Management Of Acute Variceal Bleeding Research Articles

627 Multicentre Randomised Controlled Trial Comparing the Efficacy and Safety of Adding Early Hemostatic Powder Application to Endoscopic and Medical Treatment in the Management of Acute Variceal Bleeding in Cirrhotic Patients

627 Multicentre Randomised Controlled Trial Comparing the Efficacy and Safety of Adding Early Hemostatic Powder Application to Endoscopic and Medical Treatment in the Management of Acute Variceal Bleeding in Cirrhotic Patients

Outcomes in variceal hemorrhage following the use of a balloon tamponade device

BackgroundVariceal hemorrhage is associated with high morbidity and mortality. A balloon tamponade device (BTD), such as the Sengstaken-Blakemore or Minnesota tube, may be used in cases of variceal hemorrhage. While these devices may be effective at controlling acute bleeding, the effect on patient outcomes remains less clear. We sought to describe the number of patients with variceal hemorrhage and a BTD who survive to discharge, survive to one-year, and develop complications related to a BTD. MethodsIn this retrospective study, we identified patients at a single, tertiary care center who underwent placement of a BTD for upper gastrointestinal hemorrhage between 2003 and 2014. Patient characteristics and outcomes were summarized using descriptive statistics. Results34 patients with a BTD were identified. Median age was 57.5 (IQR 47–63) and 76% (26/34) were male. Approximately 59% (20/34) of patients survived to discharge, and 41% (13/32) were alive after one year. Two patients were lost to follow-up. Of those surviving to discharge, 95% (19/20) had undergone transjugular intrahepatic portosystemic shunt (TIPS), while 36% (5/14) of patients who did not survive to discharge had TIPS (p<0.01). One complication, an esophageal perforation, was identified and managed conservatively. ConclusionIn this cohort of patients undergoing BTD placement for variceal hemorrhage, approximately 59% of patients were alive at discharge and 41% were alive after one year. Placement of a BTD as a temporizing measure in the management of acute variceal hemorrhage may be helpful, particularly when utilized as a bridge to more definitive therapy.

Suboptimal Implementation of Evidence-based Therapy for Acute Variceal Hemorrhage: A Systematic Review of Observational Studies.

Gastroenterologists should strive to improve the outcomes associated with acute variceal hemorrhage (AVH) by optimizing care delivery and clinician preparedness through training. Unfortunately, data regarding contemporary outcomes and management of AVH are limited. We performed a systematic review of cohort studies examining outcomes and management of AVH from January 1990 to September 2016. We pooled data on mortality and utilization of medical therapy, endoscopic interventions, balloon tamponade (BT), and salvage procedures (portal decompressive surgery or transjugular portosystemic shunt). The pooled 6-week mortality rate after AVH was 17.7% (95% confidence interval [CI], 14.4%-21.7%). Sclerotherapy was used in 18.7% of cases (95% CI, 9.2%-34.3%), and no endoscopic intervention was provided in 14.3% of patients (95% CI, 9.7%-20.6%). The overall rate of BT use was 10.8% (95% CI, 8.2%-14.1%). Salvage procedures were used in 5.7% (95% CI, 3.7%-8.6%), falling to 1.7% (95% CI, 0.7%-3.8%) among patients treated after 2000. Although pooled rates of timely endoscopy and vasoactive medication use were high (85.8% and 83.0%, respectively), only half of patients received prophylactic antibiotics (52.8%; 95% CI, 40.0%-66.2%). In studies that enrolled patients exclusively after 2000, 13.8% of patients (95% CI, 7.0%-25.4%) received sclerotherapy, salvage transjugular portosystemic shunt fell to 1.7% (95% CI, 0.7%-3.8%), BT use fell slightly to 8.7% (95% CI, 6.4%-11.6%), and vasoactive medication and prophylactic antibiotic use rose to 91.4% (95% CI, 86.0%-94.9%) and 62.7% (95% CI, 48.9%-74.9%), respectively. AVH is associated with high mortality rates and suboptimal implementation of evidence-based therapies including prophylactic antibiotics and endoscopic interventions, suggesting a need for quality improvement. In addition, the frequent need for BT and sclerotherapy suggests that specific attention to these procedures in gastroenterology training curricula may be warranted.

