Variceal Bleeding In Cirrhotic Patients Research Articles

Non-invasive predictors to grade esophageal varices in liver cirrhosis patients.

Portal hypertension commonly occurs due to liver cirrhosis, and esophageal varices (EV) is one of the major complications associated with it. The most common cause of death in liver cirrhosis is EV bleeding. Hence, GE screening for EV is required, which is an invasive procedure. Regular use of endoscopy results in low compliance due to cost and discomfort for patients. Hence, identifying non-invasive markers that could grade EV provides a useful screening tool for family physicians and primary health centers (PHCs) by referring the patient to higher centers for definitive treatment, which could reduce mortality due to variceal bleeding in cirrhotic patients. To assess non-invasive predictors of grade EV in patients diagnosed with liver cirrhosis. Cross-sectional study. A total of 109 patients with liver cirrhosis underwent clinical and biochemical evaluation, USG abdomen with spleen bipolar diameter, ascitic fluid analysis, and upper GE with a grade of EV are recorded. SPSS software with Student t-test, Chi-square t-test, analysis of variance, receiver operator characteristic (ROC) curves, and Spearman correlation with 95% CI is used. P <0.05 is considered significant. Aminotransferase to Platelet count Ratio Index (APRI) score >1.815, PC/SD ≤909, and SAAG >1.1g/dl showed EV in liver cirrhosis (P < 0.05). The order of prediction with ROC curves shows APRI score > PC/SD > SAAG. In grading EV, APRI scores of 1.9-2.5 and >2.5 showed small and large EV, respectively (P < 0.05). APRI score may be used in PHC as an early intervention to grade EV and refer the patient to higher centers for definitive treatment. This would prevent the progression of varices to rupture and reduce mortality due to variceal bleeds in liver cirrhosis patients.

Efficacy of propranolol versus carvedilol in prophylaxis of variceal bleeding: Randomized clinical trial.

Objective: To compare the efficacy of carvedilol and propranolol for prophylaxis of variceal bleeding in cirrhotic patients. Study Design: Randomized Controlled Trial. Setting: Department of Gastroenterology and Hepatology, PIMS, Islamabad. Period: 1st January 2022 to 31st of December 2022. Material &amp; Methods: A total of 260 patients reporting at the department suffering from liver cirrhosis with medium or large esophageal varices and had never reported for variceal bleeding previously. The patients were randomized in to 2 equal groups of 130 each through computer generated randomization. Patients in Group-A were started on dose of carvedilol 6.25mg once daily initially for 1 week, subsequently titrated to twice daily 6.25mg and titrated up if needed to maximum of 25mg twice daily. Patients in Group-B received a dosage of propranolol 20 mg BID which then escalated weekly in 20 mg steps if needed and doses were adjusted as per targeted heart rate and systolic BP. Patients were followed up over 1 year for any event of variceal bleeding. Results: Mean overall age in this study was 42.13±10 years. The ratio of male patients was higher than female patients (60% VS 40%). Carvedilol prevented variceal bleeding in 86.15% of the patients while propranolol was effective in preventing variceal bleeding in 75.38% of the patients. Hence carvedilol was significantly more effective than propranolol in preventing variceal bleeding (p=0.02). Conclusion: Carvedilol is significantly more effective in prophylaxis of variceal bleeding than propranolol in patients with medium or large esophageal varices.

The impact of thrombocytopenia on variceal bleeding in cirrhotic patients with transjugular intrahepatic portosystemic shunt

