Rupture Of Varices Research Articles

Factors involved in gastroesophageal varix-related events in patients with hepatitisC virus-related compensated and decompensated cirrhosis after direct-acting antiviral therapy.

The incidence of and factors involved in gastroesophageal varix-related events in hepatitisC virus-related cirrhosis patients, including decompensated cirrhosis, after direct-acting antiviral therapy are unclear. We conducted a multicenter study using prospective data from 478 hepatitisC virus-related cirrhosis patients treated with direct-acting antiviral therapy from February 2019 to December 2021 at 33 Japanese hospitals. Gastroesophageal varices were classified as F1 (small-caliber), F2 (moderately enlarged), or F3 (markedly enlarged) according to the Japanese criteria. Patients without varix or with F1 without red color signs were defined as low-risk varix, and patients with ≥F2 or red color signs or a history of rupture were defined as high-risk varix. Varix-related events were defined as prophylactic treatment or rupture of gastroesophageal varix. The median age was 70years, 43% of patients had decompensated cirrhosis, and 16% had high-risk varices (13% in compensated and 33% in decompensated, p<0.001). Sustained virologic response rates were 94.9% for compensated cirrhosis and 91.3% for decompensated cirrhosis (p=0.120). Across 35.7months, 25 patients received prophylactic treatment, and four experienced varix rupture. The 3-year incidence rate of varix-related events was 6.2% (3.5% in compensated and 9.9% in decompensated, p=0.001). In the multivariate analysis, high-risk varix (p<0.001), high baseline gamma-glutamyl transpeptidase levels (p<0.001), and virologic failure (p=0.004) were significantly involved in varix-related events. The cumulative incidence rate of varix-related events was significantly higher in decompensated cirrhosis than in compensated cirrhosis. Baseline varix status, baseline gamma-glutamyl transpeptidase levels, and virologic response were related to varix-related events after direct-acting antiviral therapy.

Gastroscopic treatment of acute gastric variceal rupture through the right lateral position.

Acute variceal bleeding is a life-threatening condition and a common cause of cirrhosis-related death, severe acute bleeding is difficult to treat and has a high mortality rate, drug treatment is often ineffective. We encountered a patient with cirrhosis with ruptured and bleeding gastroscopic varices requiring emergency endoscopic surgical treatment. However, in the routine left lateral position the treatment was interfered with by a fresh blood clot obscuring the gastric fundus. We were able to expose the gastric fundus by turning the patient to the right lateral position and eventually successfully treated the patient. This provides a new idea for the endoscopic treatment of acute gastric varices and may improve the success rate of treatment.

Non-invasive assessment of esophageal and fundic varices in patients with primary biliary cholangitis.

The Baveno VII consensus recommends endoscopic screening for varicose veins in cases of liver stiffness measurement (LSM) ≥ 20 kPa or platelet count ≤ 150 × 109/L. Whether this approach was appropriate for patients with primary biliary cholangitis (PBC) remains uncertain. This study expanded the observed risk factors by adding analysis of ultrasound images as a non-invasive tool to predict the risk of esophageal or fundic varices. We enrolled 111 patients with PBC whose complete ultrasound images, measurement data, and LSM data were available. The value of the periportal hypoechoic band (PHB), splenic area, and LSM in determining the risk of varicose veins and variceal rupture was analyzed. A prospective cohort of 67 patients provided external validation. The area under the receiver operating characteristic curve (AUC) for predicting varicose veins using LSM > 12.1 kPa or splenic areas > 41.2 cm2 was 0.806 (95% confidence interval (CI): 0.720-0.875) and 0.852 (95% CI: 0.772-0.912), respectively. This finding could assist in avoiding endoscopic screening by 76.6% and 83.8%, respectively, with diagnostic accuracy surpassing that suggested by Baveno VII guidelines. The AUCs for predicting variceal rupture using splenic areas > 56.8 cm2 was 0.717 (95% CI: 0.623-0.798). The diagnostic accuracy of PHB for variceal rupture was higher than LSM and splenic areas (75.7% vs. 50.5% vs. 68.5%). We recommend LSM > 12.1 kPa as a cutoff value to predict the risk of varicosity presence in patients with PBC. Additionally, the splenic area demonstrated high accuracy and relevance for predicting varicose veins and variceal rupture, respectively. The method is simple and reproducible, allowing endoscopy to be safely avoided. The measurement of the splenic area and identification of the periportal hypoechoic band (PHB) on ultrasound demonstrated high accuracy and relevance for predicting the risk of esophageal or fundic varices presence and variceal rupture, respectively. Predicting varices in patients with primary biliary cholangitis (PBC) can reduce the morbidity and mortality of gastrointestinal hemorrhage. Transient elastography (TE) and ultrasound play an important role in predicting patients with PBC with varices. TE and ultrasound can predict varicose veins and variceal rupture. Liver stiffness measurement and splenic area measurements can allow endoscopy to be safely avoided.

