Treatment Of Bleeding Esophageal Varices Research Articles

The Prediction and Treatment of Bleeding Esophageal Varices in the Artificial Intelligence Era: A Review.

Esophageal varices (EVs), a significant complication of cirrhosis, present a considerable challenge in clinical practice due to their high risk of bleeding and associated morbidity and mortality. This manuscript explores the transformative role of artificial intelligence (AI) in the management of EV, particularly in enhancing diagnostic accuracy and predicting bleeding risks. It underscores the potential of AI in offering noninvasive, efficient alternatives to traditional diagnostic methods such as esophagogastroduodenoscopy (EGD). The complexity of EV management is highlighted, necessitating a multidisciplinary approach that includes pharmacological therapy, endoscopic interventions, and, in some cases, surgical optionstailored to individual patient profiles. Additionally, the paper emphasizes the importance of integrating AI into medical education and practice, preparing healthcare professionals for the evolving landscape of medical technology. It projects a future where AI significantly influences the management of gastrointestinal bleeding, improving clinical decision-making, patient outcomes, and overall healthcare efficiency. The study advocates for a patient-centered approach in healthcare, balancing the incorporation of innovative technologies with ethical principles and the diverse needs of patients to optimize treatment efficacy and enhance healthcare accessibility.

Potentials of Endoscopic Combined Treatment of Esophageal Variceal Bleeding in Patients with Liver Cirrhosis

Background. Treatment of variceal esophageal-gastric bleeding in patients with portal hypertension is an acute challenge in urgent surgery.The aim of study was to develop a technique and evaluate the immediate and long-term effectiveness of endoscopic ligation (EL) with the use of cytoprotective treatment.Materials and methods. The study included 106 patients who were treated at the City Clinical Emergency Hospital No. 1, Voronezh, Russia. The main group consisted of 54 patients who were treated using a developed technique of combined endoscopic ligation of esophageal varices combined with the polymer alginate hemostatic sorbent (PAHS) application on ligated nodes and post-ligature defects. The comparison group consisted of 52 patients who underwent endoscopic ligation without PAHS application.Results. In the main group, total hemostasis was achieved in 52 of 54 (96.3%) patients, p = 0.027; recurrent bleeding was observed in 2-3 days after combined ligation in two (3.7%) patients. No operations were performed; two (3.7%) patients died in this group. In the comparison group, total hemostasis was achieved in 43 of 52 (82.6%) patients, p=0.027. Recurrent bleeding was observed in nine (17.3%) patients. In the comparison group, one (1.9%) patient with massive bleeding was operated on, and seven (13.5%) patients died.Conclusion. Endoscopic ligation combined with cytoprotective treatment using a polymer alginate hemostatic sorbent increases the effectiveness of local hemostasis and reduces the rate of recurrent hemorrhage from 17.3% to 3.7%, p = 0.027. Insufflation of PAHS onto ligature nodes and defects helps relieve pain, accelerates the processes of postligature defect epitheliation from 7.7% to 94.4%, p=0.0001; it also prolongates the remission of the underlying disease.

Effectiveness of Combination of Pharmacological Treatment and Endoscopic Band Ligation in Active Esophageale Varicos Bleeding