Thrombocytopenia is the most frequent haematologic disorder in patients with cirrhosis, and it is perceived as a contributory factor for bleeding events. Cirrhosis patients with portal hypertension (PHT) is often accompanied with mild to moderate thrombocytopenia when they treated with transjugular intrahepatic portosystemic shunt (TIPS). To address whether the risk of variceal hemorrhage after TIPS varies with different platelet count in patients with normal platelet count and thrombocytopenia, we conducted the retrospective controlled study to evaluate the association of platelet count with the risk of variceal bleeding after TIPS. 304 patients were selected to the study. Propensity score matching was performed to adjust for potential selection bias. 63 patients from each group could be paired. Cox proportional hazards models were used to evaluate the association between platelet and variceal bleeding after TIPS. Platelet counts of two groups are 185.0 ± 98.7 × 109/L (normal platelet count) and 70.6 ± 39.3 × 109/L (thrombocytopenia) respectively. The bleeding rates of two groups in overall cohort are 10.9% (normal platelet count) and 12.9% (thrombocytopenia). After matched, the bleeding rates of two groups are 11.1% (normal platelet count) and 14.3% (thrombocytopenia) There was no statistically significant difference in bleeding rates between the two groups, either in the whole cohort (P = 0.671) or in the matched cohort (P = 0.593). Platelet count was not associated with bleeding events after TIPS (hazard ratio (HR) 95% confidence interval: 0.986–1.005, P = 0.397 in normal platelet count and 95% confidence interval: 0.968–1.020, P = 0.648 in thrombocytopenia). Thrombocytopenia in patients with cirrhosis was not associated with the risk of variceal bleeding episodes post-TIPS. Thrombocytopenia should not be viewed as an absolute contraindication for TIPS.

Recurrent variceal bleeding in cirrhotic patients with acute kidney injury

Recurrent variceal bleeding in cirrhotic patients with acute kidney injury

Shear Wave Dispersion Slope Measured with Shear Wave Dispersion Imaging Is Associated with Variceal Hemorrhage in Cirrhotic Patients.

Portal hypertension (PH), as the main consequence of cirrhosis, leads to the development of gastroesophageal varices (GEVs). Variceal hemorrhage (VH) caused by the rupture of GEVs is a life-threatening emergency. Thus, the prediction of VH risk is considerably important. Our pilot study aimed to identify the risk factors of variceal hemorrhage (VH) in cirrhosis. Cirrhotic patients were prospectively included and divided into two groups according to the presence or absence of VH. Conventional ultrasound and shear wave dispersion (SWD) imaging were conducted to detect the portal vein diameter, spleen diameter, ascites, liver stiffness (LS) and shear wave dispersion slope (SWDS). The laboratory tests were recorded, including platelets (PLT), alanine transaminase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL) and albumin (ALB). The risk factors of VH were screened using univariate analyses and identified using multivariate logistic regression. The ROC curves were used to assess diagnostic accuracy. Comparisons between AUCs were performed using the Delong method. Sixty-five patients with 22 VHs were finally included. The SWDS, spleen diameter and ascites were identified as independent risk factors for VH. The SWDS showed good performance for diagnosing VH (AUC = 0.768, 95% CI: 0.647-0.864), and sensitively identified 95.5% (95% CI: 77.2%-99.9%) of patients with VH. Including the three risk factors in multivariate logistic regression, we obtained a formula for diagnosing VH: -20.749 + 0.804 × SWDS + 0.449 × spleen diameter + 1.803 × ascites (no ascites = 0, ascites = 1). Comparison of AUCs revealed that the formula (AUC = 0.900, 95% CI: 0.800-0.961) performed better than LS, SWDS, and spleen diameter in diagnosing VH (p &lt; 0.001; p &lt; 0.05; p &lt; 0.05). SWDS is a sensitive parameter for assessing the risk of VH. Combining the SWDS, spleen diameter and ascites resulted in good diagnostic accuracy.

Systemic exposure to propranolol in patients with chronic liver disease and its correlation with portal blood flow.