Performance of spleen stiffness measurement by 100‐Hz vibration‐controlled transient elastography, liver stiffness, APRI score and their combination for predicting oesophageal varices in liver cirrhosis

BackgroundOesophageal varices (EV) rupture remains one of the most severe complications of cirrhosis. As the gold standard to predict this accident, esophagogastroduodenoscopy (EGD) itself also has a weakness. Not all patients are convenient with this modality in clinical practice apart from the risk and cost burden. Hence, the search for other non-invasive modalities with high accuracy is still noteworthy. Among them, spleen stiffness measurement (SSM) with 100 Hz probe, liver stiffness measurement (LSM), and the aspartate amino transferase to platelet ratio index (APRI) score became popular and intensively studied with good accuracy, but the results remain conflicting. This study aims to investigate the performance of SSM, LSM, APRI score, and their combination especially as a screening tool for predicting EV in liver cirrhosis patients. MethodsIn this cross-sectional study, we included 141 patients with liver cirrhosis who had undergone endoscopy, SSM, LSM, and APRI score calculation between January and March 2023 were enrolled. Diagnostic accuracy was assessed by the area under the receiver-operator curve (AUC). Transient elastography (TE) measurement was performed using a spleen-dedicated FibroScan with a 100-Hz probe. ResultsOf the 141 patients, the most common aetiology was hepatitis B in 71 patients (50.4 %). EV were found in 116 patients. Using the AUC, SSM at a cutoff of 40 kPa had the best performance with an AUC of 0.892 (CI 95 %: 0.814–0.969, p <0.0001), with sensitivity 88.79 % and specificity 80 %). Meanwhile, LSM and APRI score had an AUC of 0.832 (CI 95 %: 0.742–0.922, p <0.0001) and 0.780 (CI 95 %: 0.660–0.900, p <0.0001), respectively. The combination of all measurement tools did not show better performance than SSM alone with an AUC of 0.892 (CI 95 %: 0.802–0.982, P <0.0001) ConclusionSSM provides better performance than LSM and APRI scores for predicting EV. Performance of SSM alone is non-inferior compare to multiple diagnostic tools combined.

Factors Affecting an Increase in Spleen Volume and Association of Spleen Volume Variation with the Clinical Outcomes of Atezolizumab and Bevacizumab Treatment for Hepatocellular Carcinoma: A Retrospective Analysis

Plain Language SummaryImmunotherapy is now the standard of care for systemic therapy in hepatocellular carcinoma (HCC). The combination of atezolizumab and bevacizumab (Atez/Bev) is recommended for the first-line treatment, while gastrointestinal varices rupture is likely to be observed during Atez/Bev. Gastrointestinal varices rupture is a fatal event and developed due to portal hypertension. Spleen volume (SpV) plays an important role in portal hypertension based on previous studies, and we examined variation in SpV during Atez/Bev treatment and investigated predictive factors that affect the increase in SpV and the association of SpV variation and pretreatment SpV with the clinical outcome of Atez/Bev. The median pretreatment SpV was 184 (130–257) cm3 and the median SpV variation was 27 (9–60) cm3. An increase in the SpV was observed in 140 patients (85.4%). Age <74 years (p = 0.03), mALBI grade 2b or 3 (p = 0.03), and pretreatment SpV ≥184 cm3 (p < 0.001) were significantly associated with increased SpV. The present study revealed that there were no significant differences in progression-free survival and overall survival between patients with and without pretreatment spleen enlargement, as well as between patients with SpV variation ≥25 cm³ and those with SpV variation <25 cm³. In conclusion, caution is warranted to detect the aggravation of portal hypertension when administering Atez/Bev to young patients or those with an impaired liver function or pretreatment spleen enlargement. The impact of spleen modulation by Atez/Bev appears to be limited on clinical efficacy.