Acute gastrointestinal system bleeding in cirrhotic patients is one of the emergencies of gastroenterology that requires rapid and careful intervention. For this reason, patients who are thought to have esophageal variceal bleeding should be referred to a center that is adequately equipped for follow-up and treatment. There are studies supporting that current approaches to the treatment of esophageal variceal bleeding have a positive effect on life expectancy. Volume replacement is an important condition in the general approach to esophageal variceal bleeding. It is recommended to maintain hemodynamic stability and keep the hemoglobin level at approximately 8 g/dL. Additionally, it is thought that prophylactic antibiotic usage in gastrointestinal system bleeding of cirrhotic patients reduces the risk of bacterial infection and has a positive effect on life expectancy. In addition to these approaches, there are also specific measures for the control of esophageal variceal bleeding and the prevention of early recurrence of these bleedings. Pharmacological treatment for esophageal variceal bleeding can be started as soon as variceal bleeding is considered, even before upper gastrointestinal system endoscopy. Similar efficacy was demonstrated in a meta-analysis of 15 studies comparing emergency sclerotherapy and pharmacological therapy (vasopressin±nitroglycerin, terlipressin, somatostatin, octreotide). In the treatment of esophageal variceal bleeding, the combination of pharmacological and endoscopic treatment seems to be the most appropriate option. A meta-analysis of 8 studies compared the combination of endoscopic treatment [(sclerotherapy or endoscopic band ligation (EBL)] with endoscopic, pharmacological treatment) for acute variceal bleeding. Combination of endoscopic and pharmacological treatment was found superior in terms of bleeding control and risk of recurrence. In this study, we evaluated the efficacy of combination of pharmacological and endoscopic band ligation in patients who admitted to the hospital with esophageal variceal bleeding.

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.

EE129 A Cost-Effectiveness Analysis for Terlipressin in Treating Bleeding Oesophageal Varices Patients in the Philippines

Bleeding Oesophageal Varices (BOV) is a life-threatening condition that affects approximately 50% of cirrhotic patients. Vasoactive agents such as octreotide, vasopressin, somatostatin, and terlipressin are mainstays in the management BOV, with efficacy in attaining hemostasis in about 75% and 67% of patients at 48 hours and at 5 days, respectively. We conducted a cost-effectiveness analysis of terlipressin in the treatment of BOV from the payer’s perspective in the Philippine setting.

Treatment for bleeding esophageal varices in people with decompensated liver cirrhosis: a network meta-analysis

article: Treatment for bleeding esophageal varices in people with decompensated liver cirrhosis: a network meta-analysis - Italian Journal of Emergency Medicine 2021 December;10(3):153-5 - Minerva Medica - Journals

Dual-energy computed tomography for non-invasive prediction of the risk of oesophageal variceal bleeding with hepatitis B cirrhosis

Oesophageal variceal bleeding (OVB) is a fatal complication of cirrhosis and/or portal hypertension. We aimed to develop a non-invasive prediction model for the risk of OVB using dual-energy computed tomography (CT). 317 oesophageal varices (OV) patients with hepatitis B virus-related cirrhosis were retrospectively assessed from January 2018 to December 2018. All patients underwent dual-energy CT scans within 14days before endoscopy. 222 of 317 patients (174 OVB-negative patients and 48 OVB-positive patients) were included in the training cohort and 95 patients (74 OVB-negative patients and 21 OVB-positive patients) were included in the validation cohort chronologically. A model with the selected conventional CT features and a model with the conventional CT and dual-energy CT features were developed. The prediction accuracy was evaluated using the receiver operating characteristic (ROC) curve. The accuracy and reproducibility of the models for OVB risk prediction of cirrhosis were validated by the validation cohort. The areas under the curve (AUC) of the two models were compared with Delong test. Diameter of oesophageal vein (OV(mm)), diameter of splenic vein (SPV(mm)), ascites (AS), iodine concentration in short gastric vein (SGV(HU)), iodine concentration in spleen (SP(HU)) were independent predictors of OVB risk (P < 0.05). Then, we developed a model with the selected conventional CT features [OV(mm), SPV(mm), AS] and a model with the conventional CT and dual-energy CT features [OV(mm), SPV(mm), AS, SGV(HU), SP(HU)]. The AUCs of the model built with the conventional CT and dual-energy CT features were higher than the model built only with the conventional CT features in the training (0.839 vs 0.809) and validation cohorts (0.798 vs 0.738). The non-invasive prediction model developed with the conventional CT and dual-energy CT features may have added value in noninvasively predicting OVB than the model built only with the conventional CT features and may have significant clinical implications on early prevention and treatment of OVB. Combination of dual-energy CT with conventional CT may have added value for non-invasive prediction of OVB compared to conventional CT.

