Bleeding In Cirrhotic Patients Research Articles

Upper gastrointestinal haemorrhage in cirrhotic patients (a French survey) epidemiology and clinical practices: a population study in 4 French areas

Upper gastrointestinal haemorrhage in cirrhotic patients (a French survey) epidemiology and clinical practices: a population study in 4 French areas

Liver transplantation in patients with previous portasystemic shunt

Liver transplantation in patients with previous portasystemic shunt

Management of variceal haemorrhage in cirrhotic patients

Editor,—We have serious concerns about several of the recent UK guidelines for the management of variceal haemorrhage in cirrhotic patients ( Gut 2000; 46 (suppl 3 and 4):iiiI–iii115), particularly those that contradict current published evidence. We highlight below the ones we feel are the most important. In the management of acute variceal bleeding, variceal ligation is not the method of first choice which was given an AI recommendation. Meta-analysis of all trials of acute bleeding of banding versus injection sclerotherapy have shown no statistically significant difference between the two treatments for either control of bleeding or survival (data derived from 12 studies with 419 patients), with no statistical heterogeneity.1 The implication of recommending ligation for acute bleeding is that double intubation would be necessary in a patient who is actively bleeding so as to attach the ligation device after the initial diagnostic endoscopy. Although there is no evidence, this would create more risk to the patient; it is common sense that a single intubation would be preferable and would take less time. At best the recommendation should be that either endoscopic technique could be used as first choice, dependent on operator expertise and facilities. Secondly, there is evidence from randomised studies of vasoactive drug therapy combined with endoscopic techniques that combination therapy is superior in terms of control of bleeding. This is based on five randomised studies with 610 patients (pooled odds ratio 0.42, 95% confidence interval 0.29–0.6).1 Publication bias assessment has shown that 29 null or negative studies would be needed to render the results non-significant, and thus this effect is fairly robust. Moreover, in several of these studies vasoactive drugs were given before diagnostic endoscopy, demonstrating their utility during the period of resuscitation before endoscopy could be safely performed, which in practice may be several … Dr R Jalan, Institute of Hepatology, University College London Medical School, 69–75 Chenies Mews, London WC1E 6HX, UK. r.jalan{at}ucl.ac.uk

Transjugular intrahepatic portosystemic shunt (TIPS) versus endoscopic variceal ligation in the prevention of variceal rebleeding in patients with cirrhosis: a randomised trial

BACKGROUND AND AIMS The transjugular intrahepatic portosystemic shunt (TIPS) is a new therapeutic modality for variceal bleeding. In this study we compared the two year survival and rebleeding rates in...

Presence of bacterial infection in bleeding cirrhotic patients is independently associated with early mortality and failure to control bleeding.

Bacterial infection is strongly associated with gastrointestinal bleeding in cirrhotic patients and seems to be related with the failure to control bleeding. The aims of this study were to assess the influence of infections on the failure to control bleeding and death in cirrhotic patients without antibiotic prophylaxis. Ninety-one consecutive bleeding cirrhotic patients were analyzed. Bleeding was managed using somatostatin with sclerotherapy for active bleeding. Screening for bacterial infection (analysis and culture of blood, urine, ascitic and other fluids, together with chest radiography) was made at time 0 and when clinical signs suggested infection. The cause of bleeding was variceal in 72 (79%) patients. Failure to control bleeding occurred in 24 (26%) patients, and 10 (11%) of the patients died. Compared with the group without infection, failure to control bleeding (65% vs 15%; P < 0.001) and mortality (40% vs 3%; P < 0.001), were observed more frequently in patients with infection. Multivariate analysis showed that bacterial infection (OR = 9.7; P < 0.001) and the presence of shock (OR = 3.5; P < 0.05) were independently associated with failure to control bleeding. Bacterial infection (OR = 12.6; P < 0.01), encephalopathy (OR = 6.9; P < 0.05), and shock (OR = 5.8; P < 0.05) were identified as predictive of death. In conclusion, in bleeding cirrhotic patients bacterial infection is associated with failure to control bleeding as well as mortality.

Variceal bleeding and portal hypertensive gastropathy.

