Rate Of Variceal Bleeding Research Articles

Efficacy and safety of variceal embolization for primary prophylaxis in cirrhosis patients with challenges in standard treatments: preliminary results.

Nonselective beta blockers (NSBBs) or endoscopic therapies are currently recommended by guidelines for preventing the first variceal bleed in patients with high-risk varices. However, there is a lack of detailed treatment strategies for patients who are intolerant to both NSBBs and endoscopic approaches. Our study aimed to assess the efficacy and safety of variceal embolization as a primary prophylaxis method in cirrhosis patients who are not suitable candidates for NSBBs or endoscopic treatments. The study included 43 cirrhotic patients with high-risk varices who were candidates for primary prophylaxis against variceal bleeding. These patients underwent variceal embolization at the Xijing Hospital between January 2020 and June 2022. The primary endpoint was the occurrence of bleeding from varices, and the secondary endpoints were the recurrence of varices and the emergence of complications. The procedure of variceal embolization had a success rate of 93.0% (40 out of 43 patients). Over a 2-year follow-up period, the rate of variceal bleeding was 11.6% (5 out of 43 patients), the recurrence rate of varices was 14.0% (6 out of 43 patients), and the rate of severe complications was limited to 2.3% (1 out of 43 patients). Variceal embolization is a viable primary prophylactic intervention for cirrhotic patients who are at risk of variceal bleeding when standard treatments, such as NSBBs or endoscopic therapies, are difficult to perform.

Maternal and fetal outcomes in pregnant patients with non-cirrhotic portal hypertension: A systematic review and meta-analysis.

Concerned studies with respect to the outcome of pregnant patients with non-cirrhotic portal hypertension are limited. Thus, a systematic review and meta-analysis of the available literature was conducted. A literature search was conducted from 1999 to December 2021 for studies evaluating pregnancy outcomes in patients with non-cirrhotic portal hypertension. Twelve studies were included in the meta-analysis. The pooled rate of variceal bleeding, ascites and severe anemia requiring blood transfusion were 9.6%, 2.3%, and 14.9%, respectively. The pooled rate of spontaneous miscarriage, gestational hypertension, delivery by cesarean section, and postpartum hemorrhage were 11.9%, 4.5%, 36.7%, and 4.7%, respectively. The pooled stillbirth rate was 2.5% and among the live births, the pooled rates of preterm birth, low birth weight, intensive care unit admission, and neonatal mortality were 21.6%, 18.7%, 15.5%, and 1.8%, respectively. Pregnancy in patients with non-cirrhotic portal hypertension is associated with increased maternal & fetal morbidity but mortality remains low.

Splenectomy Combined with Endoscopic Variceal Ligation (EVL) versus EVL Alone for Secondary Prophylaxis of Variceal Bleeding in Hepatosplenic Schistosomiasis: A Retrospective Case-Control Study.

BackgroundHepatosplenic schistosomiasis (HSS) is one of the most common causes of portal hypertension in developing countries. Variceal bleeding is the most common cause of mortality during HSS. The objective of this study was to evaluate the efficacy of splenectomy associated with endoscopic variceal ligation (EVL) compared with EVL alone in preventing variceal bleeding in patients with HSS.MethodsThis was a single-center, retrospective, case–control study. Between January 2015 and December 2019, a total of 59 patients with HSS who had at least one variceal bleeding episode and received EVL with or without splenectomy were identified and stratified. In this case–control design, 22 patients had splenectomy + EVL (case group) and 37 patients had EVL alone (control group). The main endpoints were the rate of variceal rebleeding and the mortality rate between the two groups.ResultsThe mean age of our patients was 39.92 ± 13.4 (19–75) years with a sex ratio of 1.8. The recurrence rate of variceal bleeding was significantly lower in the case group (splenectomy + EVL) than in the control group (EVL alone) (4.45% vs 27.2%, p = 0.041). There was no significant difference between the two groups in terms of mortality (4.54 vs 2.7%, p = 1.00).ConclusionSplenectomy combined with EVL was effective than EVL alone in preventing variceal rebleeding in patients with HSS.