Building Effective Quality Improvement Programs for Liver Disease: A Systematic Review of Quality Improvement Initiatives.

Quality indicators are the measurable components of clinical standards. Data are limited about the design and impact of interventions to improve quality indicators for patients with chronic liver disease. A systematic review of PubMed, Web of Science, and conference proceedings was performed to find reports of quality improvement (QI) interventions. Data regarding the several indicators were collected. The search focused on vaccination against hepatitis A or hepatitis B virus, management of spontaneous bacterial peritonitis, screening for varices, management of acute variceal hemorrhage, hepatocellular carcinoma screening, and 30-day readmissions. Fifteen studies reported on the results of QI interventions. Ten focused on specific quality indicators (1 specific to vaccination, 2 spontaneous bacterial peritonitis, 3 gastrointestinal bleeding, and 4 hepatocellular carcinoma screening); 5 focused on clinical outcomes. Most studies used a pre-post study design. Interventions included checklists, educational conferences, electronic decision supports, nurse coordinators, and systematic changes to facilitate specialist co-management. Successful interventions optimized clinical workflow, closed knowledge gaps among frontline providers, created forced functions in the electronic ordering system, added dedicated staff to manage specific indicators, and provided viable alternatives to hospitalization to reduce readmission. Unsuccessful interventions included case management, phone calls, and home visits to reduce readmissions, checklists, and educational programs. Past experience with QI provides generalizable rules for successful future interventions aimed at improved quality indicator adherence and patient outcomes.

Alcohol consumption and risk of infection after a variceal bleeding in low-risk patients.

Antibiotic prophylaxis is a cornerstone in the management of acute variceal bleeding. However, emergence of multiresistant bacteria and antibiotic-associated complications is a growing problem in cirrhosis. It has been proposed that certain low-risk populations may have good outcomes without antibiotic. We aimed to analyse the stratified risk of bacterial infection after a variceal bleeding in previously considered low-risk patients. We analysed prospective data from all consecutive cirrhotic patients with acute variceal bleeding admitted to our tertiary hospital between 2004 and 2012. All patients received somatostatin, variceal ligation and antibiotic prophylaxis. Patients were followed until day 42 or death. Patients were stratified based on Child-Pugh class. Within the low-risk strata, further one-step stratification was performed using baseline risk factors identified through logistic regression multivariate adjustment. Two hundred and fifteen patients were included. Twenty-seven patients (12.5%) developed 32 bacterial infections within 6 weeks after the index bleeding. Multivariate adjustment identified alcohol consumption as a significant risk factor for infection. Within previously considered low-risk patients (Child-Pugh A), the risk of infection was significantly higher in patients with active alcohol consumption (21.4% vs. 0% in non-drinkers, P = 0.015). The risk of infection in Child-Pugh A and B patients with non-alcohol cirrhosis receiving antibiotics was very low (2/81, 2.5%). Alcohol consumption significantly increased the risk of infection after a variceal bleeding in previously considered low-risk patients. Within Child-Pugh A class, patients with active alcohol consumption should not be considered at low risk of infection.

Portal and splanchnic hemodynamics after partial splenic embolization in cirrhotic patients with hypersplenism.

