Lower Rebleeding Rate Research Articles

An Examination of Aneurysm Rerupture Rates with Epsilon Aminocaproic Acid

Epsilon aminocaproic acid (EACA) has been used in the past to prevent cerebral aneurysm rerupture. Recent studies have indicated that short-term treatment with EACA can lower rebleeding rates without significantly increasing ischemic or thrombotic complications or permanent shunt rates. The goal of this study is to determine the efficacy of EACA in the prevention of aneurysm rerupture at a high volume subarachnoid hemorrhage center. We conducted a retrospective study of 355 consecutive subarachnoid hemorrhage patients over a 2-year period under our current protocol for EACA use. Patients were divided by presentation time to our institution and whether the patient received EACA. The primary endpoints of the study were rebleeding rates, ischemic complications, thrombotic complications, vasospasm, shunt rates, and outcomes. Rerupture rates were reduced by half in the entire pool of patients on EACA after controlling for Hunt and Hess Scores and Fisher Scores. In patients who received early aneurysm treatment, this effect persisted but was non-statistically significant due to the small numbers of reruptures. In addition, there was no evidence to suggest that EACA increased ischemic or thrombotic complications, vasospasm, or VPS rates. In patients presenting earlier than 24 h to our institution, there was a non-significant trend toward worse outcomes after EACA use. This trend was reversed in patients arriving after 24 h. There is evidence to suggest that EACA is protective from aneurysm rerupture without significant ischemic or thrombotic complications when used for less than 72 h. However, if the aneurysm is treated, this effect is modest indicating that early aneurysm treatment remains the gold standard for rerupture prevention.

Esophageal Dieulafoy Lesion: Rare Cause of Massive Upper GI Bleeding

Purpose: Introduction The Dieulafoy lesion is tortuous large caliber arteriole protruding through small mucosal defect. It is uncommon cause of upper GI bleeding and accounts for about 2% of cases of bleeding from upper GI tract. Esophageal Dieulafoy lesion is extremely uncommon and less than 10 cases have been reported so far. We report a case of massive upper GI bleeding related to esophageal Dieulafoy lesion that was successfully managed by epinephrine injection and placement of hemoclips. Case Presentation 37 year old Hispanic man with history of alcohol abuse and gastroesophageal reflux disease presented to the emergency room with sudden onset hematemesis. He was actively vomiting a large amount of fresh blood and was intubated for airway protection. There was no prior history of NSAIDs use. He underwent esophagogastroduodenoscopy (EGD) with the finding of a small actively bleeding lesion with fresh adherent clot in the lower esophagus. A total of 4 cc of epinephrine (1 mg, 1:10,000) was injected around the lesion and the clot was suctioned. After removal of clot and irrigation, it was noted that there was a very small mucosal defect with prominent visible vessel in the center with active oozing of blood. At this point two hemoclips were applied over this Dieulafoy lesion with cessation of bleeding. The EGD was otherwise normal. Patient was observed in the intensive care unit over next 24 hours and eventually discharged within 72 hours. Discussion Dieulafoy lesions can cause massive, recurrent and sometimes life threatening gastrointestinal bleeding. In the upper gastrointestinal tract, the clinical presentation is hematemesis with or without aspiration pneumonia and melena. About 75-95% of the Dieulafoy lesions are found in the stomach, predominantly along the lesser curvature. However, Dielafoy lesions are also reported in the esophagus, small intestine and colon. Esophageal Dieulafoy lesions are extremely rare. With advances in the endoscopic technique over the years, endoscopic therapeutic interventions for bleeding Dieulefoy lesions are preferred over surgery as the initial management. Epinephrine injection with or without application of band ligation or hemoclip application are described in the literature as therapeutic options. In the only published randomized control trial comparing epinephrine injection alone versus band ligation, lower rebleeding rates were observed with band ligation. However, therapeutic efficacy of hemoclips has not been compared with band ligation due to the rare nature of the disease.