Combined Pharmacological and Endoscopic Treatment for Worsening Gastroesophageal Varices in Patients with Cirrhosis.

BackgroundAt the present time, in patients with liver cirrhosis and gastroesophageal varices, primary prophylaxis of variceal bleeding made with combination therapy with non-selective β-blockers (NSBBs) and endoscopic band ligation (EBL) is not recommended. The aim of this study was to evaluate if patients with worsening varices while on NSBBs regimen benefit, in terms of bleeding and survival, from adding treatment with EBL.MethodsPatients with cirrhosis and endoscopic finding of gastroesophageal varices with high risk feature (increased variceal size and/or development of red signs) during primary prophylaxis with NSBBs, followed at the Unit of Internal Medicine and Hepatology, University and General Hospital of Padova, Italy, from 2012 to 2019, were retrospectively evaluated. When an increased bleeding risk of the varices was confirmed, patients maintained the pharmacological therapy alone or underwent also EBL. The primary endpoint of the study was the rate of variceal bleeding, the secondary endpoint was mortality at 30 months.ResultsCompared to patients treated only with NSBBs (n=56), in patients treated also with EBL (n=45), the 30‐month probability of variceal bleeding (29.1% vs 5.1%; P =0.036) was significantly reduced, while the probability of survival was similar (59.6% vs 65.7%; P=0.61). On multivariate analysis, treatment with EBL was found to be a weak protective factor for mortality (HR 0.47, P=0.044).ConclusionIn patients with liver cirrhosis, when varices show endoscopic feature of increased haemorrhagic risk, adding EBL to NSBBs is effective in reducing the probability of first bleeding.

Impact of concurrent splenectomy and esophagogastric devascularization on surgical outcomes of partial hepatectomy for hepatocellular carcinoma in patients with clinically significant portal hypertension: A multicenter propensity score matching analysis

PurposePortal hypertension due to cirrhosis is common among patients with hepatocellular carcinoma (HCC). This study aimed to compare the outcomes of partial hepatectomy in patients with HCC and clinically significant portal hypertension (CSPH) with or without concurrent splenectomy and esophagogastric devascularization (CSED). Patients and methodsFrom a multicenter database, patients with HCC and CSPH who underwent curative-intent hepatectomy were identified. Postoperative morbidity and mortality, and long-term overall survival (OS) were compared in patients with and without CSED before and after propensity score matching (PSM). ResultsOf the 358 enrolled patients, 86 patients underwent CSED. Before PSM, the postoperative 30-day morbidity and mortality rates were comparable between the CSED and non-CSED group (both P > 0.05). Using PSM, 81 pairs of patients were created. In the PSM cohort, the 5-year OS rate of the CSED group were significantly better than the non-CSED group (52.9% vs. 36.5%, P= 0.046). The former group had a significantly lower rate of variceal bleeding on follow-up (7.4% vs. 21.7%, P= 0.014). On multivariate analysis, CSED was associated with significantly better OS (HR: 0.39, P < 0.001). ConclusionHepatectomy and CSED can safely be performed in selected patients with HCC and CSPH, which could improve postoperative prognosis by preventing variceal bleeding, and prolonging long-term survival.

Clinical characteristics of cirrhosis patients with umbilical vein recanalization: A retrospective analysis.

