Bleeding Esophageal Varices Research Articles

Risk factors for rebleeding after endoscopic selective variceal devascularization in patients with hepatitis B cirrhosis and acute variceal bleeding

Objective To investigate the rebleeding rate after endoscopic selective variceal devascularization (ESVD) and the predictive factors for rebleeding in patients with hepatitis B cirrhosis and esophageal variceal bleeding (EVB). Methods The patients with hepatitis B cirrhosis and EVB who attended Beijing Ditan Hospital, Capital Medical University, from October 2010 to December 2019 and underwent ESVD for the first time were enrolled, and a total of 442 patients were screened out based on inclusion and exclusion criteria. Routine clinical indices, laboratory markers, imaging findings, and endoscopic findings were compared between patients, and the patients were followed up to observe rebleeding. The t-test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups; the chi-square test was used for comparison of categorical data between two groups. The Kaplan-Meier method was used to describe rebleeding and survival status, and a Cox regression analysis was used to determine the independent risk factors for variceal rebleeding. Results The 1-, 2-, 3-, 4-, and 5-year cumulative rebleeding rates after first ESVD treatment were 25.11%, 33.94%, 39.82%, 42.08%, and 45.02%, respectively. The univariate analysis showed that age, systolic pressure, duration of antiviral therapy ≥1 year, ascites, white blood cell count, neutrophil, and direct bilirubin were associated with rebleeding (all P Conclusion ESVD has a low rebleeding rate in the treatment of hepatitis B cirrhosis with EVB, and presence of ascites and a short duration of antiviral therapy are independent risk factors for rebleeding after treatment.

Risk factors for early rebleeding after endoscopic therapy for esophageal varices in cirrhotic patients

Objective To investigate the risk factors for early rebleeding after endoscopic ligation or sclerotherapy for esophageal variceal bleeding in cirrhotic patients. Methods A retrospective analysis was performed for the clinical data of 153 cirrhotic patients with esophageal variceal bleeding who underwent endoscopic ligation or sclerotherapy in Beijing YouAn Hospital, Capital Medical University, from May 2017 to May 2019, and according to the presence or absence of rebleeding from 72 hours to 6 weeks after endoscopic therapy, the patients were divided into rebleeding group and non-rebleeding group. A logistic regression analysis was performed to investigate independent risk factors for early rebleeding. The t-test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups; the chi-square test or the Fisher's exact test was used for comparison of categorical data between two groups. Results Early rebleeding rate was 24.8% (38/153). Compared with the non-rebleeding group, the rebleeding group had a significantly lower albumin (Alb) and significantly higher activated partial thromboplastin time and prothrombin time (all P Conclusion Portal vein thrombosis, massive ascites, Child-Pugh C liver cirrhosis, and hypoproteinemia are independent risk factors for early rebleeding after endoscopic therapy in cirrhotic patients with esophageal variceal bleeding, which should be taken seriously in clinical practice.

Taeniasis: An unexpected variceal hemorrhage trigger.

Here we report a fatal and uncommon case of esophageal variceal bleeding secondary to the presence of a Tapeworm in the upper digestive tract in a patient coming back from North Africa.

Preservation of thrombin generation in cirrhosis despite abnormal results of international normalized ratio: implications for invasive procedures.

Thrombin generation is normal or elevated in patients with cirrhosis when tested in the presence of thrombomodulin, the activator of the main natural anticoagulant protein C. However, the relationship between thrombin generation with bleeding has been little explored in literature. 97 Consecutive patients with cirrhosis were prospectively included (58 men; 54 ± 10 years) and divided into two groups international normalized ratio (INR) less than 1.5 (n = 72) or INR at least 1.5 (n = 25). 46 Healthy individuals were tested as controls. Endogenous thrombin potential (ETP) was measured without and with the addition of thrombomodulin. ETP measured without thrombomodulin was reduced in patients with cirrhosis when compared with controls, but no significant difference was found between the INR less than 1.5 and INR at least 1.5 groups (1250 ± 315.7 versus 1186 ± 238 nmol/l × min; P = 0.3572). After the addition of thrombomodulin, both groups generated thrombin comparable with controls (INR ≥ 1.5: 965.9 ± 232.3; INR < 1.5: 893.0 ± 368.6; controls: 915.0 ± 458 nmol/l × min). 80% of patients had high ETP without/with thrombomodulin ratio, demonstrating the resistance to the anticoagulant action of thrombomodulin for both groups. This was more marked in the INR at least 1.5 group (0.81 ± 0.1 versus 0.69 ± 0.2; P = 0.0042). Postligation of esophageal varices bleeding occurred in 5.2% of patients (INR < 1.5, n = 3; INR ≥ 1.5, n = 2), all of them with ETP without/with thrombomodulin ratio ranging from 0.72 to 0.90 (controls 0.57 ± 0.21). This study confirms that thrombin generation in the presence of thrombomodulin was normal in most patients with cirrhosis, including those with high INR value, but did not correlate with postligation of esophageal varices bleeding.

