length of hospitalisation was 11.4 ± 9 days (1–55) and the mean packed red blood cell requirement was 3.9 ± 3.7 (0–25). The rate of recurrent bleeding was 10.7% during initial hospitalisation. Being Child-Pugh C ( p = 0.003) and shock on admission ( p = 0.037) were independent predictors of 6-week mortality, while being Child-Pugh C ( p = 0.028), presence of hepatocellular carcinoma or other neoplasia ( p = 0.04) and partial thromboplastin time ( p = 0.021) during the initial admission were independent predictors for 1-year mortality. Mortality was not affected by the presence of active bleeding and/or white nipple at emergency endoscopy. Also presence of infection was not an adverse factor of clinical outcome in our patients. Conclusions In conclusion, the clinical outcome of patients with acute variceal bleeding is better in comparison with previous studies. The severity of liver failure as well as the presence of neoplasia mainly affects the survival.

Profilaxis secundaria mediante ligadura con bandas elásticas en varices esofagogástricas

The aim of the present study was to determine the usefulness of elastic band ligation in the prevention of hemorrhage recurrence due to esophageal-gastric varices. Sixty-five patients who survived an episode of variceal hemorrhage were included in the study. Twenty-nine patients (45%) were Child-Pugh class A, 25 (38%) were class B, and 11 (17%) were class C. The cause of cirrhosis was hepatitis C virus and alcohol in 45% and 31% of the patients, respectively. The first ligation session was performed between the third and fifth day after the hemorrhagic episode and subsequent sessions were carried out at intervals of 3-4 weeks. The ligation sessions were performed with antibiotic prophylaxis. A mean of 2.7 bands were placed per session (range 1-5), and the mean number of sessions required per patient to achieve variceal eradication was 2.5 (range 1-6). The rate of bleeding recurrence was 24.6% (16 episodes). In conclusion, endoscopic elastic band ligation is a useful technique for the eradication of esophageal varices and for the prevention of bleeding recurrence.

201 Endoscopic variceal ligation versus pharmacologic treatment for primary prophylaxis of variceal bleeding: a randomised study

Background and Aims: Bleeding varices is a major complication of liver cirrhosis; 30 70% may die from the effect of the first bleed. Primary prophylax~is is therefore an important therapeutic goal. The aim of this study is to compare Endoscopic Variceal Ligation (EVL) with medical treatment for the prevention of the first episode of variceal bleeding. Methods: 156 cirrhotic patients with risky varices were prospectively randomized to receive either EVL (51 patients), propranolol (52 patients) or Isosorbid-5-Mono-Nitrate (ISMN) (53 patients). And follow-up for 18 24 months for bleeding episodes and or mortality. Results: There was no statistically significant difference between the 3 groups as regard sex, age, Child score, etiology of cirrhosis and grade of varices. Bleeding occurred in 4 (7.5%) in EVL group, 18 (34.6%) in ISMN group and 13 (25.5%) in propranolol group. There was no difference in mortality when the 3 groups were compared (7.5% vs 11.5% vs 9.8%), P 0.78. Complications or side effects were reported in 28.3% in EVL compared to 34.6% with ISMN and 39.2% for propranolol. Conclusion: In patients with high risk esophageal varices, EVL is more effective and safer than propranolol which is more effective than ISMN for primary prophylaxis of variceal bleeding.