Umbilical Vein Recanalization (UVR) may occur in patients with long-standing portal hypertension and liver cirrhosis. This study aimed to investigate the clinical significance of UVR.Medical records of a cohort of patients with cirrhosis (n = 247) who were hospitalized at the Digestive Medicine Center of the Second Affiliated Hospital of Nanchang University from January 2012 to October 2015 were accessed. The UVR diagnosis was made by ultrasound examination and was confirmed by computerized tomography scan.The UVR incidence was 20.2% (50/247) in the cohort. The size of UVR was 9.9 ± 4.7 mm (range: 5–26.5 mm) in diameter. The UVR and non-UVR groups showed no difference in grades of hepatic encephalopathy (P = .496), Child-Pugh classification (P = .401), the incidence of moderately severe ascites (26% vs 26%, P = 1), the esophageal variceal bleeding rate (32% vs 39%, P = .402), or portal vein thrombosis (8% vs 12%, P = .580). However, the incidence of cavernous transformation of the portal vein was statistically different, that there was 0 case in the UVR group and 8 cases in the non-UVR group (P < .05).Our results suggested that UVR had little impact on the clinical manifestations of patients with liver cirrhosis, the significance of UVR as an intervention method requires further studies.

Role of Serum Ascites Albumin Gradient (SAAG) and Portal Vein Congestion Index as Non-‎Invasive Methods for Prediction of Esophageal Varices in Cirrhotic Patients ‎

Background and aim: Majority of cirrhotic patients develop varices, the rate of variceal bleeding is 10-30% yearly with ‎death rate from bleeding is 17-57%. esophagogastroduodenoscopy (EGD) is an invasive and ‎unpleasant technique carrying rare but serious complications. We aimed to investigate the serum ‎ascites albumin gradient (SAAG) and portal vein congestion index (PCI) as non-invasive methods ‎for prediction of esophageal varices (EV) in patients with liver cirrhosis‎. Patients and Methods: ‎‎125 cirrhotic patients with ascites and no past history of EGD were included. Patients were ‎grouped into; Group I: 38 cirrhotic patients without EV. Group II: 87 cirrhotic patients with EV. ‎Patients were subjected to full clinical evaluation, calculation of SAAG, abdominal ultrasound ‎with a duplex study and measurement of PCI, and Esophagogastroduodenoscopy for detection and ‎grading of esophageal varices‎ ‎.‎ Results: Cirrhotic patients with EV had higher SAAG values (1.85 ‎‏±‏‎ 0.24 gm/dl) than cirrhotic patients ‎without EV (1.27 ‎‏±‏‎ 0.15 gm/dl). Additionally, cirrhotic patients with EV showed a higher PCI ‎than those without (0.16 ± 0.02 and 0.12 ± 0.01 respectively). For prediction of EV in cirrhotic ‎patients, SAAG had AUC 0.986 (p 1.4 with sensitivity 97.70% and ‎specificity 89.47% and portal congestion index, AUC was 0.974 (p 0.135 had ‎sensitivity 90.80% and specificity 94.74%‎‎‎. Conclusion: SAAG could be used as a non-invasive predictor for the presence of EV in cirrhotic patients along ‎with SAAG cutoff >1.4 requiring clinical attention. Combination of SAAG and PCI had a high ‎ability to predict esophageal varices in cirrhotic patients with AUC 1.000‎‎‎‎‎.

Variceal bleeding is aggravated by portal venous invasion of hepatocellular carcinoma: a matched nested case-control study