Location and Size of Ruptured Intracranial Aneurysm and Serious Clinical Outcomes Early after Subarachnoid Hemorrhage: A Population-Based Study in Australasia

Background: It is uncertain whether the location and size of a ruptured intracranial aneurysm (IA) independently influences the outcome of subarachnoid hemorrhage (SAH). Objective: To determine the independent relationship of location and size of a ruptured IA with serious clinical outcomes after SAH in an Australasian population-based study. Methods: From 432 first-ever cases of primary SAH registered prospectively over 12 months in 4 Australasian cities between 1995 and 1998, the demographics, clinical features, risk factors and results of investigations were obtained, including the location and size of any ruptured IA as assessed by cerebral angiography, computed tomography and/or magnetic resonance imaging. Location was classified as either anterior (i.e. anterior communicating artery, internal carotid artery and middle cerebral artery) or posterior circulation (i.e. posterior communicating artery, posterior inferior cerebellar artery, basilar artery and vertebral artery), and size was classified as <5, 5–9 and ≧10 mm. Outcomes recorded during hospitalization were rebleeding, delayed ischemia, hydrocephalus, residual neurological impairment and in-hospital death. Logistic regression analysis was used to evaluate the effects of IA location and size on outcome, independent of other potential prognostic factors. Data are reported with odds ratios (OR) and 95% confidence intervals (CI). Results: IA location and size were confirmed separately in 299 and 252 patients, respectively. Patients with a posterior circulation IA had a lower rate of rebleeding than those with an anterior circulation IA (adjusted OR: 0.11; 95% CI: 0.02–0.87), but otherwise there was no significant relationship between IA location and outcome. Patients with a larger ruptured IA had higher risks of rebleeding (p = 0.02 for trend) and in-hospital death (p = 0.001) after controlling for age, sex, ethnicity, location of the ruptured IA and neurosurgical intervention. Conclusion: IA location in the posterior circulation was associated with a lower risk of rebleeding than IA in the anterior circulation. A larger IA size was associated with higher risks of rebleeding and in-hospital death.

Frameless stereotactic aspiration and subsequent fibrinolytic therapy for the treatment of spontaneous intracerebral haemorrhage

Background and purpose. The options for managing spontaneous intracerebral haemorrhage (ICH) include conservative treatment, surgical removal of the haematoma and minimally invasive treatment with clot aspiration and subsequent fibrinolytic therapy. The discussion over which treatment is best for ICH remains controversial and management of patients with spontaneous ICH continues to be a challenge. The purpose of this study is to investigate the feasibility and safety of frameless stereotactic aspiration and subsequent fibrinolytic therapy for the treatment of spontaneous ICH.Methods. Patients with spontaneous supratentorial ICH were treated by a frameless stereotactic aspiration using the YL-1 type of intracranial haematoma puncture needle, followed by subsequent fibrinolytic therapy with urokinase.Results. Forty-eight patients were enrolled in the study. The median age was 65 years (range, 40–79). The median initial Glasgow Coma Scale (GCS) was 10 (range 6–14). The mean initial haematoma volume was 56.5 cm3. Initial ICH volume was reduced by an average of 75% (range 50–90%). Ten patients (20.8%) died before hospital discharge. By the 3-month follow-up, another two patients had died, resulting in an overall mortality of 25.0%. For the primary end point, a good outcome (3-month GOS score >3) rate was noted in 41.7% of the patients. No intraoperative death was observed in this study. There were a total of 14 (29.2%) procedure-related complications, with an overall re-bleeding rate of 10.4%.Conclusions. Frameless stereotactic aspiration using the YL-1 type of intracranial haematoma puncture needle and subsequent fibrinolytic therapy for the treatment of spontaneous ICH is a simple and safe procedure with low re-bleeding rate and mortality.