Variceal bleeding following treatment with atezolizumab plus bevacizumab in two patients with unresectable hepatocellular carcinoma.

Bleeding-related adverse events may occur due to anti-vascular endothelial growth factors. Here, we report two cases of variceal rupture during atezolizumab plus bevacizumab (ATZ/BV) treatment for unresectable hepatocellular carcinoma (u-HCC).Case 1 involved a man in his 60s with alcoholic liver cirrhosis (LC) and u-HCC. Seventy-four days after ATZ/BV administration, the patient was admitted for hematemesis. Upper esophagogastroduodenoscopy (EGD) revealed worsening of the esophageal varices (EVs) to F2 grade with active bleeding. Endoscopic variceal ligation successfully achieved hemostasis.Case 2 involved a man in his 70s with alcoholic LC and u-HCC. The patient was admitted with hematemesis 114days after ATZ/BV administration. During EGD, the EVs deteriorated to F3 grade, although hemostasis had already been achieved. The evaluation was discontinued during the observation stage because of the worsening hepatic reserve.Neither patient had EVs warranting prophylactic treatment before ATZ/BV administration, showed a partial tumor response, or had portal vein tumor thrombus. Both patients demonstrated increased total diameters of the collateral veins and splenic volume compared to those before treatment. These findings suggest that ATZ/BV treatment may increase portal pressure. In conclusion, the administration of ATZ/BV to patients with LC and u-HCC necessitates careful management of EVs aggravation and rupture.

Endoscopic variceal ligation combined with sclerotherapy for management of gastroesophageal variceal bleeding in pediatric patients: a single-center retrospective study.

Portal hypertension (PH) frequently gives rise to severe and life-threatening complications, including hemorrhage accompanied by the rupture of esophageal and gastric varices. In contrast to the guidelines for the management of PH in adults, the optimal endoscopic management of variceal bleeding for secondary prophylaxis in children remains unclear. The present study evaluated the efficacy and safety of endoscopic variceal ligation (EVL) and endoscopic sclerotherapy (EST) to control gastroesophageal variceal bleeding in children. This retrospective study included children with gastroesophageal variceal bleeding who underwent EST or EVL at Xinhua Hospital, Shanghai Jiaotong University School of Medicine, between February 2013 and March 2020. Short-term hemostasis rate and long-term rebleeding rate were evaluated. Adverse events related to the procedures, such as esophageal ulcer, esophageal stricture, abnormal embolization, pneumonia and perforation, were also recorded. EVL (n = 8) and EST (n = 13) were performed successfully in all pediatric patients diagnosed with moderate to severe esophageal varices concurrent with gastric varices. Hemostasis was achieved during episodes of upper gastrointestinal bleeding. The mean volume of each single aliquot of cyanoacrylate injected was 0.3 ± 0.1 ml (range: 0.1-0.5 ml). Varices were eradicated in six (75%) of the eight patients who underwent EVL after a median 2 (range: 1-4) procedures and a median time of 3.40 months (range: 1.10-13.33 months). Eleven (52.4%) of the 21 patients developed rebleeding events, with the mean duration of hemostasis being 11.1 ± 11.6 months (range 1.0-39.2 months). No treatment-related complications, for example, distal embolism, occurred except for abdominal pain in one patient (4.8%). EST, alone or in combination with EVL, is an effective and safe method of managing gastroesophageal variceal hemorrhage in children undergoing secondary prophylaxis.