BackgroundWe hypothesized that portal vein tumor thrombosis (PVTT) in hepatocellular carcinoma (HCC) increases portal pressure and causes esophageal varices and variceal bleedings. We examined the incidence of high-risk varices and variceal bleeding and determined the indications for variceal screening and prophylaxis.MethodsThis study included 1709 asymptomatic patients without any prior history of variceal hemorrhage or endoscopic prophylaxis who underwent upper endoscopy within 30 days before or after initial anti-HCC treatment. Of these patients, 206 had PVTT, and after 1:2 individual matching, 161 of them were matched with 309 patients without PVTT. High-risk varices were defined as large/medium varices or small varices with red-color signs and variceal bleeding. Bleeding rates from the varices were compared between matched pairs. Risk factors for variceal bleeding in the entire set of patients with PVTT were also explored.ResultsIn the matched-pair analysis, the proportion of high-risk varices at screening (23.0% vs. 13.3%; P = 0.003) and the cumulative rate of variceal bleeding (4.5% vs. 0.4% at 1 year; P = 0.009) were significantly greater in the PVTT group. Prolonged prothrombin time, lower platelet count, presence of extrahepatic metastasis, and Vp4 PVTT were independent risk factors related to high-risk varices in the total set of 206 patients with PVTT (Adjusted odds ratios [95% CIs], 1.662 [1.151–2.401]; 0.985 [0.978–0.993]; 4.240 [1.783–10.084]; and 3.345 [1.457–7.680], respectively; Ps < 0.05). During a median follow-up of 43.2 months, 10 patients with PVTT experienced variceal bleeding episodes, 9 of whom (90%) had high-risk varices. Presence of high-risk varices and sorafenib use for HCC treatment were significant predictors of variceal bleeding in the complete set of patients with PVTT (Adjusted hazard ratios [95% CIs], 26.432 [3.230–216.289]; and 5.676 [1.273–25.300], respectively; Ps < 0.05).ConclusionsPVTT in HCC appears to increase the likelihood of high-risk varices and variceal bleeding. In HCC patients with PVTT, endoscopic prevention could be considered, at least in high-risk variceal carriers taking sorafenib.

Laparoscopic splenectomy and esophagogastric devascularization combined with fast-track principles offers greater benefit for patients with portal hypertension.

IntroductionLaparoscopic splenectomy and esophagogastric devascularization (LSED) is becoming increasingly popular in the treatment of esophageal-fundic variceal bleeding with portal hypertension (PHT) in China, and its high safety and minimal trauma have been proven. Fast-track (FT) surgery improves patient recovery and decreases postoperative complications.AimTo determine whether LSED with fast-track principles can provide better outcomes than traditional treatment for patients with PHT.Material and methodsA total of 140 patients who underwent LSED with either traditional treatment or fast-track principles in our department were retrospectively analyzed. The postoperative outcomes, complications, inflammatory mediators, portal vein thrombosis (PVT) and recurrent esophagogastric variceal bleeding rate were recorded.ResultsNo significant differences were found in the patients’ preoperative characteristics. The FT group had better outcomes than the non-FT group with respect to gastrointestinal function recovery, resumption of oral intake, and postoperative hospitalization. The incidence of postoperative complications, including pneumonia, severe ascites, and urinary tract infection, were significantly lower in the FT than the non-FT group. The C-reactive protein and interleukin 6 concentrations and the incidence of PVT were significantly lower in the FT than the non-FT group. The overall recurrent bleeding rate is 11.5% and no significant difference was found between the two groups in the follow-up period.ConclusionsLSED with fast-track principles was superior to LSED with traditional treatment in terms of postoperative outcomes, complications, postoperative inflammatory reactions, and the incidence of PVT. This strategy is safe and effective for the treatment of PHT.

Transjugular Intrahepatic Portosystemic Shunts Reduce Variceal Bleeding and Improve Survival in Patients with Cirrhosis: A Population-Based Analysis

PurposeTo investigate from a population health perspective the effects of transjugular intrahepatic portosystemic shunt (TIPS) creation on recurrent variceal bleeding and survival in patients with cirrhosis. Materials and MethodsPatients with cirrhosis who presented to outpatient and acute-care hospitals in California (2005–2011) and Florida (2005–2014) with variceal bleeding comprised the study cohort. Patients entered the study cohort at their first presentation for variceal bleeding; all subsequent hospital encounters were then evaluated to determine subsequent interventions, complications, and mortality data. ResultsA total of 655,577 patients with cirrhosis were identified, of whom 42,708 (6.5%) had at least 1 episode of variceal bleeding and comprised the study cohort. The median follow-up time was 2.61 years. A TIPS was created in 4,201 (9.8%) of these patients. There were significantly greater incidences of coagulopathy (83.9% vs 72.8%; P < .001), diabetes (45.5% vs 38.8%; P < .001), and hepatorenal syndrome (15.3% vs 12.5%; P < .001) in TIPS recipients vs those without a TIPS. Following propensity-score matching, TIPS recipients were found to have improved overall survival (82% vs 77% at 12 mo; P < .001) and a lower rate of recurrent variceal bleeding (88% vs 83% recurrent bleeding–free survival at 12 months,; P < .001) than patients without a TIPS. Patients with a TIPS had a significant increase in encounters for hepatic encephalopathy vs those without (1.01 vs 0.49 per year; P < .001). ConclusionsTIPS improves recurrent variceal bleeding rates and survival in patients with cirrhosis complicated by variceal bleeding. However, TIPS creation is also associated with a significant increase in hepatic encephalopathy.