Long‐Term Results of Esophagogastric Devascularization and Splenectomy Associated with Endoscopic Treatment in Schistosomal Portal Hypertension

Esophagogastric devascularization and splenectomy (EGDS) is the most performed operation for prophylaxis of esophageal varices bleeding recurrence in hepatosplenic schistosomiasis. Lower rebleeding rates are obtained through the association of postoperative endoscopic treatment; however, there is a dearth of studies showing long-term results. Clinical, laboratory, and endoscopic data of 97 patients submitted to EGDS with at least 5years of follow-up, were analyzed. The mean follow-up was 116.4months. Bleeding recurrence occurred in 24.7% of patients; however, this percentage was 14.6% when only variceal hemorrhage was considered. Bleeding recurrence occurred in four patients even after endoscopic evaluation demonstrated esophageal varices eradication. In the late follow-up we observed normalization of anemia, leukopenia, thrombocytopenia, hyperbilirubinemia, and a prothrombin activity time increase. No clinical or laboratory hepatic insufficiency was observed. The EGDS procedure with postoperative endoscopic treatment led to good clinical results and avoided hemorrhagic recurrence in 75.3% of schistosomal patients. There was improvement of laboratory measures of hepatic function, as well as correction of hypersplenism. Variceal hemorrhagic recurrence may occur even when esophageal varices eradication is reached.

Negative capsule endoscopy without subsequent enteroscopy does not predict lower long-term rebleeding rates in patients with obscure GI bleeding

Negative capsule endoscopy without subsequent enteroscopy does not predict lower long-term rebleeding rates in patients with obscure GI bleeding

Dedicated bleed units: should they be advocated?

Upper gastrointestinal haemorrhage (UGIH) is a common emergency, however, dedicated bleed units only exist in selected hospitals in the UK. To evaluate the rebleeding and mortality rate of patients admitted with UGIH to a tertiary centre bleed unit in comparison with the current national standards and earlier unit performance in 1995-1998. A retrospective case note review of demographics, the Rockall scores and final outcome was conducted for all patients admitted to the bleed unit over 24 months. Two hundred and fifty-five cases were identified with a mean age of 62 years and a median Rockall score of 3. Eighty-two percent of gastroscopies were performed within 24 h. Of these, 29% were undertaken after 5 p.m. Peptic ulcer and varices (15%) were the commonest diagnosis. The rebleeding (12%) and mortality rate (9%) were comparable with that of the units previous audit (P=0.47, 0.51, respectively) and the current national audit (P=0.58, 0.76, respectively). The number of patients requiring surgery has reduced from 6 to 0.4% in our unit over the last 8 years. Preendoscopy and postendoscopy Rockall scores were predictive of rebleeding (P=0.013, 0.045) and mortality (P=0.003, 0.01). This study has shown a consistently low rebleeding and mortality rate in patients with UGIH in a dedicated bleed unit. However there are limitations to the degree of improvements which can be demonstrated due to factors such as age and comorbidity.

Long-Term Outcome of Transcatheter Embolotherapy for Acute Lower Gastrointestinal Hemorrhage

We sought to assess the safety, short- and long-term efficacy, and durability of transcatheter embolization for lower gastrointestinal hemorrhage (LGH) unresponsive to endoscopic therapy and to analyze the overall survival of the embolized patients. Between January 1997 and January 2008, 122 patients were referred for angiographic evaluation to control major LGH. Overall, 43 patients (35.3%) presented with angiographic signs of contrast extravasation. In 39 patients (26 men, 13 women; mean age 67.7 years), a transcatheter embolization was performed to stop the bleeding. In all 39 patients, no contrast extravasation could be depicted on completion of angiography after embolization. Rebleeding occurred in eight patients (20%), in six of them within the first 30 days after embolization. Ischemic intestinal complications requiring surgery occurred in four patients (10%) within 24 h after embolization. Long-term follow-up depicted estimated survival rates of 70.6, 56.5, and 50.8% after 1, 3, and 5 years, respectively. Transcatheter embolotherapy to treat lower gastrointestinal bleeding is very effective, with a relatively low rebleeding and ischemic complication rate, mostly occurring within the first month after the embolization. Long-term follow-up shows a very low late rebleeding rate, and half of the embolized patients survive more than 5 years. This study shows that the majority of patients presenting with lower gastrointestinal bleeding, unresponsive to endoscopic therapy, do not benefit from transcatheter embolization. In cases of angiography extravasation, a good immediate clinical outcome-defined as high immediate success with acceptable rebleeding-and ischemic complication rate may be obtained.