Diagnostic accuracy of shear wave elastography versus laboratory parameters as non-invasive screening tool for esophageal varices

BackgroundVariceal hemorrhage from the rupture of esophageal varices is accompanied by a substantial mortality rate. So, newly diagnosed cirrhotic patients are recommended to perform screening esophago-gastroduodenoscopy (EGD) for identifying varices. The primary objective of the present research was to ascertain the most precise biochemical and ultrasonographic variables that have the potential to non-invasively forewarn the occurrence of varices in cirrhotic patients. The study evaluated different parameters such as aspartate aminotransferase-to-platelet ratio index (APRI), platelet count/splenic diameter (PC/SD), portal vein velocity (PVV), and splenic and hepatic stiffness in prediction of EV.MethodsThis is a cross-sectional study that was conducted on 100 cirrhotic patients based on clinical, laboratory, and radiological assessments. All patients were subjected to thorough clinical examinations; laboratory tests were conducted to assess liver function and calculate Child–Pugh score and non-invasive tests for detecting esophageal varices such as APRI, PC/SD, Doppler ultrasonography for assessment of PV Doppler, and hepatic and splenic elastography. All patients got an endoscopic assessment in order to examine and classify the esophageal varices.ResultsBased on the current study, we found that predictors for EV among the studied patients were the following: PC/SD ratio with odds ratio (OR) was 2.20, PVV with OR was 4.68, liver stiffness with OR was 1.99, and splenic stiffness with OR was 3.55.With ROC curve analysis, PVV has the best overall accuracy (85.4%) for prediction of EV with an area under the curve of 0.79 at cutoff point < 7.09 (cm/s) followed by splenic stiffness that has 82.6% overall accuracy with an area under the curve of 0.71 at cutoff point > 62.22 kPa.ConclusionPVV and splenic stiffness measurement hold potential as non-invasive markers for predicting the presence of esophageal varices in individuals with liver cirrhosis. Moreover, these markers can also aid in predicting the occurrence of advanced esophageal varices.

Efficacy and safety of atezolizumab plus bevacizumab in patients with portal hypertension for unresectable hepatocellular carcinoma.

Atezolizumab plus bevacizumab combination therapy (Atezo + Beva) is used as the first-line therapy for unresectable hepatocellular carcinoma (u-HCC). Serious adverse events (AEs), including rupture of esophagogastric varices, have been seen during treatment. Therefore, the relationships of efficacy, safety, and portal hypertension (PH) were analyzed. A total of 146 patients with u-HCC and Child-Pugh Scores of 5-7 received Atezo + Beva. Prophylactic treatment for varices was performed for patients with the risk of rupture of varices before the start of Atezo + Beva. A propensity score-matched cohort was created to minimize the risk of potential confounders. Efficacy was assessed in 41 propensity score-matched pairs. AEs were assessed between patients without PH (n = 80) and with PH (n = 66). In patients without PH and with PH, median overall survival was 18.4 months and 18.8 months (p = 0.71), and median progression-free survival was 8.6 months and 5.8 months (p = 0.92), respectively. On the best radiological response evaluation for Response Evaluation Criteria in Solid Tumors, the objective response rate was 31.7% and 26.8% (p = 0.81), respectively. Variceal rupture occurred in three patients with PH, but there were no significant differences in the occurrence of variceal rupture (p = 0.090) and Grade 3-4 AEs between patients without and with PH. No significant differences in efficacy and safety were observed with PH. Prophylactic treatment for varices before the start of Atezo + Beva would allow treatment to continue relatively safely.

Endoscopic ultrasound evaluation of portal cavernoma cholangiopathy and endoscopic management of choledochal variceal rupture during ERCP.

Endoscopic ultrasound evaluation of portal cavernoma cholangiopathy and endoscopic management of choledochal variceal rupture during ERCP.

Research Progress on Modified Sengstaken-Blakemore Tube Fixation and Insertion Method for the Treatment of Rupture and Bleeding of Esophagogastric Varices

Research Progress on Modified Sengstaken-Blakemore Tube Fixation and Insertion Method for the Treatment of Rupture and Bleeding of Esophagogastric Varices

Splenic Hilar Involvement and Sinistral Portal Hypertension in Unresectable Pancreatic Tail Cancer.