To assess the acute effects of partial splenic embolization (PSE) on portal and splanchnic hemodynamics in patients with cirrhosis. Ninety-five patients with hypersplenism were included in the study. Duplex examinations were performed before and 3 and 7 days after PSE. Portal and splanchnic hemodynamics including vessel cross-sectional area (CSA), mean flow velocities (cm/s), blood flows (mL/min), Doppler indices as portal congestion index (CI), liver vascular index, hepatic artery and superior mesenteric artery (SMA) pulsatility and resistive indices (PI and RI), were performed before and after PSE. In our study, 69 of 95 patients were males (72.6%) and 26 females (27.3%). Chronic hepatitis C virus infection was the main cause of cirrhosis (81.1%). PSE failed technically in six patients (6.3%). After PSE, both CSA and CI significantly decreased (p < 0.05 and <0.01). The portal vein velocity significantly increased (p < 0.01). The portal flow volume (892.4 ± 151 mL/min) did not show significant changes. The hepatic artery RI and PI showed a steady increase that became significant 7 days post-PSE (p < 0.05). The RI and PI of SMA increased significantly after 7 days of PSE (p < 0.05). PSE has an immediate portal decompression effect in patients with portal hypertension without reduction in portal flow. This effect on portal pressure should be investigated in future studies as a potential tool for management of acute variceal bleeding when other medical procedures fail.

Noncirrhotic portal hypertension: Medical and endoscopic management.

Noncirrhotic portal hypertension: Medical and endoscopic management.

Outcomes of Endoscopic Variceal Ligation in Patients With ESLD: A Single-Center Experience

Introduction: Bleeding from esophageal varices is a feared complication of end stage liver disease. Endoscopic intervention can be employed as a first-line modality in an attempt to prevent the initial bleed and to acutely manage a variceal hemorrhage. However, there is a risk of bleeding as a complication of the procedure. Current recommendations are to continue interval endoscopic variceal ligation (EVL) until all varices have been eradicated. Methods: We conducted a retrospective review of the endoscopic and electronic medical record from June 2010 to August 2014 for patients who underwent EVL for bleeding or prevention of bleeding from esophageal varices. Relevant clinical data abstracted included age, gender, etiology of liver disease, Childs Class, MELD score, pre-procedure values of: INR, platelets, hemoglobin, number of units given for transfusion of fresh frozen plasma, platelets or packed red blood cells, a history of GI bleeding, if indication of EVL was urgent or emergent (defined as intervention performed within 24 hours of presentation for GI bleeding), number of bands applied per patient, endoscopic appearance of varices and signs of recent hemorrhage or propensity to bleed, if there was repeat evaluation for GI bleeding within 4 weeks of EVL, and death within 4 weeks of EVL. Results: 249 patients underwent a total of 392 endoscopies for EVL (Table 1). There were 110 (44.2%) women and 139 (55.8%) men. The mean age of cohort was 57.4 years, with 32 (12.9%) having Child Class C disease. Of the 392 endoscopies performed, 99 of those 249 patients (39.8%) had a history of prior bleeding. Mean INR was 1.5, platelet count was 113 x10(9)/L and hemoglobin was 11.6 g/dL. 62 (24.9%) endoscopies were performed within 24 hours of admission for GI bleeding for an acute indication, whereas the rest of the procedures were done for prevention. Post banding chest pain was seen in 3 patients (.76%). There were 8 events (2%) in which patients had upper GI bleeding after EVL with a mean time of 7.5 days to re-bleeding. 6 patients (2.4%) died within 4 weeks of EVL. These patients underwent emergent EVL and ultimately expired with multi-system organ failure in the setting of hypovolemic shock.Table 1: Clinical Characteristics and DemographicsConclusion: Rebleeding rate after EVL was 2% with estimated mortality of 2.4%. Endoscopic variceal ligation is safe and well tolerated and should continue to be used for management of acute variceal hemorrhage and for primary prevention of esophageal variceal bleeding.Table 2: Outcomes and Complications

A Clinical Decision Rule Based on the AST-to-Platelet Ratio Index Improves Adherence to Published Guidelines on the Management of Acute Variceal Bleeding.