Negative Capsule Endoscopy Does Not Predict Lower Rebleeding Rate in the Long Term: A Study to Evaluate the Long-Term Clinical Outcomes of Patients with Obscure Gastrointestinal Bleeding After Capsule Endoscopy Guided Therapy

Negative Capsule Endoscopy Does Not Predict Lower Rebleeding Rate in the Long Term: A Study to Evaluate the Long-Term Clinical Outcomes of Patients with Obscure Gastrointestinal Bleeding After Capsule Endoscopy Guided Therapy

Long-term follow-up of patients with small bowel angiodysplasia on capsule endoscopy: Determinants of a higher clinical impact and rebleeding rate

the clinical impact of small-bowel angiodysplasia has not been defined. We present a prospective study to determine the features of individuals with a higher risk of rebleeding or a worse clinical outcome. thirty patients with angiodysplasia found on CE were included and followed for 12 months. Angiodysplasia were classified by their size as small (<or= 10 mm) or large (> 10 mm). We also studied angiodysplasia lesion numbers in each patient. Rebleeding was defined as a hemoglobin drop of more than 2 g/dl in the absence of melena or hematochezia in the case of occult GI bleeding, or with any or both manifestations. a therapeutic procedure was carried out in 13 patients (43.4%). Individuals with large angiodysplasia had higher transfusion requirements, a higher proportion of therapeutic procedure performed after CE, lower hemoglobin concentration, and a lower rebleeding rate. Patients with ten or more angiodysplasia lesions had also higher transfusion requirements and lower hemoglobin levels, but we found no differences in the number of therapeutic procedures or rebleeding rate between both groups. On follow up rebleeding was detected in 5 patients (16.7%), all of them with small angiodysplasias. Rebleeding was more frequent in patients who did not receive further interventions (23.53 vs. 7.69%; p = 0.037). angiodysplasia size >or= 10 mm determines a worse clinical impact and more possibilities of receiving a therapeutic procedure. Our findings support that patients with large lesions would benefit from therapeutic interventions with a reduction in rebleeding rate.

The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the Management of Portal Hypertension

Transjugular intrahepatic portosystemic shunt (TIPS) is an interventional radiology technique that has shown a 90% success rate to decompress the portal circulation. As a non-surgical intervention, without requirement for anesthesia and very low procedure-related mortality, TIPS is applicable to severe cirrhotic patients, who are otherwise untreatable, for example, nonsurgical candidates. TIPS constitutes the most frequently employed tool to achieve portosystemic shunting. TIPS acts by lowering portal pressure, which is the main underlying pathophysiologic determinant of the major complications of cirrhosis. Regarding esophagogastric variceal bleeding, TIPS has excellent hemostatic effect (95%) with low rebleeding rate (<20%). TIPS is an accepted rescue therapy for first line treatment failures in 2 settings (1) acute variceal bleeding and (2) secondary prophylaxis. In addition, TIPS offers 70% to 90% hemostasis to patients presenting with recurrent active variceal bleeding. TIPS is more effective than standard therapy for patients with hepatic venous pressure gradient >20mm Hg. TIPS is particularly useful to treat bleeding from varices inaccessible to endoscopy. TIPS should not be applied for primary prophylaxis of variceal bleeding. Portosystemic encephalopathy and stent dysfunction are TIPS major drawbacks. The weakness of the TIPS procedure is the frequent need for endovascular reintervention to ensure stent patency. The circulatory effects of TIPS are an attractive approach for the treatment of refractory ascites and hepatorenal syndrome, yet TIPS is not considered first line therapy for refractory ascites owing to unacceptable incidence of portosystemic encephalopathy. Pre-TIPS evaluation taking into account predictors of outcome is mandatory. The improved results achieved with covered-stents might expand the currently accepted recommendations for TIPS use.