Variceal Bleed and Portal Hypertensive Gastropathy in a Noncirrhotic Patient with Isolated Splenomegaly

Portal hypertension caused by cirrhosis is the most common etiology of esophageal varices. However, abnormalities of the splenoportal axis in the absence of liver disease may also cause portal hypertension resulting in varices. We report a rare case of esophageal variceal bleed in a noncirrhotic patient with isolated splenomegaly secondary to chronic granulocyte colony stimulating factor (G-CSF) therapy. The patient is a 26-year-old male with Cohen syndrome who required long-term G-CSF treatment for chronic neutropenia. He presented with large volume hematemesis and pancytopenia in the setting of known splenomegaly with no evidence of cirrhosis. An urgent EGD revealed active variceal bleeding and portal hypertensive gastropathy. The patient was appropriately resuscitated and underwent a successful transjugular intrahepatic portosystemic shunt and CT-guided coil placement for the bleeding varices. We are the first to report variceal bleed as a complication of long-term G-CSF use, a life-threatening consequence that requires urgent intervention.

Efficacy of Endoscopic Variceal Ligation in the Control of Variceal Bleeding: A Real World Setting

Background: Combined pharmacological and endoscopic therapy, particularly endoscopic variceal ligation (EVL), is the first-line treatment for acute esophageal variceal bleeding (EVB). In patients with rebleeding, the rescue treatment with a transjugular intrahepatic portosystemic shunt (TIPS) is recommended. However, in a real world setting where the accessibility to TIPS is limited, repeated endoscopic therapy is inevitably performed. Objective: To study the outcomes of EVL on rebleeding and mortality in the resource-limited setting. Materials and Methods: Patients who underwent EVL during 2017 to 2018 are included. Patients were treated with vasoactive drugs and EVL until the eradication of varices. We focus on the outcome of a second attempt at EVL to control EVB. The rebleeding and mortality rate within 6 months after the combined treatment were collected. Logistic regression analysis was performed to identify risk factors of rebleeding. Results: There were 339 EVL performed during the 2-year period. Of these procedures, EVL was indicated to control acute EVB in 118 patients. EVB in 98 patients (83%) were successfully controlled in only one session of EVL, while those of 20 patients (17%) required at least 2 sessions to control the recurrent EVB. In the rebleeding group, no patient rebled within 5 days after the first EVL, while 15 patients (75%) rebled within 6 weeks. Once rebled, the second EVL was performed. There were 5 patients (25%) whom the second EVL failed to control the recurrent EVB. Those recurrent EVB were finally controlled by the other endoscopic therapy. The 6-week mortality after rebleeding was 15%. Hepatocellular carcinoma and creatinine are factors associated with recurrent EVB within 6 weeks with odds ratio (OR) 5.96 (95% CI 1.41 to 25.19, p = 0.02) and OR 1.47 (95% CI: 1.02 to 2.11, p = 0.04), respectively. Conclusion: The second attempt at endoscopic therapy can be considered to control recurrent EVB after the first EVL with a success rate of 75% in area where an accessibility to a treatment with TIPS is limited. Keywords: Endoscopic therapy, Outcomes, Real world, Recurrent, Variceal bleeding

End-stage liver disease in persons with hemophilia and transfusion-associated infections