Propranolol is a beta-blocker used for the prevention of variceal bleeding in cirrhotic patients. We investigated the pharmacokinetics of propranolol in patients with chronic liver disease compared to that in healthy individuals. The relative amount of portal blood flow was measured to investigate the correlation of portal blood flow and the systemic exposure of propranolol. Thirty healthy subjects, 18 patients with chronic active hepatitis (CAH), and 54 patients with cirrhosis were included in this prospective study. Blood samples for pharmacokinetic analysis were taken up to 8 h post-dose. The portal blood flow was estimated by H/L ratio using thallium-201 (201TI) per rectal scintigraphy. A total of 78 subjects completed the study. The area under the concentration-time curve (AUC) to the last measurable time (AUClast, ng⋅h/mL) were 150.2 ± 154.1, 112.2 ± 84.7, and 204.0 ± 137.3 in healthy subjects, CAH patients, and cirrhosis patients, respectively. AUCrmlast showed positive correlation with the H/L ratio in patients with chronic liver disease (r = 0.5817, p < 0.0001). In conclusion, the patients with cirrhosis showed higher systemic exposure to propranolol than healthy subjects or patients with CAH. The increase in systemic exposure to propranolol was correlated with the decrease in portal blood flow.

The Portosystemic Shunt for the Control of Variceal Bleeding in Cirrhotic Patients: Past and Present.

Based on an experience of more than 50 years in the treatment of portal hypertension (PHT), the authors review and analyze the evolution of the surgical portocaval shunt (PCS). We would like to provide an insight into the past of PCS, in order to compare it with the current state of the treatment of PHT complications. As a landmark of the past, we shall present statistics of more than 500 cases of PHT operated between 1968 and 1983. From this group, 238 patients underwent surgical portocaval shunting during a fifteen-year period. The behavior of the portal hemodynamics following PCS was studied and the postoperative decrease in portal pressure (PP), as well as the residual PP, were recorded. The portal manometric determinations were made by electronic recordings using the Hellige device and direct intraoperative recordings through the catheterization of a ramus in the portal area. The results of PCS are superposable, in terms of hemodynamic efficiency, with those of the intrahepatic shunt (TIPS—transjugular intrahepatic portosystemic shunt). The authors discuss the current place of PCS, in obvious decline in comparison with the situation 50 years ago. The current methods of controlling variceal bleeding represent obvious progress. PCS remains with very limited indications, in specific situations when the other therapeutic methods have failed or are not recommended.

Platelet Count/Spleen Thickness Ratio and the Risk of Variceal Bleeding in Cirrhosis With Esophagogastric Varices.

IntroductionThe platelet count/spleen thickness ratio (PC/ST ratio) is associated with the grade of esophagogastric varices (EGV) in cirrhotic patients, but little is known about its relationship with esophagogastric variceal bleeding (EGVB). The aim of this study was to investigate the association between the PC/ST ratio and the risk of EGVB within 1 year in cirrhotic patients.MethodsA total of 1,354 patients with cirrhosis who had EGV were enrolled in this cohort study. A logistic regression model was used to determine the association between the PC/ST ratio and the risk of EGVB within 1 year in patients with cirrhosis by adjusting the PC/ST ratio with all the important clinical variables and confounders.ResultsThe quartile values of the PC/ST ratio were 1.01, 1.36, and 1.98, respectively. The PC/ST ratio was an independent risk factor for variceal bleeding in cirrhotic patients with moderate or severe EGV. After adjusting for multiple variables, the relationship was still unchanged. The odds ratios of the first EGVB in these patients were 5.07-fold at non-adjustment and 3.28-fold after multivariate adjustment. The odds ratios of rebleeding in these patients from the lowest to the highest quartile were 2.34-fold at non-adjustment and 2.01-fold after multivariable adjustment. The PC/ST ratio ≤ 1.36 elevated the 1-year risk of first-time variceal bleeding or rebleeding in cirrhotic patients with moderate or severe EGV (All P < 0.05).ConclusionThe PC/ST ratio ≤ 1.36 is an independent risk factor for the onset of first bleeding or rebleeding in cirrhotic patients with moderate or severe EGV.

Propranolol vs. band ligation for primary prophylaxis of variceal hemorrhage in cirrhotic patients with ascites: a randomized controlled trial.