Pancreatic tail cancer (PTC) frequently displays splenic hilar involvement (SHI), but its impact on clinical outcomes remains unclear. We investigated the clinical impact of SHI in patients with unresectable PTC. We retrospectively reviewed all patients with unresectable PTC who received first-line therapy at our institution from 2016 to 2020. Of the 111 included patients, 48 had SHI at diagnosis. SHI was significantly associated with younger age, liver metastasis, peritoneal dissemination, larger tumor size, modified Glasgow prognostic score of 1 or more, splenic artery involvement, gastric varices, and splenomegaly. Shorter median overall survival (OS; 9.3 vs. 11.6 months, p = 0.003) and progression-free survival (PFS; 4.3 vs. 6.3 months, p = 0.013) were observed in SHI patients. Poor performance status of 1 or 2, tumor size > 50 mm, hepatic metastasis, mGPS of 1 or 2, and SHI (hazard ratio: 1.65, 95% confidence interval: 1.08-2.52, p = 0.020) were independent predictors of shorter OS. Splenic artery pseudoaneurysm rupture and variceal rupture were rare and only observed in cases with SHI. Splenic hilar involvement is associated with worse outcomes in pancreatic tail cancer.

Black esophagus: Massive bleeding in cirrhosis does not always mean variceal rupture

Black esophagus: Massive bleeding in cirrhosis does not always mean variceal rupture

Efficacy, Safety, and Clinical Outcomes of Splenorenal Shunt Surgery as a Therapeutic Intervention for Portal Hypertension Patients

Highlights: 1. This study systematically reviewed the efficacy, clinical outcomes, and safety of the splenorenal shunt procedure with a comprehensive and meticulous approach.2. The splenorenal shunt procedure is an innovative surgical intervention that offers a viable option for the management of portal hypertension. Abstract Portal hypertension is the second most common gastrointestinal bleeding in cirrhosis and non-cirrhosis patients. The splenorenal shunt surgery is a potential intervention that may be considered for portal hypertension patients with clinical symptoms such as upper gastrointestinal bleeding caused by the rupture of gastro-esophageal varices. In this study, the researchers aimed to analyze the efficacy, clinical outcomes, and safety of splenorenal shunt surgery in portal hypertension patients. The sources were obtained from electronic search databases, including PubMed, Google Scholar, and ScienceDirect, using the keywords "Efficacy," "Safety," and "Clinical Outcomes." in relation to splenorenal shunt surgery in portal hypertension patients. The researchers set specific criteria for inclusion and exclusion to select the articles. This systematic review revealed the efficacy of the splenorenal shunt procedure with favorable outcomes. The success rate of splenorenal shunt surgery in reducing the clinical symptoms of portal hypertension varied between 66% and 100%. The prevailing complications observed in this study were shunt thrombosis, rebleeding, and thrombocytopenia. However, notable improvements could be achieved with general treatment. In terms of short- and long-term clinical outcomes, the splenorenal shunt procedure demonstrated favorable results. It can be concluded that splenorenal shunt surgery provides excellent clinical outcomes and should be considered a viable treatment option for patients with both cirrhotic and non-cirrhotic portal hypertension.

5-MTHF enhances the portal pressure reduction achieved with propranolol in patients with cirrhosis: A randomized placebo-controlled trial