Optimal management of acute upper gastrointestinal bleeding (UGIB) depends on identifying a variceal versus nonvariceal etiology. An objective measure predicting etiology could guide early management pending endoscopy. The AST-to-platelet ratio index (APRI) score has been studied as a marker of cirrhosis and portal hypertension, but has not been evaluated in the setting of acute UGIB. In this single-center retrospective cohort study, we reviewed endoscopy reports and other data for patients with acute UGIB, and classified episodes as variceal bleeds or other. We assessed the diagnostic utility of the APRI score relative to other objective measures by Area Under the Receiver Operating Characteristic (AUROC) curve analysis. We constructed a clinical decision rule based on the APRI score, and assessed how it would have changed management. The APRI score performed well in predicting a variceal etiology of acute UGIB, with AUROC 0.89. We developed a clinical decision rule using an APRI score of 0.4 to guide early management of acute UGIB patients. Retroactively applying this to our cohort, adherence to published guidelines for administration of octreotide and antibiotics would have increased from 56% to 91%. The APRI score is an objective metric that helps predict a variceal etiology of acute UGIB. Using our proposed decision rule could improve adherence to guidelines on management of acute variceal bleeding. Although we were unable to demonstrate a survival benefit, improved adherence to evidence-based guidelines serves as a metric related to this most important outcome measure. Prospective study to validate these findings is indicated.

PWE-125 Transjugular intrahepatic portosystemic shunt insertion is safe and effective in district general hospital setting

Introduction Transjugular intrahepatic portosystemic shunt (TIPS) insertion is a recognised rescue treatment for uncontrollable bleeding due to portal hypertension and can also be used for refractory ascites. TIPS is usually performed by interventional radiology (IR) and normally in a 9teaching9 hospital setting. Reported mortality rates are 27–50%. 1 At our institution, a large DGH, a 24-hour IR-led TIPS service has been established since 2007. The aim of this study was to assess technical success, complications and mortality associated with TIPS. Method Using a TIPS database, we conducted analysis of patients who had undergone a TIPS procedure between 2007 and 2014. Data collected included demographics, indication, success rate, short and long term complications and mortality. A total of 32 patients were identified and case notes were available for 25. Results Of the 25 patients identified, 18 (72%) were male. The mean age was 48.4 (25–73.) Child–s score was A in 5 (20%), B in 11 (44%) and C in 9 (36%). Six patients (24%) had a MELD 18. The commonest underlying aetiology was alcohol in 12 (48%), alcohol and HCV in 6 (24%) and NASH in 3 (12%). The commonest indication was uncontrolled/recurrent bleeding in 18 (60%), gastric varices in 3 (12%) and refractory ascites in 4 (16%). Six (24%) had undergone OGD once before TIPS, 9 (36%) had 2 OGDs and 4 (16%) had 3. Technical success was achieved in 23 (92%). Two patients underwent further TIPS refashioning. There was one TIPS thrombosis soon after insertion. Of 21 patients receiving TIPS for bleeding, 18 (86%) required no further endoscopies. Three patients rebled (14%) requiring repeated endoscopy. There were no significant procedure-related complications. Severe refractory hepatic encephalopathy occurred in only 1 patient (4%). The 30-day mortality was 28% (7 patients) and 1-year mortality was 44% (11). Most deaths occurred in patients with Child–s C disease (4 patients at 30-days and 7 at 1-year) with no 30-day mortality in Child–s A. Three patients aged over 65 underwent TIPS, 2 died within 30 days (Child–s B) and 1 within 1 year (Child–s A.) All patients who died had a MELD score >15. The commonest cause of death was either rebleeding or multiorgan failure. Conclusion TIPS can be safely and effectively performed in a DGH setting with success, complication and mortality rates comparable to larger 9teaching9 centres. As with other studies, severity of liver disease and age are important predictors of mortality. Disclosure of interest None Declared. Reference Loffroy R, et al . Transjugular intrahepatic portosystemic shunt for the management of acute variceal hemorrhage. World J Gastro . 2013 October 7;19(37):6131-6143