Cirrhosis can be the end stage of any chronic liver disease. At the time of diagnosis of cirrhosis varices are present in about 60% of decompensated and 30% of compensated patients. The risk factors for the first episode of variceal bleeding in cirrhotic patients are the severity of liver dysfunction, large size of varices and the presence of endoscopic red colour signs but only one-third of patients who have variceal haemorrhage have the above risk factors. Recent interest has been directed at identifying haemodynamic factors that may reflect the pathophysiological changes which lead to variceal bleeding, e.g. it has been confirmed that no bleeding occurs if HVPG falls below 12 mmHg and also a hypothesis has been put forward in which bacterial infection is considered a trigger for bleeding. Pharmacological treatment with beta-blockers is safe, effective and is the standard long-term treatment for the prevention of recurrence of variceal bleeding. Combination of beta-blockers with isosorbide-5-mononitrate needs further testing in randomized controlled trials. The use of haemodynamic targets for reduction in HVPG response needs further study, and surrogate markers of pressure response need evaluation. If endoscopic treatment is chosen, variceal ligation is the modality of choice. The combination of simultaneous variceal ligation and sclerotherapy does not offer any benefit. However, the use of additional sclerotherapy for the complete eradication of small varices after variceal ligation needs to be evaluated. The results of current prospective randomized controlled trials comparing variceal ligation with pharmacological treatment are awaited with great interest. Finally, the use of transjugular intrahepatic portosystemic shunt (TIPS) for the secondary prevention of variceal bleeding is not substantiated by current data, as survival is not improved and because of its worse cost-benefit profile compared to other treatments. In contrast, there still is a role for the selective surgical shunts in the modern management of portal hypertension. The ideal patients should be well compensated cirrhotics, who have had troublesome bleeding - either who have failed at least one other modality of therapy (drugs or ligation), have bled from gastric varices despite medical or endoscopic therapy, or live far from suitable medical services. Recently, ligation has been compared to beta-blockers for primary prophylaxis but so far there is no good evidence to recommend banding for primary prophylaxis, if beta-blockers can be given.

Endoscopic sclerotherapy plus propranolol versus propranolol alone in the primary prevention of bleeding in high risk cirrhotic patients with esophageal varices: A prospective multicenter randomized trial

Background: Analysis of primary prevention studies of the use of β-blockers has shown clear reductions in variceal bleeding in cirrhotic patients with varices. In contrast, the usefulness of prophylactic endoscopic sclerotherapy, alone or in combination with propranolol, in the management of these patients is still under investigation. The present study compared the efficacy of combined sclerotherapy and propranolol versus propranolol alone in the primary prevention of hemorrhage in cirrhotic patients with varices and high (greater than 18 mm Hg) intraesophageal variceal pressure. Methods: Patients were randomly assigned to propranolol (42 patients) or to propranolol plus sclerotherapy (44 patients). The mean duration of follow-up was 26.8 ± 7.7 and 24.6 ± 9.8 months, respectively. Results: During this period 23% of the patients in the combination group experienced at least 1 episode of bleeding due to varices or congestive gastropathy as compared with 14% in the propranolol group (not significant). Twenty-three patients (52%) in the combination group developed complications as compared with 8 (19%) in the propranolol group ( p = 0.002). The mortality rate was similar in both groups (14% and 18%, respectively). The only independent factor predictive of survival was the level of serum albumin. Conclusions: Endoscopic sclerotherapy should not be used for the primary prevention of hemorrhage in cirrhotic patients at high risk of variceal bleeding who are undergoing treatment with propranolol. (Gastrointest Endosc 2000;51:652-8.)