Efficacy and safety of anticoagulation in non-malignant portal vein thrombosis in patients with liver cirrhosis: a systematic review and meta-analysis.

BackgroundThe role of anticoagulation in treating non-malignant portal vein (PV) thrombosis (PVT) in patients with liver cirrhosis remains unclear. In our meta-analysis, we aimed to evaluate the efficacy and safety of anticoagulation for the treatment of non-malignant PVT in these patients.MethodsWe conducted a meta-analysis to estimate the effects of anticoagulation on non-malignant PVT in patients with liver cirrhosis. We assessed the rates of PV recanalization, variceal bleeding, and any bleeding.ResultsWe included 9 observational studies which involved 474 patients. The rate of PV recanalization was significantly higher in patients who received anticoagulation compared to those who did not: 65.2% vs. 25.2%; relative risk (RR) 2.31, 95% confidence interval (CI) 1.80-2.96; P<0.00001. Variceal bleeding was significantly lower in patients who received anticoagulation: 0.1% vs. 18.5%; RR 0.15, 95%CI 0.04-0.55; P=0.004. Any bleeding was similar between patients who received anticoagulation and those who did not: 10.3% vs. 22.7%; RR 0.43, 95%CI 0.09-1.99; P=0.28.ConclusionsAnticoagulation use increased the rate of PV recanalization in cirrhotic patients with non-malignant PVT. Anticoagulation decreased the rate of variceal bleeding and did not increase the rate of any bleeding.

Effect of Nonselective β-Blockers on Mortality in Patients With End-Stage Cirrhosis.

Background: Data regarding safety of nonselective β-blockers (NSBBs) in patients with end-stage cirrhosis are conflicting, making it difficult for practitioners to justify if benefits outweigh the risks. Objective: Evaluate the effect of NSBB use on mortality in patients with end-stage cirrhosis. Methods: We performed a dual-center retrospective study of patients who received octreotide for a variceal bleed. Patients were stratified into 2 groups based on whether or not a NSBB was prescribed at hospital discharge. The primary outcome was 24-month mortality. Multivariable logistic regression, with 24-month mortality as the dependent variable, was performed to identify independent risk factors for the primary outcome. Results: 255 patients met inclusion criteria; 24-month mortality was 32.8%. The NSBB and no-NSBB groups had similar mortality rates at 24 months (32.0% vs 38.5%, P = 0.51). Mortality at 3 months (11.6% vs 23.3%, P = 0.08) and 12 months (22.2% vs 30.0%, P = 0.36) were similar, and there were no differences in rate of variceal bleeding (22.7% vs 13.3%, P = 0.34) or cirrhosis-related cause of death (20.4% vs 23.3%, P = 0.81). In the multivariable model, age, model for end-stage liver disease with sodium and hepatocellular carcinoma were independent risk factors for 24-month mortality. NSBB therapy had no effect on 24-month mortality (adjusted odds ratio = 1.05; 95% CI = 0.32 to 3.40). Conclusion and Relevance: In patients with end-stage cirrhosis, use of NSBBs did not affect 24-month mortality. More research is needed to determine when, and if, NSBBs should be discontinued in end-stage cirrhosis.

Long-term patency and clinical outcome of the transjugular intrahepatic portosystemic shunt using the expanded polytetrafluoroethylene stent-graft.