Portal Hypertension and Variceal Hemorrhage

Gastrointestinal bleeding in patients with cirrhosis can occur from a number of different causes, including portal hypertension, gastric antral vascular ectasia, and acute variceal hemorrhage. The management of these conditions involves a combined medical and endoscopic approach, with radiologic and surgical therapies restricted to refractory cases. This review covers the natural history of gastroesophageal varices, portal hypertensive gastropathy, and gastric antral vascular ectasia; diagnostic principles; primary and secondary prophylaxis relating to esophageal variceal hemorrhage; and treatment overviews for gastric variceal hemorrhage, portal hypertensive gastropathy, and gastric antral vascular ectasia. Figures show the pathophysiology of complications of cirrhosis, esophageal varices as seen during an upper endoscopic procedure, natural history of esophageal varices in patients with cirrhosis, portal hypertensive gastropathy, gastric antral vascular ectasia, and management principles for acute variceal hemorrhage, esophageal variceal ligation, and gastric varices. Tables list the prevalence of various etiologies of hemorrhage in patients with cirrhosis, current recommendations for follow-up screening and surveillance of varices, sensitivities and specificities of some noninvasive markers, and principles of initial management of acute variceal hemorrhage. This review contains 8 highly rendered figures, 4 tables, and 44 references.

Endoscopic Management of Variceal Haemorrhage

One of the most important complications of portal hypertension, in the setting of liver cirrhosis or of non-cirrhotic portal hypertension, is upper gastrointestinal bleeding from ruptured gastroesophageal varices and portal hypertensive gastropathy. The management of the acute variceal bleeding is a multidisciplinary process that includes the initial assessment of the patient, effective resuscitation, timely diagnosis, control of bleeding and prevention of early rebleeding and complications such as infection, hepatorenal syndrome, or hepatic encephalopathy. Antibiotic prophylaxis, conservative targets for blood transfusions and combination therapy with vasoactive drugs and endoscopic treatments are the first-line measures in the management of acute variceal bleeding; transjugular intrahepatic portosystemic shunts should be proposed early to high-risk patients or as a rescue therapy for those who fail first-line treatment.

Combination of splanchnic vasoconstrictors and endoscopic band ligation is an effective treatment strategy for acute variceal hemorrhage; but how do we get those drugs approved by the FDA?

Combination of splanchnic vasoconstrictors and endoscopic band ligation is an effective treatment strategy for acute variceal hemorrhage; but how do we get those drugs approved by the FDA?

Endoscopy management algorithms: role of cyanoacrylate glue injection and self-expanding metal stents in acute variceal haemorrhage

Mortality from acute variceal bleeding (AVB) has improved markedly over the last 2–3 decades due to increased specialisation and standardisation of medical and endoscopic practice culminating in the production of...

Optimizing General Management of Acute Variceal Bleeding in Cirrhosis

As soon as acute gastrointestinal bleeding is confirmed in patients with portal hypertension, treatment with vasoactive drugs and prophylactic antibiotics should be instituted. Once hemodynamic stability has been achieved, emergency endoscopy should be performed and endoscopic therapy (preferably with legation) should be carrier out when variceal bleeding is disclosed. It is advisable to maintain drug therapy for 5 days to prevent early rebleeding. When this treatment fails, TIPS should be considered. Balloon tamponade is indicated in patients with massive bleeding, as a bridge until definitive treatment could be instituted. Self-expanding metal stents are an alternative to tamponade which may even improve the outcomes. Recent data suggest that patients at high-risk of failure may benefit from invasive treatments such as early TIPS, while those with low-risk may do well with less intensive therapy including shorter administration of vasoactive drugs. However, these possibilities should be further investigated in future studies providing therapy according to stratification of risk.

TIPS in Variceal Bleeding: New and Old Indications

Variceal bleeding is one of the most dreaded complications of cirrhosis and its occurrence is associated with significant morbidity and mortality. During the past 30 years preventative therapies have reduced the risk of the first variceal bleed. Once variceal bleeding occurs use of pharmacologic and endoscopic therapies prevent rebleeding in most patients. The existing recommendations are that TIPS only be used in those patients who fail medical therapy. We reviewed recent literature focusing on the role of early TIPS in management of acute variceal hemorrhage and prevention of re-bleeding.