Many persons with hemophilia were infected with hepatitis C and B viruses (HCV, HBV) and HIV, but the consequences of these transfusion-acquired infections are poorly defined. We estimated the risk of HCV-related end-stage liver disease (ESLD) and the associations of age, HBV, and HIV with that risk. All 1816 HCV-seropositive hemophilic patients at 16 centers were followed for up to 16 years. Of these, 624 were HIV(-) and 1192 were HIV-coinfected; 135 had persistent HBV surface antigenemia, 1374 had resolved HBV infection, and 287 were HBV-uninfected. ESLD was defined as bleeding esophageal varices, hepatic encephalopathy, persistent ascites, or death excluding nonhepatic causes of these conditions. Competing risk models were used to estimate the annual hazard rate and cumulative incidence of ESLD. Proportional hazards models were used to estimate relative hazards of ESLD with covariates. ESLD developed in 127 of the HCV/HIV-coinfected participants, with an estimated 16-year cumulative incidence of 14.0% (95% confidence interval [CI], 11.6%-16.4%). Without HIV, 10 HCV-infected participants developed ESLD, for a significantly lower cumulative incidence of 2.6% (95% CI, 1.0%-4.3%, P <.0001). ESLD risk increased steeply with age in both groups. With HIV, ESLD risk was increased 8.1-fold (95% CI, 1.9-35.2) with HBV surface antigenemia, 2.1-fold (95% CI, 1.3-3.3) with fewer than 0.2 x 10(9)/L (200/microL) CD4(+) lymphocytes, and 1.04-fold (95% CI, 1.03-1.06) per year of age. Thus, HIV is associated with a markedly increased risk of HCV-related ESLD for persons with hemophilia, particularly with HBV infection, low CD4(+) lymphocytes, or older age.

Effect of L-Ornithine L-Aspartate on the quality of life in patients with esophageal and gastric variceal bleeding

Annotation. The aim of the study was to evaluate the dynamics of changes in the quality of life of patients with liver cirrhosis complicated by esophageal and gastric variceal bleeding while taking L-Ornithine L-Aspartate. 67 patients with a confirmed diagnosis of liver cirrhosis complicated by esophageal and gastric variceal bleeding were included in the study. All patients were randomly divided into two groups – experimental group (34 patients, standard therapy, supplemented with L-Ornithine L-Aspartate) and comparison group (33 patients, standard therapy). To evaluate the effectiveness of the treatment, the quality of life was assessed using the Gastrointestinal Symptom Rating Scale questionnaire on days 1st–2nd, 7th and 30th. Parametric values were evaluated using Student's t-test, non-parametric values - using the Mann-Whitney test. The intensity of the studied syndromes at the beginning of the study did not differ significantly in both groups. It is explained by the homogeneity of the patient population. In patients of the experimental group, there was a tendency to a more rapid progressive decrease in the intensity of the studied parameters both during their stay in the hospital and after discharge. The improvement in the quality of life after discharge of patients of the experimental group from the hospital is associated with the continuation of the course of taking L-Ornithine L-Aspartate in the form of granules. A moderate decrease in the intensity of the studied syndromes during hospitalization in patients of the comparison group can be explained by the appointment of only standard intensive care. After the patients of the comparison group were discharged from the hospital and the intensive care was stopped, no changes in the quality of life were observed. Thus, the administration of L-Ornithine L-Aspartate to patients with liver cirrhosis complicated by esophageal and gastric variceal bleeding can significantly improve the quality of life and reduce the intensity of dyspeptic, pain, diarrheal, constipation and reflux syndromes. It is planned to evaluate the long-term results of the use of L-Ornithine L-Aspartate in this patient population.

An Unexpected Favourable Evolution of Advanced Stage Cirrhosis.

The elimination of the aetiological factors causing liver injury is the cornerstone in preventing decompensation and improving prognosis in patients with cirrhosis.Spontaneous complete recanalization of the portal vein may occur.A transjugular intrahepatic portosystemic shunt (TIPS) is effective in managing some of the major complications of portal hypertension, such as refractory ascites, and provides secondary prophylaxis of oesophageal variceal haemorrhage.

Liver Stiffness-Based Strategies Predict Absence of Variceal Bleeding in Cirrhotic Hepatitis C Virus-Infected Patients With and Without Human Immunodeficiency Virus Coinfection After Sustained Virological Response.