BackgroundTransjugular intrahepatic portosystemic shunt (TIPS) creation is an established treatment option to management the complications of portal hypertension. Recent data on the long-term outcomes of TIPS are scarce.Materials and methodsIn this single-institution retrospective study, 495 patients underwent TIPS with the Fluency stent-grafts between December 2011 and June 2015 were evaluated. The cumulative rates of TIPS dysfunction, hepatic encephalopathy (HE), survival, and variceal rebleeding were determined using the Kaplan–Meier method. Cox regression analysis was used to assess the parameters on TIPS patency, occurrence of HE and all-cause mortality.ResultsTechnical success was 98.2%. TIPS-related complications occurred in 67 patients (13.5%) during the index hospital stay. TIPS creation resulted in an immediate decrease in mean portosystemic pressure gradient from 23.4 ± 7.1 mmHg to 7.6 ± 3.5 mmHg. The median follow-up period was 649 days. Primary TIPS patency rates were 93%, and 75.9% at 1 and 3 years, respectively. Previous splenectomy was associated with a higher risk of TPS dysfunction. The cumulative survival rates were 93.4% and 77.2% at 1 and 3 years, respectively. The 1- and 3-year probability of remaining free of variceal bleeding rates were 94.2% and 71.4%, respectively.ConclusionsThis retrospective single-center experience with TIPS using the Fluency stent-grafts demonstrates good long-term patency and favorable good clinical results. Previous splenectomy strongly predicts shunt dysfunction.

Daily Norfloxacin vs. Weekly Ciprofloxacin to Prevent Spontaneous Bacterial Peritonitis: A Randomized Controlled Trial.

For the prevention of spontaneous bacterial peritonitis (SBP) in cirrhotic patients with ascites, norfloxacin 400 mg per day is recommended as a standard regimen. This study aims to investigate whether ciprofloxacin once weekly administration is not inferior to norfloxacin once daily administration for the prevention of SBP. This is an investigator-initiated open-label randomized controlled trial conducted at seven tertiary hospitals in South Korea. Liver cirrhosis patients with ascites were screened, and enrolled in this randomized controlled trial if ascitic protein ≤1.5 g/dL or the presence of history of SBP. Ascitic polymorphonucleated cell count needed to be <250/mm3. Patients were randomly assigned into norfloxacin daily or ciprofloxacin weekly group, and followed-up for 12 months. Primary endpoint was the prevention of SBP. One hundred twenty-four patients met enrollment criteria and were assigned into each group by 1:1 ratio (62:62). Seven patients in the norfloxacin group and five patients in the ciprofloxacin group were lost to follow-up. SBP developed in four patients (4/55) and in three patients (3/57) in each group, respectively (7.3% vs. 5.3%, P = 0.712). The transplant-free survival rates at 1 year were comparable between the groups (72.7% vs. 73.7%, P = 0.970). Incidence of infectious complication, hepatorenal syndrome, hepatic encephalopathy, and variceal bleeding rates were not significantly different (all P = ns). The factors related to survival were models representing underlying liver function. Once weekly ciprofloxacin was as effective as daily norfloxacin for the prevention of SBP in cirrhotic patients with ascites.

Clinical outcome of portal vein thrombosis in patients with digestive cancers: A large AGEO multicenter study