Drug treatment for bleeding oesophageal varices

At the time of diagnosis of cirrhosis, varices are present in about 60% of decompensated and 30% of compensated patients. The risk factors for the first episode of variceal bleeding in cirrhotic patients are the severity of liver dysfunction, a large size of the varices and the presence of endoscopic red colour signs, but only a third of patients who suffer variceal haemorrhage demonstrate the above risk factors. The only treatment that does not require sophisticated equipment or the skills of a specialist, and is immediately available, is vasoactive drug therapy. Hence, drug therapy should be considered to be the initial treatment of choice and can be administered while the patient is transferred to hospital, as has been done in one recent study. Moreover, drug therapy is no longer considered to be only a ‘stop-gap’ therapy until definitive endoscopic therapy is performed. Several recent trials have reported an efficacy similar to that of emergency sclerotherapy in the control of variceal bleeding. Furthermore, recent evidence suggests that those patients with high variceal or portal pressure are likely to continue to bleed or re-bleed early, implying that prolonged therapy lowering the portal pressure over several days may be the optimal treatment. Pharmacological treatment with beta-blockers is safe, effective and the standard long-term treatment for the prevention of recurrence of variceal bleeding. The combination of beta-blockers with isosorbide-5-mononitrate needs further testing in randomized controlled trials. The use of haemodynamic targets for the reduction of the HVPG response needs further study, and surrogate markers of the pressure response need evaluation. Ligation has recently been compared with beta-blockers for primary prophylaxis, but there is as yet no good evidence to recommend banding for primary prophylaxis if beta-blockers can be given.

UK guidelines on the management of variceal haemorrhage in cirrhotic patients

UK guidelines on the management of variceal haemorrhage in cirrhotic patients

Fibrinolytic and hemostatic abnormalities in gastro-esophageal variceal bleeding in cirrhotic patients

Fibrinolytic and hemostatic abnormalities in gastro-esophageal variceal bleeding in cirrhotic patients

3573 Endoscopic variceal banding compared with transjugular intrahepatic portosystemic shunt in the prevention of esophageal variceal rebleeding. a randomized trial.

Introduction: Variceal hemorrhage in cirrhotic patients persists to be a major complication of portal hypertension. This is due to the high mortality after a bleeding event and the eminent risk of death following an episode of rebleeding. First line endoscopic treatment to prevent variceal rebleeding is variceal banding (VB) instead of endoscopic sclerotherapy. In a randomized trial, we compared endoscopic variceal band ligation with transjugular intrahepatic portosystemic shunt (TIPS) for the prevention of esophageal variceal rebleeding. Patients and Methods: Thirty-seven cirrhotic patients with a first episode of variceal hemorrhage were included in our study (TIPS: n=18; VB: n=19). Results of rebleeding and survival were analyzed on an intention-to-treat basis employing the Kaplan-Meier method. Results: This study showed that TIPS reduced variceal rebleeding in trend but not significantly (TIPS vs. ligation: 2/18 patients [11 %] vs. 4/19 patients [21%], p>0.05). We found no significant difference between TIPS and VB regarding mortality. Encephalopathy was documented in six patients of the TIPS group [33%] and in five patients of the band ligation group [26%]. Duration of hospitalization did not differ significantly for patients treated with either TIPS or variceal banding (p=0.43). However, cost of material totaled for TIPS-placement and follow-up interventions exceeded that of VB (TIPS-group: US $ 4370/patient; VB-group: US $ 214/patient). Conclusion: In summary, there was no significant difference between TIPS and VB in prevention of variceal rebleeding. To prevent rebleeding from esophageal varices endoscopic band ligation is as effective as TIPS. Regarding the costs of material and hospitalization time, endoscopic variceal banding seems to be the reasonable therapeutic alternative compared to TIPS.We, therefore, recommend band ligation as the first line treatment for the prevention of esophageal variceal bleeding. To our experience, however, second line treatment could be TIPS in patients with recurrent episodes of variceal bleeding despite band ligation.

Variceal band ligation and variceal band ligation plus sclerotherapy in the prevention of recurrent variceal bleeding in cirrhotic patients: a randomized, prospective and controlled trial