In the setting of hepatitis C virus (HCV) active infection, liver stiffness (LS)-based strategies identify patients with low risk of developing esophageal variceal bleeding (VB) episodes, in whom unnecessary upper esophagogastroduodenoscopy (UGE) screening can be safely avoided. However, after sustained virological response (SVR), data on the accuracy of the criteria predicting this outcome in HCV-infected patients with cirrhosis, with or without human immunodeficiency virus (HIV) coinfection, are very limited. This was a multicenter prospective cohort study, where HCV-monoinfected patients and HIV/HCV-coinfected individuals were included if they had (1) SVR with direct-acting antiviral-based therapy; (2) LS ≥9.5 kPa previous to treatment; and (3) LS measurement at the SVR time-point ≥14 kPa. Diagnostic accuracy of HEPAVIR, expanded Baveno VI, and HIV cirrhosis criteria, at the time of SVR, was evaluated. Missed VB episodes, negative predictive values (NPVs), and number of spared UGEs were specifically assessed. Four hundred thirty-five patients were included, 284 (65%) coinfected with HIV. Seven (1.6%) patients developed a first episode of VB after SVR. In patients without a previous VB episode, HEPAVIR, expanded Baveno VI and HIV cirrhosis criteria achieved NPV for first VB episode after SVR of 99.5% (95% confidence interval [CI], 97.1%-100%), 100% (95% CI 97.8%-100%), and 100% (95% CI 98%-100%) while sparing 45%, 39%, and 44% of UGEs, respectively. When considering HIV coinfection, the performance of the 3 criteria was similar, both in HCV-monoinfected and HIV/HCV-coinfected individuals. After SVR, predictive LS-based strategies accurately identify HCV-infected patients, HIV coinfected or not, with low risk of developing VB during follow-up. In these specific patients, using HIV cirrhosis criteria maximize the number of spared UGEs while missing no VB episode.

Band ligation versus sclerotherapy for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis.

Portal hypertension commonly accompanies advanced liver disease and often gives rise to life-threatening complications, including haemorrhage from oesophageal and gastrointestinal varices. Variceal haemorrhage commonly occurs in children with chronic liver disease or portal vein obstruction. Prevention is therefore important. In adults, numerous randomised clinical trials have demonstrated benefits of non-selective beta-blockers and endoscopic variceal ligation as primary prevention in decreasing the risk of variceal haemorrhage. In children, band ligation, beta-blockers, and sclerotherapy have been proposed as alternatives for primary prophylaxis of oesophageal variceal bleeding. However, primary prophylaxis is not the current standard of care in children because it is unknown whether those treatments are of benefit or cause harm when used for primary prophylaxis of oesophageal variceal bleeding in children and adolescents. To determine the benefits and harms of band ligation versus sclerotherapy for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis. We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, PubMed, Embase, LILACS, and Science Citation Index Expanded (27 April 2020). We scrutinised the reference lists of retrieved publications, and performed a manual search from the main paediatric gastroenterology and hepatology conferences (NASPGHAN and ESPGHAN) abstract books from 2008 to 2019. We searched ClinicalTrials.gov, FDA, EMA, and WHO for ongoing clinical trials. There were no language or document type restrictions. We planned to include randomised clinical trials irrespective of blinding, language, or publication status for assessment of benefits and harms. If the search for randomised clinical trials retrieved quasi-randomised and observational studies, then we read them through to extract information on harms. We planned to summarise data from randomised clinical trials by standard Cochrane methodologies. We planned to assess risk of bias and use GRADE to assess the certainty of evidence per outcome. Our primary outcomes were all-cause mortality, serious adverse events and liver-related morbidity, and quality of life. Our secondary outcomes were oesophageal variceal bleeding and adverse events not considered serious. We planned to analyse data with intention-to-treat. We planned to use Review Manager 5 to analyse the data. We found no randomised clinical trials assessing band ligation versus sclerotherapy for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. Randomised clinical trials assessing the benefits or harms of band ligation versus sclerotherapy for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis are lacking. Therefore, trials with adequate power and proper design, assessing the benefits and harms of band ligation versus sclerotherapy on patient-relevant clinical outcomes such as mortality, quality of life, failure to control variceal bleeding, and adverse events are needed. Unless such trials are conducted and the results become published, we cannot make any conclusions regarding the benefits or harms of these two interventions.