IntroductionManagement of portal vein thrombosis (PVT) in cancer patients remains discussed. AimsThe objective of this multicenter retrospective study was to investigate the management and outcome of PVT in patients with digestive cancers other than hepatocellular carcinoma (HCC). MethodMain inclusion criteria were trunk or branch PVT in patients with locally advanced or metastatic digestive cancers. Predictive factors of bleeding and overall survival (OS) were evaluated in univariate and multivariate analysis. ResultsBetween 2012 and 2016, 118 patients with PVT and digestive cancers were identified. The majority had a pancreatic cancer (50%). Sixty-six percent of patients had trunk PVT location. Endoscopic screening of portal hypertension was performed in only 7 patients (1%) and 5 had esophageal varices. Gastrointestinal bleeding occurred in 22 patients (19%) and 12 patient deaths (17%) were related to a gastrointestinal hemorrhage. Metastatic disease (HR=2.83 [95%CI 1.47–5.43], p<0.01) and gastrointestinal hemorrhage (HR=1.68 [95%CI 1.01–2.78], p=0.04) were associated with OS in multivariate analysis. Only trunk PVT location was significantly associated with gastrointestinal hemorrhage in multivariate analysis (HR=5.56 [95%CI 1.18–26.32], p=0.03). ConclusionA high rate of variceal bleeding leading to death was found in this cohort. Endoscopic screening and the efficacy of prophylactic treatment of variceal bleeding remain to be evaluated in a prospective study.

The value of 125iodine implantation combining transcatheter arterial chemoembolization to prevent digestive tract bleeding in patients with portal vein tumor thrombus in primary hepatocellular carcinoma

Objective This study was to investigate the value of CT guided 125iodine implantation combining transcatheter arterial chemoembolization(TACE) to prevent digestive tract bleeding in patients with portal vein tumor thrombus in primary hepatocellular carcinoma. Methods Forty patients with portal vein tumor thrombus which were diagnosed to have primary hepatocellular carcinomas by diagnostic criteria of Chinese Anti-Cancer Association were collected prospectively. They were divided into the treatment group and the control group, with 20 patients in each group. The treatment group was treated by TACE for hepatic tumor and 125iodine seed implantation for portal vein tumor thrombus, while the control group was treated by TACE for hepatic tumor and only given β-blockers medicines after treatment. Intraoperative and postoperative surgery-related complications were observed. Three months after surgery, enhanced abdominal CT scanning was performed to evaluate treatment effects which were divided into complete response (CR), partial response (PR), and progressive disease (PD) and stable of disease (SD), and the local tumor control rates were calculated. The bleeding rates and mortality after 3 months, 6 months, 12 months were recorded. Treatment effects of the two groups were compared with continuously correction Chi-square test, bleeding rates were compared with Fisher test, and survival rates were analyzed with Kaplan-Meier survival curve and compared with Log-rank test. Results Overall the 40 patients were treated successfully without serious surgery-related complications. In the treatment group, there were 8 patients with PR, 6 with SD and 6 with PD, and the local control rates were 40% (8/20). In the control group, there were 1 patient with PR, 6 patients with SD and 13 with PD. The difference of the local control rates was statistically significant (χ2= 5.161, P=0.023).The bleeding rates at 3, 6 and 12 months were 2, 2 and 3 cases in the treatment group, for control group they were 2, 6 and 10 cases respectively. There was no statistical difference between the 3 months and 6 months bleeding rates (P values were 1.000 and 0.235), but for 12 months bleeding rates, the difference was statistically significant (P=0.041).The 1 year cumulative survival rates of the treatment group and control group were 70% (14/20) and 40% (8/20), and the difference was statistically significant (χ2= 4.675, P=0.031). Conclusion The treatment of 125iodine implantation combining transcatheter arterial chemoembolization in patients with portal vein tumor thrombus in primary hepatocellular carcinoma can reduce variceal bleeding rate and improve survival rate. Key words: Liver neoplasms; Portal vein; Gastrointestinal hemorrhage; Radiology, interventional

Primary Prophylaxis for Variceal Bleeding and the Improved Survival of Patients with Newly Diagnosed Hepatocellular Carcinoma.