Treatment for bleeding oesophageal varices in people with decompensated liver cirrhosis: a network meta-analysis.

Treatment for bleeding oesophageal varices in people with decompensated liver cirrhosis: a network meta-analysis.

Current situation of screening, prevention and treatment of bleeding esophageal varices in cirrhotic portal hypertension in Tibet region: a multicenter study

Objective: To investigate and analyze the current situation, screening, clinical characteristics, prevention and treatment of bleeding esophageal varices in cirrhotic patients with portal hypertension in Tibet region. Methods: Clinical data of cirrhotic patients with portal hypertension through March 2017 to February 2020 from Tibet region were collected and analyzed retrospectively. Results: 511 cases with liver cirrhosis were included in the study, of which 185 cases (36.20%) had compensated cirrhosis and 326 cases (63.80%) had decompensated cirrhosis. Further analysis of the etiological data of liver cirrhosis showed that 306 cases (59.88%) were of chronic hepatitis B, 113 cases (22.11%) of alcoholic liver disease, and 68 cases (13.31%) of chronic hepatitis B combined with alcoholic liver disease. Among patients with compensated liver cirrhosis, 48 cases (25.95%) underwent endoscopic examination of which 33 diagnosed as high-risk variceal bleeding. However, none of these 33 cases had received non-selective β-blocker therapy, and only four patients had received endoscopic variceal banding therapy. Among patients with decompensated liver cirrhosis, 83 cases (25.46%) had a history of upper gastrointestinal bleeding, 297 cases (91.10%) had ascites, 23 cases (7.05%) had hepatic encephalopathy, and 3 cases (0.92%) had hepatorenal syndrome. Among the patients with a history of upper gastrointestinal bleeding, 42 cases (50.60%) had received secondary preventive treatment for bleeding esophageal varices, including 39 cases of endoscopic treatment, 1 case of endoscopic combined drug treatment, 3 cases of interventional treatment, and 2 cases of surgical treatment. Conclusion: Chronic hepatitis B and alcoholic liver diseases are the main causes of liver cirrhosis in Tibet region. Moreover, this region lacks screening, prevention and treatment for bleeding esophageal varices in cirrhotic patients with portal hypertension. Therefore, it is necessary to increase the screening of high-risk groups to prevent and improve the first-time bleeding, and promote multidisciplinary team to prevent and treat re-bleeding.

Comparison of Therapies for Secondary Prophylaxis of Esophageal Variceal Bleeding in Cirrhosis: A Network Meta-analysis of Randomized Controlled Trials

PurposeThe decision regarding the optimal secondary prophylactic treatment for esophageal variceal bleeding (EVB) in hepatic cirrhosis is controversial. A network meta-analysis was conducted to assess the benefits of various treatments for the secondary prophylaxis of EVB in patients with cirrhosis. MethodsA thorough examination of databases, including EMBASE, PubMed, and Cochrane Database of Controlled Trials, was conducted to identify relevant randomized controlled trials up to December 2019. Key primary outcomes included mortality and rebleeding. Within the identified databases, a network meta-analysis was performed. Results were expressed by using a 95% credible interval (CrI) and odds ratios (ORs). The quality of results was assessed by using the Grading of Recommendations, Assessment, Development and Evaluation approach. FindingsForty-eight trials with 4415 participants with cirrhosis and portal hypertension who had a history of recent variceal bleeding were included. Carvedilol ranked first (surface under the cumulative ranking curve [SUCRA], 87.4%) in overall survival, and some advantage was suggested; however, the findings were not statistically significant, compared with endoscopic variceal ligation + nonselective beta-blockers (NSBB) (OR, 0.59; CrI, 0.28, 1.3), NSBB + isosorbide mononitrate (OR, 0.67; CrI, 0.33, 1.4), and transjugular intrahepatic portosystemic shunt (TIPS) (OR, 0.52; CrI, 0.24, 1.1). NSBB + isosorbide mononitrate (SUCRA, 63.9%) ranked higher than NSBB + endoscopic variceal ligation (SUCRA, 49.6%) in reducing mortality. TIPS (SUCRA, 98.8%) ranked higher than other treatments in reducing rebleeding but did not confer any survival benefit. ImplicationsTIPS ranks first in preventing rebleeding of secondary prophylaxis of EVB and carvedilol shows outstanding efficacy in improving survival. International Prospective Register of Systematic Reviews: identifier CRD42019131814.