The long-term outcome of patients with bleeding gastric varices after balloon-occluded retrograde transvenous obliteration

The purpose of our study was to evaluate the long-term outcome and complications of balloon-occluded retrograde transvenous obliteration (B-RTO) in patients with hemorrhage from gastric fundal varices. Thirty-four consecutive patients with bleeding from gastric varices who were treated with B-RTO were enrolled in this study between December 1994 and September 2005 (urgent cases, n = 12; elective cases, n = 22). The long-term outcome, complications, and various liver functions were evaluated. Complete obliteration was achieved in 31 of 34 (91%) patients with an acute bleeding episode. In one of the remaining patients, there was a technical failure, and the other two had only partial obliteration. The two patients with partial obliteration did not obtain hemostasis. Thus, the rate of hemostasis was 94% (31/33). Gastric varices disappeared in all patients with complete obliteration during the treatment. The rate of gastric variceal eradication was 91%. Variceal rebleeding from esophageal varices occurred in three patients. The rate of rebleeding was 10% (3/31). Rebleeding from gastric varices was not observed after complete obliteration. None of the patients showed worsening of their Child-Pugh score. Although the 5-year cumulative worsening rate of esophageal varices was 52%, neither portal hypertensive gastropathy nor ectopic varices were observed. The patients with worsening esophageal varices were successfully treated with an endoscopic procedure. The 5-year survival rate was 68%. B-RTO is useful for treatment of bleeding gastric varices, achieving high eradication of gastric varices, a low rebleeding rate, and a fairly good prognosis with improved hepatic function.

Comparison of Frame-Based and Frameless Stereotactic Hematoma Puncture and Subsequent Fibrinolytic Therapy for the Treatment of Supratentorial Deep Seated Spontaneous Intracerebral Hemorrhage

This study compared the technical implications and clinical outcome of patients treated for an intracerebral hemorrhage using two minimally invasive procedures: frame-based stereotactic hematoma aspiration and frameless navigation-guided hematoma aspiration followed by fibrinolysis. Thirty patients with a spontaneous supratentorial intracerebral hemorrhage, which was treated by a frame-based (n=15) and frameless (n=15) hematoma aspiration followed by subsequent fibrinolysis with urokinase, were retrospectively reviewed. The data for the two subsets of patients were analyzed with regard to hematoma reduction, Glasgow Coma Scale (GCS), and degree of weakness. In the frame-based stereotactic hematoma aspiration group, the volume of the hematoma was 15.4-100.0 mL (mean: 40.7+/-24.4), the GCS upon admission was 4-15 (mean: 10.1+/-3.0), and the grade of weakness upon admission was 1-5 (mean: 2.1+/-0.9). On the other hand, in the frameless navigation-guided hematoma aspiration group, the hematoma volume was 15.2-62.0 mL (mean: 30.0+/-15.2), the GCS upon admission was 7-15 (mean: 13.0+/-2.4), and the grade of weakness upon admission was 1-4 (mean: 2.3+/-1.2). The drainage catheter was in place for a mean duration of 5.1+/-2.4 days (range: 1-12 days). In the frame-based group, the initial hematoma was reduced by -115-88.5% (mean: 52+/-31.5) immediately after surgery, and 90.5% (41-100%) of the initial volume 14 days after surgery. In the frameless group, the initial hematoma was reduced by 11.7-90.8% (mean 57.3+/-25.1) immediately after surgery and 95.8% (87.7-100%) 14 days after surgery. The GCS score and the degree of weakness were evaluated 14 days after surgery, and the Glasgow outcome scale (GOS) score was evaluated at discharge. There were no statistically significant differences between the two groups. The frame-based group and the frameless group followed by fibrinolysis had similar outcomes, and both procedures effectively reduced the intracerebral hemorrhage volume within a short period of time. In addition, these procedures are simple, precise, safe, and brief with a very low rebleeding rate and mortality.