Recent studies have debated the utility of beta-blockers to prevent variceal hemorrhage (V.H.) in cirrhosis patients with ascites. We aimed to evaluate the safety and efficacy of propranolol (PPL) compared to endoscopic variceal ligation (EVL) for V.H. primary prevention in patients with ascites. Cirrhosis patients with ≥ grade 2 ascites and varices needing primary prophylaxis were randomly assigned to receive either PPL (n = 80) or EVL (n = 80). Patients were followed monthly until 12months or transplant or death. The primary endpoint was 12-month transplant-free-survival (TFS). Secondary endpoints were the incidence of V.H., acute kidney injury (AKI), and control of ascites. Baseline characteristics were similar between the groups. PPL-group had a lower 12-month TFS (76.0% vs. 89.7%; p = 0.02) as compared with EVL-group. Mean arterial pressure ≤ 82mmHg and MELD-sodium were the independent predictors of mortality. Incidence of VH was comparable between PPL and EVL-groups [6 (7.5%) vs. 2 (2.5%), p = 0.13]. In PPL vs. EVL-group, more patients had worsening of ascites (15% vs. 5%; p = 0.03), developed refractory ascites (13.7% vs.3.7%; p = 0.02), relapse of ascites (37.1% vs. 16.4%, p < 0.01), and AKI (26.2% vs. 12.5%; p = 0.02). Side effects were comparable between the two groups. Primary VH-prophylaxis with PPL is associated with lower survival, poor control of ascites, and increased risk of AKI in cirrhosis patients with ≥ grade 2 ascites. PPL and EVL are equally effective in preventing V.H. Serial monitoring of blood pressures and renal functions is needed in cirrhosis patients with ascites on PPL (NCT02649335).

Duodenal Necrosis and Nonvariceal Digestive Bleeding After Terlipressin Administration for Treatment of Hepatorenal Syndrome: a Case Report of a Novel Side Effect of a Commonly Used Drug

BackgroundTerlipressin is widely used for treatment of hepatorenal syndrome and variceal bleeding in cirrhotic patients. However, it may be associated with side effects, especially those related to vasoconstriction, such as myocardial infarction or intestinal ischemia. This is a case report of a cirrhotic patient with nonvariceal upper gastrointestinal bleeding after duodenal necrosis due to the use of terlipressin, a novel side effect not yet described in literature to the best of our knowledge. Case reportA 51-year-old male patient, with alcoholic liver cirrhosis and hepatitis C virus infection, was admitted presenting oliguria associated with severe ascites and lower limb edema. His Model for End Stage Liver Disease–Sodium score was 19 and his serum creatine level was 2.12 mg/dL. Albumin infusion was performed for 48 hours, but his serum creatinine level reached 3.46 mg/dL. Terlipressin infusion was started in continuous infusion and serum creatinine levels progressively decreased. However, the patient presented hemorrhagic shock secondary to hematemesis after 7 days. Upper digestive endoscopy showed an extensive ulcerated lesion in the duodenal bulb, reaching 70% of its lumen, with hematic residues and necrotic foci. Terlipressin was suspended and proton pump inhibitors were started. Despite intensive care, the patient developed severe encephalopathy and reentrant seizures. He eventually died 10 days after the bleeding event. ConclusionsWe described a case of nonvariceal upper gastrointestinal bleeding secondary to duodenal necrosis, which was caused by visceral ischemia induced by terlipressin. Given its fatality potential, this novel side effect should be remembered when using this medication in cirrhotic patients.

A non-invasive model based on the virtual portal pressure gradient to predict the first variceal hemorrhage in cirrhotic patients.