Efficacy of endoscopic treatments for acute esophageal variceal bleeding in cirrhotic patients: systematic review and meta-analysis.

Background and aim Guidelines recommend use of ligation and vasoactive drugs as first-line therapy and as grade A evidence for acute variceal bleeding (AVB), although Western studies about this issue are lacking. Methods We performed a systematic review and meta-analysis of randomized controlled trials (RCT) to evaluate the efficacy of endoscopic treatments for AVB in patients with cirrhosis. Trials that included patients with hepatocellular carcinoma, use of portocaval shunts or esophageal resection, balloon tamponade as first bleeding control measure, or that received placebo or elective treatment in one study arm were excluded. Results A total of 8382 publications were searched, of which 36 RCTs with 3593 patients were included. Ligation was associated with a significant improvement in bleeding control (relative risk [RR] 1.08; 95 % confidence interval [CI] 1.02 – 1.15) when compared to sclerotherapy. Sclerotherapy combined with vasoactive drugs showed higher efficacy in active bleeding control compared to sclerotherapy alone (RR 1.17; 95 % CI 1.10 – 1.25). The combination of ligation and vasoactive drugs was not superior to ligation alone in terms of overall rebleeding (RR 2.21; 95 %CI 0.55 – 8.92) and in-hospital mortality (RR 1.97; 95 %CI 0.78 – 4.97). Other treatments did not generate meta-analysis. Conclusions This study showed that ligation is superior to sclerotherapy, although with moderate heterogeneity. The combination of sclerotherapy and vasoactive drugs was more effective than sclerotherapy alone. Although current guidelines recommend combined use of ligation with vasoactive drugs in treatment of esophageal variceal bleeding, this study failed to demonstrate the superiority of this combined treatment.

Endoscopic Therapy and Radiologic Intervention of Acute Gastroesophageal Variceal Bleeding.

Acute gastroesophageal variceal hemorrhage is a dreaded complication in patients with liver cirrhosis. Endoscopic therapy and radiologic intervention for gastroesophageal bleeding have rapidly developed in the recent decades. Endoscopic treatment is initially performed to stop variceal hemorrhage. For the treatment of esophageal variceal bleeding, endoscopic variceal ligation (EVL) is considered the endoscopic treatment of choice. In cases of gastric variceal hemorrhage, the type of gastric varices (GVs) is important in deciding the strategy of endoscopic treatment. Endoscopic variceal obturation (EVO) is recommended for fundal variceal bleeding. For the management of gastroesophageal varix type 1 bleeding, both EVO and EVL are available treatment options; however, EVO is preferred over EVL. If endoscopic management fails to control variceal hemorrhage, radiologic interventional modalities could be considered. Transjugular intrahepatic portosystemic shunt is a good option for rescue treatment in refractory variceal bleeding. In cases of refractory hemorrhage of GVs in patients with a gastrorenal shunt, balloon-occluded retrograde transvenous obliteration could be considered as a salvage treatment.

Treatment for bleeding oesophageal varices in people with decompensated liver cirrhosis: a network meta-analysis

Treatment for bleeding oesophageal varices in people with decompensated liver cirrhosis: a network meta-analysis

Safety and effectiveness of midazolam for cirrhotic patients undergoing endoscopic variceal ligation.