Severe respiratory failure due to embolization of cyanoacrylate sclerosant

### Learning Point for Clinicians N-butyl-2-cyanoacrylate sclerotherapy is increasingly used for the management of acute variceal haemorrhage. Sudden respiratory distress post-endoscopic sclerotherapy should prompt investigation for pulmonary embolization of cyanoacrylate sclerosant. Gastric variceal bleeding is a serious complication of portal hypertension with significant morbidity and mortality to the patient. Endoscopic injection of N-butyl-2-cyanoacrylate (N-BCA) is widely used for the control of gastric variceal bleeding with initial haemostasis of 87–100%.1,2 We present a case of severe respiratory failure due to pulmonary embolization of cyanoacrylate sclerosant used in variceal sclerotherapy with accompanying radiographic images. A 47-year-old man with known …

Historical overview and review of current day treatment in the management of acute variceal haemorrhage.

Variceal haemorrhage is one of the most devastating consequences of portal hypertension, with a 1-year mortality of 40%. With the passage of time, acute management strategies have developed with improved survival. The major historical treatment landmarks in the management of variceal haemorrhage can be divided into surgical, medical, endoscopic and radiological breakthroughs. We sought to provide a historical overview of the management of variceal haemorrhage and how treatment modalities over time have impacted on clinical outcomes. A PubMed search of the following terms: portal hypertension, variceal haemorrhage, gastric varices, oesophageal varices, transjugular intrahepatic portosystemic shunt was performed. To complement this, Google™ was searched with the aforementioned terms. Other relevant references were identified after review of the reference lists of articles. The review of therapeutic advances was conducted divided into pre-1970s, 1970/80s, 1990s, 2000-2010 and post-2010. Also, a summary and review on the pathophysiology of portal hypertension and clinical outcomes in variceal haemorrhage was performed. Aided by the development of endoscopic therapies, medication and improved radiological interventions; the management of variceal haemorrhage has changed over recent decades with improved survival from an often-terminating event in recent past.

Ligation of Esophageal Varices

Esophageal varices are present in majority of the patients with hepatic cirrhosis at the time of diagnosis, especially in those with advanced liver disease. Variceal size, red wale marks on varices, and advanced liver disease are risk factors for variceal hemorrhage. Esophageal variceal ligation (EVL) is a standard endoscopic procedure in the management of acute variceal bleeding and is beneficial in the primary and secondary prophylaxis of esophageal variceal bleeding. Multiband devices are commonly used for EVL. Various endoscopic techniques, common clinical scenarios, and procedure-related complications in EVL are described in the video manuscript provided. This article is part of an expert video encyclopedia.

Transjugular intrahepatic portosystemic shunt for the management of acute variceal hemorrhage

Acute variceal hemorrhage, a life-threatening condition that requires a multidisciplinary approach for effective therapy, is defined as visible bleeding from an esophageal or gastric varix at the time of endoscopy, the presence of large esophageal varices with recent stigmata of bleeding, or fresh blood visible in the stomach with no other source of bleeding identified. Transfusion of blood products, pharmacological treatments and early endoscopic therapy are often effective; however, if primary hemostasis cannot be obtained or if uncontrollable early rebleeding occurs, transjugular intrahepatic portosystemic shunt (TIPS) is recommended as rescue treatment. The TIPS represents a major advance in the treatment of complications of portal hypertension. Acute variceal hemorrhage that is poorly controlled with endoscopic therapy is generally well controlled with TIPS, which has a 90% to 100% success rate. However, TIPS is associated with a mortality of 30% to 50% in such a setting. Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and endoscopic sclerotherapy failure, before the clinical condition worsens. Furthermore, admission to specialized centers is mandatory in such a setting and regional protocols are essential to be organized effectively. This review article discusses initial management and then focuses on the specific role of TIPS as a primary therapy to control acute variceal hemorrhage, particularly as a rescue therapy following failure of endoscopic approaches.