This study aimed to establish a non-invasive model based on the virtual portal pressure gradient (vPPG) to predict the first variceal hemorrhage (VH) in patients with cirrhosis. This single-center study prospectively enrolled cirrhotic patients as the training and validation cohorts during different time periods. The PPG-detection software (PPGS 1.0) was used to perform vPPG calculation, which involves 2 steps including three-dimensional (3D) reconstruction of portal vein tree and subsequent application of computational fluid dynamics. All patients were given standard primary prophylaxis against VH and followed up for 2years. Data from the training cohort were assessed using univariate and multivariate Cox regression and Kaplan-Meier analyses, by which a nomogram with its dynamic form was developed to estimate the probability of VH. In the training cohort (n = 128), 37 (28.9%) experienced VH during 2-year follow-up. Four variables including vPPG ≥ 10.5mmHg (p < 0.001), PLT < 56 × 109/L (p = 0.048), albumin < 32g/L (p < 0.001) and INR ≥ 1.2 (p = 0.022) were identified as independent risk factors of VH, among which vPPG showed the best diagnostic performance (AUC 0.875). Subsequently, these predictors were incorporated into the nomogram, of which C-indexes were 0.891 and 0.926 for the training and validation cohorts, respectively. Calibration curves demonstrated a great calibration ability of the model. At the threshold probabilities of 0.1-0.6 (1year) and 0.1-1.0 (2years), this nomogram could offer more net benefits in decision curve analysis. The vPPG-based nomogram could be used for risk stratification of the first VH in patients with cirrhosis.

Assessment of variceal bleeding in cirrhotic patients: accuracy of multi-detector computed tomography

BackgroundEsophageal variceal hemorrhage (EVH) has been shown to be a leading cause of mortality in patients with portal hypertension. Our purpose was to assess the utility of multi-detector computed tomography (MDCT) features in the assessment of esophageal varices (EVs) and esophageal variceal hemorrhage (EVH). This prospective study included 85 cirrhotic patients who underwent MDCT and Upper Gastrointestinal Tract (UGIT) endoscopy within 2 weeks. Four radiologists evaluated the presence of EVs and the presence and size of different collaterals. Multivariable logistic regression analysis was calculated to investigate the significant predictors influencing EV and EVH.ResultsFindings of EV with MDCT were the best predictor of EV or EVH. The presence (and/or size) of following collaterals had significant association with both EV and EVH: paraesophageal (p < 0.001, < 0.001), short gastric (p = 0.024, 0.010), gastric varicosities (p < 0.001, < 0.001), coronary (p < 0.001, < 0.001), and main coronary vein (MCV) (p < 0.001, = 0.011). We proposed an imaging-based model (presence of coronary collaterals, main coronary vein size > 3.5 mm, presence of short gastric collaterals, presence of gastric varicosities, size > 1.5 mm) with 97% sensitivity, 91% specificity, and 94% accuracy to predict EVs. We suggested another model (presence of paraesophageal collaterals, presence of short gastric vein (SGC), SGC size > 2.5 mm, main coronary vein size > 3.5 mm, gastric varicosities size > 1.5 mm, size of EVs > 4 mm, and Child C score) to predict EVH with 98% sensitivity, 81% specificity, and 89.5% accuracy. Inter-observer agreement was high in the detection of EVs (W. Kappa = 0.71–0.88).ConclusionMDCT is an effective modality in the diagnosis of EVs. At MDCT, the presence and/or size of various collaterals including para-esophageal, short gastric, coronary collaterals, and gastric varicosities are accurate predictors for either EVs existence or EVH. We suggested two computed tomography imaging-based models with high reproducibility and acceptable accuracy for the prediction of EV and EVH. With cirrhotic patients, we recommend that radiologists report collaterals in their daily practice.

Non-selective beta-blockers in patients with ascites: Thecomplex interplay among the liver, kidney and heart.

Non-selective beta-blockers (NSBBs) are the cornerstone of the primary and secondary prophylaxis of variceal bleeding in cirrhotic patients. They additionally prevent ascites development and death in compensated patients with clinically significant portal hypertension. After ascites onset, NSBBs remain beneficial for preventing further decompensations. However, as the cirrhosis progresses, the inflammation increases, systemic vasodilatation worsens, ascites turns refractory and cardiodynamic equilibrium becomes extremely fragile. In this scenario, NSBBs can critically impair the cardiac reserve and facilitate a haemodynamic breakdown, imperilling renal perfusion. Consequently, NSBB treatment should be carefully monitored or even avoided in such patients, and other options for portal hypertension management should be considered. In the present review, we explore the effects of NSBBs in patients with ascites and discuss the complex interplay among their hepatic, systemic and renal haemodynamic effects in this scenario.