Simple Clinical Predictors May Obviate Urgent Endoscopy in Selected Patients With Nonvariceal Upper Gastrointestinal Tract Bleeding

The validated Blatchford risk score (BRS) predicts outcomes in patients with nonvariceal upper gastrointestinal tract bleeding, before endoscopy; completion of the Rockall score requires endoscopy. The aims of this study were to predict whether the modified BRS (mBRS) can predict (1) endoscopic high-risk stigmata (HRS) and (2) rebleeding and mortality. Clinical and demographic characteristics on 1869 patients from 6 Canadian provinces were prospectively entered into the Registry for Upper GI Bleeding and Endoscopy database, recording 30-day rebleeding and mortality. The Rockall score and mBRS (hemoglobin level, hemodynamic instability, and presence of melena, liver disease, or cardiac failure; urea and syncope were not recorded) were calculated. Logistic regression was used to assess the association between an mBRS of 1 or less with HRS and with rebleeding and mortality. The mean (SD) age of the patients was 66 (17) years, with 62% men and a mean of 2.5 comorbidities. Of the 1860 patients with 30-day rebleeding data, 334 (18.0%) rebled; 5.3% died. The mBRS was 0 in 3% and 1 or less in 9.8% of patients; HRS were seen in 31.0% of patients. An mBRS of 1 or less was associated with lower rebleeding (5% vs 19%; P<.001) and mortality (0.5% vs 5.8%; P=.003), and was significant in multivariate analysis for rebleeding (odds ratio, 0.24; 95% confidence interval, 0.12-0.48) and mortality (odds ratio, 0.12; 95% confidence interval, 0.02-0.90). The HRS were less frequent when the mBRS was 1 or less (16.9% vs 32.7%; odds ratio, 0.4; 95% confidence interval, 0.3-0.6). Patients with a low mBRS with HRS had a low rebleeding rate (3.3%) and a lower apparent benefit from endoscopic therapy. An mBRS of 1 or less identifies approximately 10% of patients with gastrointestinal tract bleeding with a low likelihood of having HRS and a low risk of adverse outcomes. A prospective randomized study is required to examine whether this subgroup of patients presenting after hours could be discharged safely from emergency departments with arrangements for (urgent) outpatient endoscopy.

Comparación de las estenosis esofágicas producidas por escleroterapia o ligadura de varices

Variceal ligation (VL) eradicates esophageal varices faster than endoscopic sclerotherapy (ES) with a lower rebleeding rate and fewer secondary effects. However, most studies have evaluated the short-term effects of these treatments and some late complications may be overlooked. To determine the incidence and the characteristics of stenosis, we included 253 cirrhotic patients treated endoscopically for variceal bleeding from 1988 to 2004 in our hospital. ES was carried out with ethanolamine 5% and polidocanol 1.5%. ES and VL were carried out every 15 days until varices were eradicated and then at 3-, 6- and 12-month intervals; if varices reappeared, the initial treatment was repeated. Stenosis was considered mild when esophageal size was more than 10 mm and severe when the endoscope could not be passed through the stricture. We found stenosis in seven out of 105 (6.7%) ES-treated patients and in 10 out of 148 (6.7%) VL-treated patients. The clinical characteristics of the patients and the previous number of endoscopic sessions were similar in both groups. Four out of seven ES patients developed stenosis during the first eradication process (mean: 11 months, 1-60), but this early stenosis was observed in one out of 10 VL patients (mean: 20 months, 1-72). Stenosis was severe in three out of seven ES patients (43%) but in only two out of ten VL patients (20%) (NS). The incidence of esophageal stenosis was similar after treatment of esophageal varices with ES and VL, although VL had a tendency to produce later stenosis.

Long-Term Follow-Up of Patients with Obscure Gastrointestinal Bleeding After Negative Capsule Endoscopy

Capsule endoscopy (CE) is one of the widely accepted investigations for obscure gastrointestinal bleeding (OGIB), but little is known about the impact of CE on the long-term outcome of patients with OGIB. We studied the long-term outcome of patients with OGIB after CE examination. Forty-nine consecutive patients (45% men, mean age 58.3 yr) who underwent CE for OGIB were studied. The most clinically relevant finding that was related to bleeding was identified by CE. All patients were followed up for at least 12 months for clinical overt and occult bleeding. The median follow-up was 19 months (range 12 to 31). Possible bleeding lesions were detected by CE in 31 (63.3%) patients, and 15 (30.6%) patients, underwent further interventions including laparotomy and push enteroscopy. The overall long-term rebleeding rate in this cohort was 32.7%. The cumulative rebleeding rate was significantly lower in patients with a negative CE (5.6%) than in patients with a positive CE (48.4%, p=0.03 log-rank test). The sensitivity and negative predictive value of CE in predicting rebleeding were 93.8% and 94.4%, respectively. Patients with OGIB and negative CE had a very low rebleeding rate, and further invasive investigations can be deferred.