Background: The combination treatment of band ligation plus sclerotherapy has been proposed to hasten variceal eradication. The aim of this study was to assess the efficacy of band ligation alone versus band ligation plus sclerotherapy in the prevention of recurrent variceal bleeding. Methods: Eighty cirrhotic patients were randomized to group I (band ligation) with 41 patients or to group II (band ligation plus sclerotherapy) with 39 patients in whom polidocanol (2%) was injected 1 to 2 cm proximal to each band. Results: At baseline, both groups were similar with regard to clinical, demographic and laboratory data. Mean follow-up time (standard error) for group I was 336.5 ± 43.4 days and for group II 386.1 ± 40.1 days ( p = 0.4). No statistical differences were observed between group I and group II in relation to recurrence of bleeding (31.7% vs. 23%, p = 0.38), treatment failure (24.4% vs. 12.8%, p = 0.18), death (39% vs. 30.8%, p = 0.44) and variceal eradication (65.8% vs. 74.4%, p = 0.40). Group II had a significantly higher number of complications than group I, 30.8% versus 7.3%, respectively ( p = 0.05). The number of bleeding related deaths was higher in group I than in group II (22% vs. 10.3%, respectively; p = 0.15). Conclusions: No significant difference was observed between band ligation and band ligation plus sclerotherapy in prevention of recurrent variceal bleeding. Furthermore, there was a higher incidence of complications in the latter group. (Gastrointest Endosc 2000;51:157-63.)

A prospective randomized trial between the prophylactic endoscopicvariceal ligation and propranolol administration for prevention offirst bleeding in cirrhotic patients with high-risk esophageal varices

A prospective randomized trial between the prophylactic endoscopicvariceal ligation and propranolol administration for prevention offirst bleeding in cirrhotic patients with high-risk esophageal varices

Efficacy of Octreotide and Sclerotherapy in the Treatment of Acute Variceal Bleeding in Cirrhotic Patients: A Prospective, Multicentric, and Randomized Clinical Trial

Background: Sclerotherapy is the most widely used method for treatment of acute variceal bleeding. Previous reports have suggested that octreotide infusion is as effective as sclerotherapy. Our aim was to investigate the efficacy and safety of octreotide in comparison with sclerotherapy in controlling variceal bleeding. Methods: Seventy-six cirrhotic patients were randomized to receive either sclerotherapy (n = 37) or octreotide (n

Prospective study of the Baveno II consensus conference criteria inbleeding cirrhotic patients

PROSPECTIVE STUDY OF THE BAVENO II CONSENSUS CONFERENCE CRITERIA IN BLEEDING CIRRHOTIC PATIENTS P. Cal~s, N. Lacave, C. Silvain, J.E Vinel, D. Lebrec France. Key events in upper gastrointestinal bleeding due to portal hypertension are defined according to the results of the consensus conference of Baveno II. These criteria defined 3 events: a) qualitative (active bleeding) or quantitative (clinically significant) aspects of bleeding, b) criteria of failure to control bleeding; c) time frames. However, the application of these criteria results in certain difficulties. The aim of our study was to prospectively study the accuracy and limits of these criteria in two situations: clinical trial and practice. Methods: lrst study: the application of Baveno II criteria was evaluated during the design and the interpretation of results in a randomized trial of a somatostatin analogue in addition to endocopic treatment in 196 patients cirrhotic. 2 *d study: Baveno lI criteria were applied to control patients in a setting of clinical practice. Patients with cirrhosis without bleeding but admitted in emergency for acute complication of cirrhosis were included. Results: lrst study: criteria of clinically significant bleeding and blood transfusions should be extended beyong 24 and 6 hrs, respectively. The first time point for control of bleeding (6hr) is too early and could be fixed at 12 hr. Indeed, at 6 hr following admission, 13% of patients have not yet received endoscopic treatment. During the 5 first days, failure to conlxol bleeding was observed in 82/196 pts, 39% of these cases were in disagreement with clinical judgement. In 15% (n=i2) this was due to a simple criteria: tachycardia whose cause were: delayed transfusion (n=6), fever (n=2), other (n=2) unknown (n=2). 2 nd study: criteria of failure to control bleeding were noted in 50% of patients without bleeding. Conclusion: Baveno II criteria have improved the definitions of keys events. However, they are hampered by false positive criteria of failure to control bleeding in 39% of bleeding patients enrolled in a trial to 50% of patients without bleeding. Improvements are proposed. Cirrhosis and its complications, pathophysiology and clinical aspects

The response of the variceal pressure to pharmacotherapy predicts the risk of variceal bleeding in cirrhotic patients

Nevens, ; EI Atti, E. Abd; Setijoso, E.; Bogaerts, K.; Verbeke, ; Fevery, J. Author Information

Treatment of chronic bleeding from gastric antral vascular ectasia (GAVE) with estrogen-progesterone in cirrhotic patients: an open pilot study.