Gastrointestinal bleeding in patients with pancreatic cancer: Causes and haemostatic treatments.

Gastrointestinal bleeding is a rare but severe complication of pancreatic ductal adenocarcinoma. The purpose of this study was to describe the causes and treatments of non-postoperative gastrointestinal bleeding in patients with pancreatic ductal adenocarcinoma, and explore the parameters associated with therapeutic effectiveness. This was a single-centre observational retrospective study (2000-2017) with data collected from the prospectively coded diagnostic hospital's database system including patients with pancreatic ductal adenocarcinoma who had a gastrointestinal bleeding episode. Effectiveness of haemostatic treatment was assessed according to transfusion requirements and immediate and long-term haemostatic efficacy; the latter defined as no bleeding recurrence. The population included 72 patients with pancreatic ductal adenocarcinoma who had 94 episodes of gastrointestinal bleeding. The main causes of gastrointestinal bleeding were gastroduodenal tumour invasion (56.4%) and oesophageal variceal bleeding due to left-sided portal hypertension (19.1%). In cases of gastrointestinal bleeding caused by tumour invasion, the main treatment was therapeutic endoscopy (41.5%). Among patients who had gastrointestinal bleeding by tumour invasion treated by endoscopy or radiation therapy, haemostatic immediate efficacy rates were 70.6% and 100%, respectively. Bleeding recurrence rates were 35.3% and 25.0%, for patients treated by endoscopy or radiation therapy, respectively, for a first episode of gastrointestinal bleeding by tumour invasion. Transfusion requirements, before and after treatment, were not different in patients treated by haemostatic radiation therapy for gastrointestinal bleeding by tumour invasion compared to other treatments (odds ratio 0.3, 95% CI (0.06-1.59); p = 0.16). The median survival after all-cause gastrointestinal bleeding was 2.72 months (1.43-4.01). Gastroduodenal tumour invasion was the main cause of gastrointestinal bleeding in patients with pancreatic ductal adenocarcinoma; haemostatic radiation therapy is a potential interesting option for gastrointestinal bleeding treatment in this context.

Clinical usage of serum albumin to ascitic fluid albumin gradient and ascitic fluid total protein in pediatric ascites

Abdominal paracentesis is performed as a diagnostic test in children with ascites. Serum albumin to ascitic fluid albumin gradient (SAAG) is frequently used in adults to distinguish types of portal hypertension. We aim to investigate the utilization of SAAG and other biomarkers in determining the etiology of significant ascites in children. In this retrospective study, children aged 0-21 years with significant ascites were identified using International Classification of Diseases, Ninth Revision (ICD-9) codes and medical records during the period 1983-2010. Medical records of children who had abdominal paracentesis were examined in detail. 207 children had significant ascites and of those children, 20 (9.6%) had abdominal paracentesis. Our data showed that high albumin gradient (SAAG ≥ 1.1 g/dL) differentiates causes of ascites secondary to portal hypertension (cirrhosis, hepatic vein outflow obstruction, or congestive hepatopathy) from other causes. In addition, ascitic fluid total protein (AFTP) may help in differential diagnosis of ascites. Children with high SAAG manifest clinical features of portal hypertension including esophageal varices or variceal hemorrhage. Among patients with initially unclear causes of ascites, SAAG and AFTP can provide guidance for appropriate investigations.

Hepatic Encephalopathy and Spontaneous Bacterial Peritonitis Improve Cirrhosis Outcome Prediction: A Modified Seven-Stage Model as a Clinical Alternative to MELD.