Endoscopic variceal ligation (EVL) is an established treatment for esophageal variceal bleeding. Midazolam (MDZ) is most commonly used for sedation during endoscopic procedures. However, adverse events (AEs) may occur more frequently in patients with cirrhosis due to altered MDZ metabolism. We retrospectively reviewed the records of 325 patients with cirrhosis who received EVL. No significant differences were found in treatment outcome and procedure time among 151 patients in the MDZ group and 169 patients in the non-MDZ group. Desaturation (23.2% vs. 7.7%, p<0.01), bradycardia (22.5% vs. 17.2%, p=0.03), and hepatic encephalopathy (HE) (6.6% vs. 0.6%, p<0.01) were more common in the MDZ group than in the non-MDZ group. Logistic regression analyses revealed that an Eastern Cooperative Oncology Group (ECOG) score of ≥2 (p<0.01) and the use of MDZ (p<0.01) were associated with the development of overall AEs. An ECOG score of ≥2 (p=0.01), high serum creatinine level (p=0.02), and the use of MDZ (p<0.01) were significant risk factors for HE. Extreme caution should be taken when sedating patients with cirrhosis receiving EVL due to the AEs associated with the use of MDZ.

Advances in the effect of carvedilol in prevention and treatment of esophageal variceal bleeding in patients with cirrhosis

Advances in the effect of carvedilol in prevention and treatment of esophageal variceal bleeding in patients with cirrhosis

Advance in endoscopic treatment of esophageal variceal bleeding

Esophageal variceal bleeding is the most dangerous complications of portal hypertension caused by cirrhosis.It is a common emergency of digestive diseases, with characteristics of a large amount of bleeding, difficulties in rescue and high mortality.Treatment methods include drug therapy, surgical treatment, interventional therapy, combined therapy, endoscopic therapy, etc.Endoscopic therapy has become the main means to treat EVB because of its high success rate of hemostasis, little trauma and rapid hemostasis.With the continuous improvement of endoscopic equipment and technology, endoscopic treatment plays a more prominent role in the rescue process.This article reviews the endoscopic treatment of esophageal variceal bleeding. Key words: Esophageal Variceal Bleeding; Portal Hypertension; Endoscopic Treatment

Does Diet Affect Post-EVL Rebleeding Rates? A Review of High-Risk Hospitalized Patients

Introduction: There is lacking evidence evaluating the impact of time to feeding and type of diet after endoscopic treatment of esophageal varices. We conducted a retrospective chart review with the aim of evaluating the impact of time to feeding and the type of diet on the incidence of rebleeding for patients treated endoscopically for bleeding gastroesophageal varices. Methods: We conducted a retrospective chart review at Elmhurst Hospital Center, cirrhotic patients presenting with an acute esophageal variceal bleed treated endoscopcially with band ligation between 2000 and 2016 were enrolled. Patient demographics, information pertaining to their cirrhosis and variceal stage, time to diet initiation, diet type and rebleeding information was collected.Table: Table. Patient DemographicsResults: A total of 49 patients were enrolled in the study, 39 were male (80%). Median age was 58, 10/22/17 patients were child pugh A/B/C respectively. INR median 1.4, Platelet count Median 87,000. Initial hemostasis was achieved in 100% of acute esophageal variceal bleeds. The total number of rebleeders was 19(39%), with 1 (5%) rebleed ocurring 30 days after band ligation. Twenty-Five patients resumed diet on post op day 1, 9 (36%) patients had rebleeding (8 clear liquids, 1 regular diet) out of which only 1 (11%) occurred < 5 days post op (clear liquid). Out of 9 patients that resumed diet on day 2, 4 (44%) (2 clear liquid, 1 pureed and 1 regular diet) rebled. Conclusion: Timing of initiation of dietary intake after the initial treatment of bleeding esophageal varices may play a role in rebleeding. Further studies are warranted to determine their relationship.