Gastric antral vascular ectasia (GAVE) is a rare cause of chronic bleeding in cirrhotic patients. Treatment of GAVE with surgical or nonsurgical portal decompression, beta-blockers, or endoscopic therapy provides disappointing results. In the present study, we evaluated the efficacy of estrogen-progesterone therapy, which has been reported to control chronic bleeding in gastrointestinal vascular malformations, such as Osler-Weber Rendu disease or angiodysplasia, in GAVE-related chronic bleeding. Six cirrhotic patients who bled chronically from GAVE were included. Three had alcoholic cirrhosis, two cryptogenic cirrhosis, and one primary biliary cirrhosis. Grade 1 esophageal varices were noted in four patients. Bleeding could not be controlled by beta-blockers, and endoscopic therapy was not considered given the extension of the antral vascular lesions. Before the start of therapy, transfusion requirements averaged 3.5 units/month over a 1.5-11 month period of observation. Patients were then treated with a combination of ethynil estradiol 30 microg and noretisterone 1.5 mg daily. During follow-up (range 3-12 months), bleeding did not recur in four patients; in one patient, treatment with estrogen progesterone decreased the need for transfusions from 4 units/month to 1.4 unit/month; this patient stopped the treatment inadvertently after 6 months and severe anemia recurred with a need for 4 units of blood in the following month; reintroduction of the treatment resulted in an increase of hemoglobin levels without the need for blood transfusions during the following 4 months. In the last patient, a 5-month treatment did not improve chronic bleeding. The present study suggests that estrogen-progesterone therapy is useful in the treatment of chronic bleeding related to GAVE; however, these findings require confirmation by a controlled trial.

Treatment of chronic bleeding from gastric antral vascular ectasia (GAVE) with estrogen-progesterone in cirrhotic patients: an open pilot study

OBJECTIVE: Gastric antral vascular ectasia (GAVE) is a rare cause of chronic bleeding in cirrhotic patients. Treatment of GAVE with surgical or nonsurgical portal decompression, β-blockers, or endoscopic therapy provides disappointing results. In the present study, we evaluated the efficacy of estrogen-progesterone therapy, which has been reported to control chronic bleeding in gastrointestinal vascular malformations, such as Osler-Weber Rendu disease or angiodysplasia, in GAVE-related chronic bleeding. METHODS: Six cirrhotic patients who bled chronically from GAVE were included. Three had alcoholic cirrhosis, two cryptogenic cirrhosis, and one primary biliary cirrhosis. Grade 1 esophageal varices were noted in four patients. Bleeding could not be controlled by β-blockers, and endoscopic therapy was not considered given the extension of the antral vascular lesions. RESULTS: Before the start of therapy, transfusion requirements averaged 3.5 units/month over a 1.5–11 month period of observation. Patients were then treated with a combination of ethynil estradiol 30 μg and noretisterone 1.5 mg daily. During follow-up (range 3–12 months), bleeding did not recur in four patients; in one patient, treatment with estrogen progesterone decreased the need for transfusions from 4 units/month to 1.4 unit/month; this patient stopped the treatment inadvertently after 6 months and severe anemia recurred with a need for 4 units of blood in the following month; reintroduction of the treatment resulted in an increase of hemoglobin levels without the need for blood transfusions during the following 4 months. In the last patient, a 5-month treatment did not improve chronic bleeding. CONCLUSIONS: The present study suggests that estrogen-progesterone therapy is useful in the treatment of chronic bleeding related to GAVE; however, these findings require confirmation by a controlled trial.

The use of endoscopic band ligation for the prophylaxis of variceal haemorrhage

The use of endoscopic band ligation for the prophylaxis of variceal haemorrhage

Surgery for esophageal varix bleeding in cirrhotic patients during the era of liver transplants

Surgery for esophageal varix bleeding in cirrhotic patients during the era of liver transplants