Classification of cirrhosis based on clinical stages is rapid and based on five stages at present. Two other relevant events, hepatic encephalopathy (HE) and spontaneous bacterial peritonitis (SBP), can be considered in a clinical perspective but no study has implemented a seven-stage classification and confirmed its value before. In addition, long-term validation of the Model for End-Stage Liver Disease (MELD) in large cohorts of patients with cirrhosis and comparison with clinical findings are insufficient. Therefore, we performed a study to address these items. From the Chang-Gung Research Database (CGRD), 20,782 patients with cirrhosis were enrolled for an historical survival study. The MELD score, the five-stage clinical score (i.e., occurrence of esophageal varices (EV), EV bleeding, ascites, sepsis) and a novel seven-stage clinical score (i.e., occurrence of EV, EV bleeding, ascites, sepsis, HE, SBP) were compared with their Cox models by receiver operating characteristic (ROC) analysis. The addition of HE and SBP to the seven-stage model had a 5% better prediction result than the five-stage model did in the survival ROC analysis. The result showed that the seven clinical stages are associated with an increased risk for mortality. However, the predicted performances of the seven-stage model and MELD system are likely equivalent. In conclusion, the study (i) proved that clinical staging of cirrhosis based on seven items/stages had higher prognostic value than the five-stage model and (ii) confirmed the validity of the MELD criteria vs. clinical assessment.

Potential Value of Splenectomy for the Life Quality and Long-term Survival of Patients with Cirrhosis

Patients with cirrhosis will gradually develop portal hypertension (PHT) and esophagogastric varices, and subsequently the more severe and often lethal complications such as bleeding esophageal varices, ascites, spontaneous bacterial peritonitis, renal dysfunction and hepatic encephalopathy. To date, there is still not any effective therapy for the prevention of the development these serious complications. The initial factor leading to PHT is an increase in hepatic resistance. Then, the increase in portal blood ?ow contributes to the maintenance and exacerbation of PHT, as well as the formation of esophagogastric varices and lethal complications. Increasing evidence shows that, enlarged spleen not only contributes to the increase in portal venous inflow, but also plays a contributory role in promoting almost all lethal complications of cirrhosis through its resulted hypersplenism together with other mechanisms. So, we hypothesize that prophylactic splenectomy may efficiently delay the progression of cirrhosis and improve life quality and long-term survival of patients with cirrhosis.

Primary prevention of bleeding from esophageal varices in patients with liver cirrhosis: An update and review of the literature.

All patients with liver cirrhosis and portal hypertension should be stratified by risk groups to individualize different therapeutic strategies to increase the effectiveness of treatment. In this regard, the development of primary prophylaxis of variceal bleeding and its management according to the severity of portal hypertension may be promising. This paper is to describe the modern principles of primary prophylaxis of esophageal variceal bleeding in patients with liver cirrhosis. The PubMed and EMbase databases, Web of Science, Google Scholar, and the Cochrane Database of Systematic Reviews were used to search for relevant publications from 1999 to 2019. The results suggested that depending on the severity of portal hypertension, patients with cirrhosis should be divided into those who need preprimary prophylaxis, which aims to prevent the formation of esophageal varices, and those who require measures that aim to prevent esophageal variceal bleeding. In subclinical portal hypertension, therapy should be etiological and pathogenetic. Cirrhosis with clinically significant portal hypertension should receive nonselective β-blockers if they have small esophageal varices and risk factors for variceal bleeding. Nonselective β-blockers are the first-line drugs for the primary prevention of bleeding from medium to large-sized esophageal varices. Endoscopic band ligation is indicated for the patients who are intolerant to nonselective β-blockers or in the case of contraindications to pharmacological therapy. In summary, the stratification of cirrhotic patients by the severity of portal hypertension and an individual approach to the choice of treatment may increase the effectiveness of therapy as well as improve survival rate of these patients.

Fibrosis index predicts variceal bleeding and reduces need for nonselective beta-blocker in compensated cirrhosis with initial small esophageal varices without red-color sign.