Reply

Potential conflict of interest: Dr. Morillas advises for and is on the speakers' bureau for Gilead, AbbVie, Merck, and Bristol‐Myers Squibb. Dr. Escorsell received grants from Vital Therapies. Dr. Garcia‐Pagan received grants from Gore, Exalenz, and Novartis. Reply: We sincerely thank Gundling et al. for their letter. We totally agree with them that migration after deployment of self‐expanding esophageal covered metal stents (SX‐ELLA Danis) is not an uncommon complication of this device. In fact, some researchers reported an incidence of stent migration as high as 25%.1 However, migration by itself should not be considered as an adverse event or equivalent to treatment failure—unless it gives rise to a specific complication or rebleeding. Of course, in our study, we considered the possibility of immediate stent migration. Accordingly, surveillance chest x‐ray was routinely scheduled for its detection immediately after and at 12 hours following the procedure. This was also the very reason for which we allowed repositioning or replacement of the esophageal stent during the first 24 hours after its deployment. We chose this time lapse because of the recognized high risk of rebleeding during the first 24 hours, a risk that is known to progressively decrease thereafter.4 As mentioned in the article, one of our patients randomized to receive the esophageal stent actually was treated by a Sengstaken tube because of a defect in the stent delivery system (rupture of the gastric balloon). In addition, 2 patients experienced stent migration, which was detected in the plain chest x‐ray performed immediately after stent deployment. In both instances, stent migration was immediately corrected, by repositioning the stent in 1 case and by removing the migrated stent and placement of a second one in the other case. These were considered technical problems rather than complications, given that none were associated with failure in controlling bleeding or with the development of clinical complications. Admitedly, we do not know whether such an early detection of the stent migration in our 2 patients and its rapid resolution prevented the development of subsequent serious complications. Therefore, we agree with Gundling et al. that migration after the deployment of self‐expanding esophageal metal stents represents a potential complication in the treatment of bleeding esophageal varices. Nevertheless, its consequences may be mitigated by scheduling a plain chest x‐ray immediately after stent deployment and periodically thereafter, because this allows its early recognition and resolution.

Clinical effects of endoscopic ligation combined with tissue glue injection in treatment of esophageal variceal bleeding

Clinical effects of endoscopic ligation combined with tissue glue injection in treatment of esophageal variceal bleeding

Results of treatment of esophageal variceal hemorrhage with endoscopic injection of n-butyl-2-cyanoacrylate in patients with Child-Pugh class C cirrhosis.

Background and study aims: The results of endoscopic treatment with elastic band ligation for esophageal variceal bleeding in patients with Child-Pugh class C cirrhosis remain poor. In comparison with treatment with elastic band ligation, we have found lower rates of rebleeding and mortality with n-butyl-2-cyanoacrylate injections. Thus, the aim of the current study was to describe our unit’s 10 years of experience with injection of n-butyl-2-cyanoacrylate to control esophageal variceal ruptures in patients with Child-Pugh class C cirrhosis. Patients and methods: A single-center, retrospective study was conducted. Sixty-three patients with Child-Pugh class C cirrhosis had been admitted to the center with an acute episode of esophageal variceal bleeding. All were treated with injection of n-butyl-2-cyanoacrylate. The patients were assigned to 1 of 2 groups according to their Child-Pugh class C cirrhosis scores: group I (score range, 10 through 13 points) and group II (score, 14 or 15 points). The 3 variables studied were rates of initial failure to control bleeding, failure to prevent rebleeding (secondary prophylaxis), and mortality. Patients in the 2 groups (group I, n = 50; group II, n = 13) had similar characteristics. Results: Bleeding was successfully controlled in almost 75 % of the patients during the first 5 days after treatment, with no significant differences observed between groups I and II. There were no significant differences between the 2 groups with respect to mortality rate for the first 5 days after treatment. Thirty-four patients (54 %) were free of bleeding at 6 weeks after treatment, with a significant difference noted between the groups: group I, 64 %, versus group II, 15.4 % (P < 0.001). The overall mortality rate was 44.4 %, with a significant difference noted between the groups: group I, 34 %, versus group II, 84.6 % (P < 0.001). Conclusion: Endoscopic injection of n-butyl-2-cyanoacrylate is a valid treatment option to control esophageal variceal bleeding in patients with a Child-Pugh class C cirrhosis score in the range of 10 through 13 points.