Usefulness of Transjugular Intrahepatic Portosystemic Shunt in the Management of Bleeding Ectopic Varices in Cirrhotic Patients

To evaluate the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the control of bleeding from ectopic varices. From 1995 to 2004, 24 cirrhotic patients, bleeding from ectopic varices, mean age 54.5 years (range 15-76 years), were treated by TIPS. The etiology of cirrhosis was alcoholic in 13 patients and nonalcoholic in 11 patients. The location of the varices was duodenal (n = 5), stomal (n = 8), ileocolic (n = 6), anorectal (n = 3), umbilical (n = 1), and peritoneal (n = 1). TIPS controlled the bleeding in all patients and induced a decrease in the portacaval gradient from 19.7 +/- 5.4 to 6.4 +/- 3.1 mmHg. Postoperative complications included self-limited intra-abdominal bleeding (n = 2), self-limited hemobilia (n = 1), acute thrombosis of the shunt (n = 1), and bile leak treated by a covered stent (n = 1). Median follow-up was 592 days (range 28-2482 days). Rebleeding occurred in 6 patients. In 2 cases rebleeding was observed despite a post-TIPS portacaval gradient lower than 12 mmHg and was controlled by variceal embolization; 1 patient underwent surgical portacaval shunt and never rebled; in 3 patients rebleeding was related to TIPS stenosis and treated with shunt dilatation with addition of a new stent. The cumulative rate of rebleeding was 23% and 31% at 1 and 2 years, respectively. One- and 2-year survival rates were 80% and 76%, respectively. The present series demonstrates that bleeding from ectopic varices, a challenging clinical problem, can be managed safely by TIPS placement with low rebleeding and good survival rates.

High re-bleeding rate in young adults after subarachnoid haemorrhage from giant aneurysms

Low re-bleeding rates within the first 14 days of aneurysmal subarachnoid haemorrhage are reported in young patients. Furthermore, re-bleeding rate for giant aneurysms does not exceed 20% according to the literature. Our own clinical impression is that the re-bleeding rate seems to be much higher in giant aneurysms than reported, particularly in young patients. The aim of this study was to evaluate re-bleeding rate after subarachnoid haemorrhage following rupture of giant aneurysms in a younger population. We reviewed records of 23 patients who were treated in our institution for subarachnoid haemorrhage from giant aneurysms between 1994 and 2003. By definition, the aneurysms were larger than 25 mm in diameter. Five patients were younger than 40 years of age at the time of the aneurysmal subarachnoid haemorrhage. All younger patients (<40 years of age) showed re-bleeding after the first subarachnoid haemorrhage within the first 14 days of the initial event. In four patients (20%) older than 40 years at the time of the haemorrhage re-bleeding could be observed within the first 14 days of subarachnoid haemorrhage. We can confirm the re-bleeding rate of approximately 20% in patients suffering from subarachnoid haemorrhage (SAH) in the group of patients older than 40 years of age. However, younger patients seem to be at much higher risk of re-bleeding from giant aneurysms.

Comparison of Esophageal Stenosis Produced By Endoscopic Sclerotherapy or Ligation of Varices

Variceal Ligation (VL) eradicates esophageal varices faster than Endoscopic sclerotherapy (ES) with a lower rebleeding rate and fewer secondary effects. However, the majority of studies are short term and late complications are probably not detected. Patients. We analyzed our database that included 253 cirrhotic patients treated endoscopically for variceal bleeding from 1988 till 2004 looking for the incidence and the characteristics of stenosis. The stenosis was considered slight when the esophageal size was more than 10 mm and severe when it was not possible to pass through the stricture with the endoscope.

Early HVPG measurement and TIPS for acute variceal hemorrhage: Is sooner really better?

Early HVPG measurement and TIPS for acute variceal hemorrhage: Is sooner really better?