BackgroundVarious non-invasive markers predicting hepatic fibrosis are poor predictors of esophageal variceal bleeding (EVB). Elastography performs well but resource-limited. Controversy for small EV prevention also exists. We aim to investigate if a non-invasive marker could predict subsequent EVB within 1 and 2 years in patients with compensated liver cirrhosis (CLC), initial small EV without red-color sign (RCS), without use of non-selective beta-blockers (NSBB) and endoscopic variceal ligation (EVL). This marker would also be tested if it could help reduce use of NSBB, thereby avoiding potential side effects and saving medical costs.MethodsIn this retrospective cohort study, 6,803 CLC patients fulfilling the inclusion-exclusion criteria were enrolled between 2001 and 2018, and were followed-up for 1 year, 2 years. The primary outcomes were subsequent EVB within 1 and 2 years of enrollment. Another 281 CLC patients with NSBB use were compared for additional outcome analysis.ResultsIn total, 539 patients and 710 patients experienced EVB within 1 year and 2 years, respectively. The fibrosis index (FI) with cut-off value of 3.95 showed a negative predictive value (NPV) of 94.3% and an area under receiver operating characteristic (AUROC) of 62.95% for predicting subsequent EVB within 1 year. The EVB and mortality of patients with FI <3.95 and not taking NSBB were significantly lower than those of the other 3 groups. Similar results were demonstrated within 2 years.ConclusionsIn CLC patients with initial small EV and no RCS, low FI scores showed a high NPV and moderate AUROC in predicting subsequent EVB and mortalities, signifying clinically non-significant portal hypertension. Patients with low FI scores and not taking NSBB had significantly lowest EVB and mortality. The medical cost savings for cutting NSBB in these patients would be estimated at least $3 million per year in the U.S. Further randomized control trial study needed to validate this screening tool.

S2192 Over-the-Scope Clip as Rescue Treatment for Bleeding Gastric Varices

INTRODUCTION: We present a case of gastrointestinal bleeding in a patient with pancreatitis-induced splenic vein thrombus. This case highlights an important etiology of gastric varices, a known complication of treating them, as well as a method for treating refractory bleeding. CASE DESCRIPTION/METHODS: An 18-year-old male with ALL s/p post allogeneic HSCT, chronic pancreatitis, bowel perforations s/p ileostomy presented with gastrointestinal bleeding. The patient had hospitalizations at other institutions with intermittent melena and occasional hematemesis. After multiple upper endoscopies that did not identify the etiology of bleeding, he was referred to our hospital for double balloon enteroscopy. His hemoglobin was down to 5.9 g/dL (baseline 9-10 g/dL). EGD was performed with plan for double balloon enteroscopy, but a large blood clot was seen in the stomach. A nodular area in the fundus was actively bleeding. Given concern for an isolated gastric varix (IGV-1), EUS-guidance was used to inject coils and N-butyl-2-cyanoacrylate into the gastric varices with adequate hemostasis. Follow-up imaging noted extensive portal and splenic vein embolization from the glue. The patient developed recurrent melena and an emergent TIPS placement with coronary vein coil embolization was performed. Recurrent gastrointestinal bleeding was again noted. CT angiography was obtained and revealed a splenic vein thrombus. The patient underwent a balloon-occluded antegrade transvenous obliteration with glue/coil embolization of a smaller vessel feeding the gastric varix. However, GI bleeding was again noted. A repeat endoscopy was subsequently performed with placement of three over the scope clips (OTSC) on the varix for successful hemostasis. DISCUSSION: Gastric varices are often associated with cirrhosis but can occur in patients with non-cirrhotic portal hypertension (i.e., splenic vein thrombosis). Cyanoacrylate glue injection is recommended for acute bleeding from IGV. A known complication of glue injection is the risk of embolization (approximately 1–2%). Endoscopic ultrasound guided coil deployment can act as a scaffold at the time of glue injection to reduce this risk. OTSC have been used successfully in esophageal variceal bleeding. We report the first successful use of OTSC for gastric varices which should be considered as salvage therapy.Figure 1.: Gastric varices with hemostasis after endoscopic ultrasound-guided coil and glue injection.Figure 2.: Portal vein embolization after endoscopic ultrasound-guided coil and N-butyl-2-cyanoacrylate injection.Figure 3.: Recurrent gastric variceal bleeding with hemostasis after successful over the scope clip deployment.