β-blockers reduce hepatic venous pressure gradient (HVPG) by decreasing portal inflow, with no reduction in intrahepatic vascular resistance. 5-Methyltetrahydrofolate (5-MTHF) can prevent oxidative loss of tetrahydrobiopterin (BH4), a cofactor for endothelial nitric oxide synthase coupling. It also converts homocysteine (tHcy) into methionine and enables the degradation of asymmetric dimethylarginine (ADMA), an inhibitor of endothelial nitric oxide synthase. The aim of this study was to evaluate the effects of 5-MTHF in combination with propranolol on HVPG and nitric oxide bioavailability markers in patients with cirrhosis and portal hypertension. Sixty patients with cirrhosis and HVPG ≥12mmHg were randomized 1:1 to receive treatment with 5-MTHF+propranolol or placebo+propranolol for 90 days under double-blind conditions. HVPG and markers of nitric oxide bioavailability (BH4, ADMA and tHcy) were measured again at the end of treatment. Groups were similar in terms of baseline clinical and hemodynamic data and nitric oxide bioavailability markers. HVPG decreased in both groups, but the magnitude of the change was significantly greater in the group treated with 5-MTHF+propranolol compared to placebo+propranolol (percentage decrease, 20 [29-9] vs. 12.5 [22-0], p=0.028), without differences in hepatic blood flow. At the end of treatment, 5-MTHF+propranolol (vs. placebo+propranolol) was associated with higher BH4 (1,101.4 ± 1,413.3 vs. 517.1 ± 242.8pg/ml, p<0.001), lower ADMA (109.3 ± 52.7 vs. 139.9 ± 46.7μmol/L, p=0.027) and lower tHcy (μmol/L, 11.0 ± 4.6 vs. 15.4 ± 7.2μmol/L, p=0.010) plasma levels. In patients with cirrhosis and portal hypertension, 5-MTHF administration significantly enhanced the HVPG reduction achieved with propranolol. This effect appears to be mediated by improved nitric oxide bioavailability in the hepatic microcirculation. 2014-002018-21. Currently, the pharmacological prevention of cirrhosis complications due to portal hypertension, such as esophageal varices rupture, is based on the use of β-blockers, but some patients still present with acute variceal bleeding, mainly due to an insufficient reduction of portal pressure. In this study, we sought to demonstrate that the addition of folic acid to β-blockers is more effective in reducing portal pressure than β-blockers alone. This finding could represent the basis for validation studies in larger cohorts, which could impact the future prophylactic management of variceal bleeding in cirrhosis. Enhancing the benefit of β-blockers with a safe, accessible, cost-effective drug could improve clinical outcomes in cirrhosis, which in turn could translate into a reduction in the rates and costs of hospitalization, and ultimately into improved survival.

Predictive Value of Spectral Computed Tomography Parameters in Esophageal Variceal Rupture and Bleeding in Cirrhosis.

To evaluate the value of the spectral CT parameters in predicting the risk of esophageal variceal bleeding in cirrhosis with portal hypertension and to provide a reference for clinical diagnosis and treatment. Seventy-eight patients were divided into an esophageal variceal bleeding group and a non- esophageal variceal bleeding group. A comparison of variables including age, gender, platelet count, Child-Pugh classification, and spectral parameters between the 2 groups was done. Baseline model and spectral model were constructed with conventional parameters and conventional parameters coupled with spectral parameters, respectively. The 2 models were analyzed by the Receiver Operating Characteristic (ROC) curve. The baseline model was established based on 4 conventional parameters and evaluated by ROC curve analysis. The spectral model was constructed based on the variables in the baseline combined with normalized iodine density in the liver parenchyma for the arterial phase, normalized iodine density in the liver parenchyma for the portal phase, normalized iodine density in the splenic parenchyma for the portal phase, diameter of the main portal vein, diameter of the splenic vein, and normalized iodine density of the left gastric vein. Normalized iodine density of the left gastric vein, normalized iodine density in the liver parenchyma for the portal phase, and Child-Pugh classification were the influencing factors of esophageal variceal bleeding in cirrhosis patients. The Area Under Curve (AUC) for the baseline and spectral models were compared (0.664 vs. 0.860) and the difference was found to be statistically significant (P < .001). The use of spectral CT parameters in consort with the conventional parameters can improve the diagnostic effectiveness of esophageal variceal bleeding in cirrhosis cases and screen for high-risk esophageal variceal bleeding patients. It may also provide an objective basis for the clinical prevention and treatment of esophageal variceal bleeding.

DEATH DUE TO HEMORRAGIC SHOCK DUE TO RUPTURE ESOPHAGEAL VARICES: CLINICAL AND AUTOPSY BASED CASE REPORT

This is a case report of A 27 years old female was brought to the emergency department with the complaint of progressive abdominal distension with pain in abdomen and early satiety for last few months. On further clinical, radiological and laboratory evaluation, patient was diagnosed with portal hypertension with splenomegaly and got collapsed during the course of treatment. On autopsy examination, the cause of death was hemorrhagic shock due to rupture of esophageal varices.