Adherence to Non-Selective Beta Blockers for Prevention of Variceal Bleeding in Cirrhotic Patients.

Background and AimLong-term use of non-selective beta blockers (NSBBs) is essential for the prevention of esophageal variceal bleeding in liver cirrhosis but may impair the patient’s adherence. The present study aimed to investigate the adherence to NSBBs to prevent variceal bleeding in cirrhotic patients.MethodsAll patients who had an indication of NSBBs for the prophylaxis of variceal bleeding between February 2018 and June 2019 were screened. Clinical pharmacists gave pre-medication education and recorded the adherence to NSBBs during the patients’ hospitalizations. Factors associated with poor adherence were evaluated by univariate logistic regression analysis. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. The relationship between poor adherence during follow-up and variceal bleeding after discharge was also evaluated.ResultsOverall, 108 patients were screened, of whom 12 were intolerant to NSBBs. Among the 96 remaining patients who could take NSBBs, the average change of heart rate after NSBBs was −10.49 b.p.m. Twenty-two (22.9%) patients had poor adherence to NSBBs due to their refusal to take NSBBs (n = 2), complete forgetfulness to take NSBBs (n = 10), and refusal or forgetfulness to monitor heart rate (n = 10). Univariate logistic regression analysis demonstrated that only older age was significantly associated with poor adherence (OR: 1.065, 95% CI: 1.019–1.114, P = 0.005). Patients with poor adherence during follow-up were more likely to develop variceal bleeding after discharge.ConclusionA significant proportion of cirrhotic patients had poor adherence to NSBBs during their hospitalizations. Further studies should explore how to improve the patient’s adherence to NSBBs.

Comparing the Effectiveness of Carvedilol and Propranolol to Prevent Reoccurrence of Esophageal Variceal Bleeding in Patients with Liver Cirrhosis.

Objective: To compare the efficacy of carvedilol and propranolol to prevent reoccurrence of esophageal variceal bleeding in patients with liver cirrhosis. Study Design: Place and Duration: Department of Gastroenterology and Hepatology, Ayub Teaching Hospital, Abbottabad, Pakistan for six months duration from 15th November 2020 to 15th May 2021. Methods: Total one hundred and forty patients of ages between 18-65 years were presented in this study. Patients detailed demographics age, sex, body mass index and Child-Turcotte-Pugh (CTP) class were recorded after taking written informed consent. Patients were equally (n=70) divided into two groups. Group A had 70 patients and received carvedilol while group B had 70 patients and received propranolol for 6 months. Reoccurrence ofesophageal variceal bleeding in cirrhotic patients among both groups were observed at 2nd, 4th and 6th months and patients pulse rate, arterial pressure and portal vein flow were recorded at these time points. Complete data was analyzed by SPSS 26.0 version. Results: Mean age of the patients in group A was 40.38 ± 5.87 years with mean BMI 28.09 ± 7.33 kg/m2 and in group B mean age was 39.43 ± 12.69 years with mean BMI 27.53 ± 8.84 kg/m2. In group A 45 (64.3%) patients were males and 25 (35.7%) were female patients while in group B 50 (71.43%) were male patients and 20 (28.7%) patients were females. We found that there was no statistically significant difference observed among both groups regarding these demographic variables. Reoccurrence of bleeding observed in group A was significantly lower (among 20 (28.6%) cases) as compared to group B (among 36 (51.43%) cases). Pulse rate, mean arterial pressure and portal vein flow was found lower in the carvedilol group as compared to propanol group with p value &lt; 0.05 upon follow up at2,4 and 6 months. Conclusion: We found in this study that the drug carvedilol was more effective and safe to prevent reoccurrence of esophageal variceal bleeding in cirrhotic patients as compared to propanol. Keywords: Cirrhotic patients, Carvedilol, Propanol, Portal vein flow, Mean arterial pressure

Predictors of early rebleeding after endoscopic therapy of first variceal bleeding in liver cirrhosis