S1934 An Unusual Case of Post Esophageal Variceal Banding Dysphagia

INTRODUCTION: Bleeding esophageal varices are a major cause of mortality in patients with liver cirrhosis. Primary prophylaxis is achieved with non-selective beta-blockers or esophageal variceal ligation (EVL). Less than 20% of post-EVL patients suffer from minor complications such as transient dysphagia and chest discomfort. We present a rare case of significant dysphagia associated with the formation of an esophageal ring that occurred after EVL in a patient with cirrhosis and chronic gastroesophageal reflux disease (GERD). CASE DESCRIPTION/METHODS: A 56-year-old man with hepatitis B-related liver cirrhosis (MELD-Na 14), large esophageal varices (EV) and intolerance to beta-blockers, small gastroesophageal varix (GOV1), chronic GERD due to a hiatal hernia, and non-compliance to proton pump inhibitors (PPI), underwent an EVL with five bands. He presented three months later for follow up and a repeat EGD uncovered scar tissue within the vicinity of a Schatzki ring above the gastroesophageal junction. He underwent repeat variceal ligation with 5 bands. He presented one month later with symptoms of mild, intermittent solid food dysphagia. He was counseled to take his PPI daily and reported resolution of symptoms a few weeks thereafter. Repeat EGD, seven weeks later did not reveal a Schatzki ring and was only notable for small varix that was treated with one band ligation. DISCUSSION: GERD, an independent risk factor for bleeding varices has been reported in 40% of cirrhotic patients. Literature also documents reduced pressure of the lower esophageal sphincter up to one month after EVL, which may promote acid reflux. It can be postulated that the mucosal defect caused by EVL may lead to increased scar tissue formation in a patient with GERD. In our patient, treatment with PPI led to a complete resolution of his dysphagia and the disappearance of the Schatzki ring. A trial of PPI may be warranted prophylactically after EVL, especially in patients with GERD.Figure 1.: Endoscopic view of a Schatzki ring in the distal esophagus.Figure 2.: Endoscopic view of the lower esophagus after trial of PPI with a demonstration of resolution of Schatzki ring.Figure 3.: Endoscopic view of a single medium-sized varix in the lower esophagus.

S1223 Automated Endoscopy Template Improves Provider Adherence to Esophageal Varices Surveillance Guidelines

INTRODUCTION: Esophageal variceal (EV) hemorrhage is a significant cause of morbidity and mortality in patients with cirrhosis. Though timely endoscopic follow-up for EV surveillance improves outcomes, there remains significant practice variation regarding recommended follow-up interval after variceal detection on esophagogastroduodenoscopy (EGD). In this quality improvement study, we aimed to improve adherence to EV surveillance recommendations per American Association for the Study of Liver Diseases (AASLD) and American Society for Gastrointestinal Endoscopy (ASGE) by implementing prescriptive templates in an endoscopy reporting software. METHODS: A pre-post study was conducted at a single academic center between 1/2018 and 3/2020. Interventions included (1) surveying faculty/fellows to identify barriers of knowledge/adherence to guidelines, (2) disseminating uniform follow-up recommendations derived from AASLD/ASGE best practices, and (3) developing an automated prescriptive template in PENTAX endoPRO software to standardize procedural documentation and follow-up recommendations. Outcomes included adherence to standardized follow-up recommendations of (1) ≤2 years for small varices, (2) ≤3 months for medium/large varices or endoscopic variceal ligation (EVL), or (3) initiation of a non-selective beta blocker. RESULTS: Among 2,363 EGDs performed prior to the intervention in 2018, EV were noted on 218 EGDs with the majority (54%) without documentation of EV size. Of the 127 EGDs with documented EV size and/or EVL, only 63% provided guideline-based follow-up recommendations. On the pre-intervention survey (n = 24), suboptimal adherence was due to variability in provider practices with regards to follow-up intervals due to conflicting guidelines and low satisfaction rate (19%) with the current endoscopy reporting template. Development of an automated template to standardize guideline-based follow-up was implemented on 6/2019. After template implementation, the rate of adherence to guideline-based recommendations improved quarterly from a baseline of 69% to 74%, 80%, and 94%, respectively (Figure 1). CONCLUSION: Suboptimal adherence to recommended guidelines for EV-related care was due to variability in provider practices based on differing recommendations between societal guidelines and inadequate documentation of variceal size. Our intervention utilizing standardized automated prescriptive templates in endoPRO led to improved overall adherence to guideline-based EV surveillance recommendations.Figure 1.: Compliance Rate of Esophageal Varices Surveillance Recommendations.