Increased Spleen Volume in Hepatocellular Carcinoma Patients Treated with Atezolizumab plus Bevacizumab in Comparison to Lenvatinib: A Retrospective Analysis

Introduction: We previously reported 2 cases of esophageal varices rupture during atezolizumab and bevacizumab (Atez/Bev) treatment, in which the spleen volume gradually increased. The aim of this retrospective study is to compare the chronological change in spleen volume of patients treated with Atez/Bev and lenvatinib (LEN). Methods: Seventy-two patients (Atez/Bev group, n = 26; LEN group, n = 46) were included in this retrospective study. The splenic parenchyma area was measured based on CT imaging. We used mixed-effect regression models with random intercepts to test the difference in the rate of change in spleen volume between the Atez/Bev and LEN groups. Results: The median age of the Atez/Bev and LEN groups was 74.0 (71.0–82.0) and 72.0 (67.5–76.0), respectively. About 80% patients were male. The mALBI grade was classified as 1, 2a, 2b, and 3 in 10 (38.5%), 6 (23.1%), 10 (38.5%), and zero (0.0%) patients, respectively, in the Atez/Bev group and 21 (45.7%), 9 (19.6%), 15 (32.6%), and 1 (2.2%) patient in the LEN group (p = 0.9). The median baseline neutrophil-to-lymphocyte ratio (NLR) was 2.61 (1.80–3.41) in the Atez/Bev group and 2.71 (1.76–3.67) in the LEN group (p = 1.0). The median baseline spleen volume was 185 (132–246) cm³ in the Atez/Bev group and 231 (150–355) cm³ in the LEN group. The spleen volume gradually increased during Atez/Bev treatment (2.41 cm³ per week), while it was mostly consistent during LEN treatment (0.32 cm³ per week). Among patients with mALBI grade 2b or 3, the spleen volume increased in the Atez/Bev group (2.99 cm³ per week) and slightly decreased in the LEN group (0.82 cm³ per week), without statistical significance (p = 0.07). Among patients with a baseline NLR of >2.68, the spleen volume increased at a rate of 2.57 cm³ per week in the Atez/Bev group and decreased at a rate of 1.18 cm³ per week in the LEN group. The difference in the slope of the two groups was statistically significant (p = 0.04). Discussion/Conclusion: Atez/Bev treatment could result in an increased spleen volume. Caution is required when managing patients treated with Atez/Bev, especially those with a high NLR.

Upper gastrointestinal bleeding in patients with liver cirrhosis

Upper gastrointestinal bleeding (UGIB) is a potentially life-threatening emergency that remains a common cause of admission to hospital for cirrhotic patients. This re­tro­s­pec­tive study included 230 patients, over a period of two years, who presented with UGIB and underwent emer­gen­cy gastroscopy at the County Emergency Clinical Hos­pi­tal Târgu-Mureş. The patients were divided into two groups (patients with variceal bleeding versus non-variceal ble­eding, and alcoholic cirrhosis versus viral cirrhosis). Com­­pa­ri­sons were made to identify the sources of digestive ble­eding, the risk factors and the clinical outcomes, such as mortality, need for transfusion and hemostasis. This study shows that esophageal varices are the main cause of UGIB in cirrhotic patients regardless the etiology, but al­most a half experience bleeding from a non-variceal source, the most common being peptic ulcer. Bleeding from a non-variceal source is as severe as variceal rupture, re­­quir­­ing the same number of transfusions, with a similar rate of rebleeding and mortality. Male young patients with al­co­ho­lic cirrhosis have a higher risk of UGIB and need more trans­fu­sions than in patients with viral cirrhosis. The large num­ber of patients requiring endoscopic hemostasis re­veals the importance of upper digestive endoscopy to specify the etio­lo­gy and establish the appropriate treat­ment.

RECURRENT STOMAL VARICEAL BLEEDING IN CIRRHOSIS: MANAGEMENT WITH TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT AND EMBOLIZATION

Gastrointestinal (GI) bleeding is a common complication of cirrhosis and portal hypertension. Most cases are secondary to gastro-esophageal variceal rupture, managed endoscopically1. Stomal bleeding is rare and there’s no standard therapy2. We present a case of a cirrhotic patient with recurrent stomal hemorrhage successfully treated with transjugular intrahepatic portosystemic shunt (TIPS) and stomal varices embolization.