BackgroundDespite the great advancement in therapeutic modalities for esophageal varices, early variceal rebleeding still occurs at high rates leading to an exaggeration of the morbidity and mortality for cirrhotic patients, so meticulous follow-up with optimum prediction and proper preventive measures for early variceal rebleeding are mandatory for increasing survival of those patients. In this respect, we evaluated the clinical, laboratory, abdominal ultrasound, and endoscopic criteria of variceal cirrhotic patients as possible risk predictors of early variceal rebleeding after endoscopic control of first variceal bleeding. All included patients were followed up blindly for 12 weeks after endoscopic control of bleeding for ascertainment of first variceal rebleeding. The demographic, clinical, laboratory, abdominal ultrasound, and upper gastrointestinal endoscopic criteria were evaluated for all patients at first admission.ResultsBy univariate regression analysis, the statistically significant predictors for early variceal rebleeding were serum albumin, serum bilirubin, prothrombin concentration, Child-Pugh score, platelet count, spleen diameter, ascites, portal vein diameter and velocity, variceal size, variceal location, and red color sign. By using multivariate regression analysis, the most independent significant predictors were Child-Pugh score (sig: 0.001 and OR: 1.661), platelets count (sig: 0.000 and OR: 0.956), portal vein velocity (sig: 0.000 and OR: 0.664), variceal grading (sig: 0.000 and OR: 3.964), and variceal red color sign (sig: 0.000 and OR: 4.964). We used the multivariate regression coefficients for the significant predictors to build up early variceal rebleeding risk (EVRR) score with a significant discriminatory performance (AUC: 0.965 and sig: 0.000).ConclusionChild-Pugh score, platelet count, portal vein velocity, variceal grading, and variceal red color sign are independent risk predictors for early variceal rebleeding after successful control of first variceal bleeding in cirrhotic patients. Our proposed EVRR score could be helpful for the prediction of early variceal rebleeding in cirrhotic patients after endoscopic control of acute variceal bleeding; however, it should be externally validated in large prospective studies.

Serum Soluble CD163 as a Predictor of Esophageal Varices and Variceal Bleeding in Cirrhotic Patients

ABSTRACT Background: Bleeding of esophageal varices (OV) is also bearing elevated mortality in patients with liver cirrhosis (LC). The best standard diagnostic investigation for OV is upper gastrointestinal (GI) endoscopy. Patients and endoscopic units alike are burdened by the endoscopic screening of all patients with liver cirrhosis. The use of non-invasive OV detection reduces the need for endoscopic screening. Objective: The aim of the current work was to test serum soluble CD 163(sCD163) as a predictor of the presence, and grade of OV and as non-invasive indicator of having severe variceal bleeding. Patients and Methods: This cross-sectional study included a total of 70 cirrhotic patients, attending at the Hepatology and Gastroenterology Unit, Department of Internal Medicine, Benha University Hospital, Egypt. To detect OV, all patients underwent upper GI endoscopy, and serum sCD163 levels were assessed using an ELISA technique. Results: Patients with OV had a higher mean value of sCD163 levels (8.71±8.42 ng/ml) than patients without OV (2.89±1.02 ng/ml), however this was not statistically significant (P=0.13). sCD163 level was significantly higher in large OV group (10.75±9.26 ng/ml) than small OV group (3.75±0.92 ng/ml), (P=0.001). The rate of significant variceal bleeding is closely linked to serum higher sCD163 levels more than (4.63 ng/ml). Conclusion: It could be concluded that serum sCD163 could be a non-invasive indicator of the presence of OV in cirrhotic patients. It may also be used for the prediction of the size of OV and the probability of severe variceal bleeding.

Comparative Efficacy of Terlipressin and Octreotide along with Endoscopic Band Ligation in the Management of Esophageal Variceal Bleeding

Esophageal variceal bleeding is a medical emergency that carries a high mortality rate despite appropriate management. Terlipressin and Octreotide are two common agents used as adjuvant agents in the management of variceal bleeding. The objective of this study is to compare the effectiveness of Terlipressin with Octreotide along with endoscopic band ligation in the management of esophageal variceal bleeding in cirrhotic patients. This randomized control study was carried out at the Department of General Medicine, Fatima Memorial Hospital, Lahore, for six months extending from February 2019 to July 2019. A total of 100 cirrhotic patients were selected /based on predetermined inclusion and exclusion criteria. The patients were randomly divided into two groups of equal strength. Hence, 50 patients were included in Group A and 50 patients were included in Group B along with banding. Group A received Terlipressin whereas Group B received Octreotide. The two groups were monitored for variceal bleeding for 72 hours. The mean age of the patients in Group A was 55.9±7.3 years and for the patients in Group B it was 56.8±7.4 years. In Group A, 36 (72.0%) male and 14 (28.0%) female patients were included. In Group B, there were 34 (68.0%) male and 16 (32.0%) female patients. In Group A, the treatment was effective for 46 (92.0%) patients and in Group B, 36 (72.0%) patients had an effective treatment. It is concluded from this study that Terlipressin is statistically more effective than Octerotide in terms of preventing esophageal variceal bleeding.

Bacteremia as a risk factor for variceal upper gastrointestinal tract bleeding in cirrhotic patients: a hospital-based study

BackgroundThe presence of bacteremia as a complication of variceal bleeding in patients with liver cirrhosis had been investigated by many studies. The aim of this study was to assess the bacteremia as a risk factor for variceal upper gastrointestinal tract bleeding in cirrhotic patients. A cross-sectional study was conducted on 99 patients with chronic liver disease divided into three groups: group I included 35 patients presented with first attack of variceal bleeding, group II included 35 patients presented with recurrent attacks of variceal bleeding, and group III included 29 patients with no history of previous variceal bleeding as a control group. Routine laboratory tests were done, upper GI endoscopy, blood culture, and measurement of procalcitonin level in blood.ResultsPatients with recurrent variceal bleeding had statistically (p < 0.05) the highest percentage of positive blood culture followed by patients with first variceal bleeding and the control (60% vs 45.7% vs 24.1%) respectively. In addition to procalcitonin results, patients with recurrent variceal bleeding had statistically the highest values of PCT followed by patients with first variceal bleeding and the control (1.92 vs 0.325 vs 0.22 ng/ml) respectively. Multivariate regression analysis showed that procalcitonin and hemoglobin only was the significant predictors for variceal bleeding. Hemoglobin at cutoff value of ≤ 9.6 and procalcitonin (ng/dl) at cutoff value of > 1.76 is the most specific in predicting bleeding 86.21%, 86.21% (CI 95%) respectively.ConclusionBacteremia and procalcitonin are risk factor for variceal bleeding in cirrhotic patients. Procalcitonin can be used as easily measurable and surrogate biomarker for bacteremia and variceal bleeding.

Risk factors for early rebleeding after endoscopic therapy for esophageal varices in cirrhotic patients

Objective To investigate the risk factors for early rebleeding after endoscopic ligation or sclerotherapy for esophageal variceal bleeding in cirrhotic patients. Methods A retrospective analysis was performed for the clinical data of 153 cirrhotic patients with esophageal variceal bleeding who underwent endoscopic ligation or sclerotherapy in Beijing YouAn Hospital, Capital Medical University, from May 2017 to May 2019, and according to the presence or absence of rebleeding from 72 hours to 6 weeks after endoscopic therapy, the patients were divided into rebleeding group and non-rebleeding group. A logistic regression analysis was performed to investigate independent risk factors for early rebleeding. The t-test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups; the chi-square test or the Fisher's exact test was used for comparison of categorical data between two groups. Results Early rebleeding rate was 24.8% (38/153). Compared with the non-rebleeding group, the rebleeding group had a significantly lower albumin (Alb) and significantly higher activated partial thromboplastin time and prothrombin time (all P Conclusion Portal vein thrombosis, massive ascites, Child-Pugh C liver cirrhosis, and hypoproteinemia are independent risk factors for early rebleeding after endoscopic therapy in cirrhotic patients with esophageal variceal bleeding, which should be taken seriously in clinical practice.