We evaluated the impact of primary variceal bleeding prophylaxis on long-term outcomes of patients newly diagnosed with hepatocellular carcinoma (HCC). A retrospective cohort of 898 patients newly diagnosed with HCC without a history of variceal bleeding [age 57.4±10.4, males 718 (80.0%)] were analyzed for new onset variceal bleeding during follow-up. Variceal bleeding occurred in 72 patients (8.0%) during follow-up. The presence of portal vein thrombosis [hazard ratio (HR) 3.90; 95% confidence interval (CI) 2.09-7.30; p<0.001] and the presence of the red color sign or ≥grade 2 varices at index endoscopy (HR 7.64; 95% CI 4.56-12.80; p<0.001) were independent risk factors for variceal bleeding. The occurrence of variceal bleeding was an independent risk factor for mortality (HR 1.39; 95% CI 1.06-1.82; p=0.015). The cumulative incidence rate of variceal bleeding at 1year was 2.1, 15.3, and 34.2% for those non-indicated for primary prophylaxis (n=760), indicated for primary prophylaxis and received prophylaxis (n=98), and indicated for primary prophylaxis but did not received prophylaxis (n=40) (p<0.001). Primary prophylaxis for variceal bleeding for indicated patients was associated with a reduced risk of mortality in all patients (HR 0.54; 95% CI 0.33-0.88; p=0.014) and in propensity-matched patients (HR, 0.54; 95% CI 0.31-0.95; p=0.033). Variceal bleeding was independent risk factor for survival of newly diagnosed HCC patients. Screening and providing primary prophylaxis for indicated patients should be considered for patients with HCC.

Application of a standardised protocol for hepatic venous pressure gradient measurement improves quality of readings and facilitates reduction of variceal bleeding in cirrhotics.

Hepatic venous pressure gradient (HVPG) measurement is recommended for prognostic and therapeutic indications in centres with adequate resources and expertise. Our study aimed to evaluate the quality of HVPG measurements at our centre before and after introduction of a standardised protocol, and the clinical relevance of the HVPG to variceal bleeding in cirrhotics. HVPG measurements performed at Singapore General Hospital from 2005-2013 were retrospectively reviewed. Criteria for quality HVPG readings were triplicate readings, absence of negative pressure values and variability of ≤ 2 mmHg. The rate of variceal bleeding was compared in cirrhotics who achieved a HVPG response to pharmacotherapy (reduction of the HVPG to < 12 mmHg or by ≥ 20% of baseline) and those who did not. 126 HVPG measurements were performed in 105 patients (mean age 54.7 ± 11.4 years; 55.2% men). 80% had liver cirrhosis and 20% had non-cirrhotic portal hypertension (NCPH). The mean overall HVPG was 13.5 ± 7.2 mmHg, with a significant difference between the cirrhosis and NCPH groups (p < 0.001). The proportion of quality readings significantly improved after the protocol was introduced. HVPG response was achieved in 28 (33.3%, n = 84) cirrhotics. Nine had variceal bleeding over a median follow-up of 29 months. The rate of variceal bleeding was significantly lower in HVPG responders compared to nonresponders (p = 0.025). The quality of HVPG measurements in our centre improved after the introduction of a standardised protocol. A HVPG response can prognosticate the risk of variceal bleeding in cirrhotics.

EFFICACY OF CARVEDILOL COMBINED WITH ENDOSCOPIC VARICEAL LIGATION IN THE PREVENTION OF RECURRENT VARICEAL BLEEDING IN PATIENTS OF CIRRHOSIS

Background: The recurrent variceal bleeding is still very high with a very poor prognosis. The combination of a non-selective beta-blocker and endoscopic variceal ligation (EVL) is still a standard therapy for the prevention, but many patients showed no response to propranolol. Carvedilol is a new, non-selective beta-blocker having intrinsic alpha-blocker activity, but the data about the efficacy and safety of carvedilol is still very limited. This study is aimed at assessing the efficacy and safety of carvedilol combined with EVL in the prevention of recurrent variceal bleeding. Patients and methods: 33 patients having variceal bleeding were enrolled. All patients received carvedilol and were performed the EVL until variceal eradication. All the patients were followed after 9 months. Results: rate of variceal eradication of oesophageal varices was 87.88%; the recurrence rate of variceal bleeding was 12.12% after 9 months. The side effects of carvedilol were rare and not severe, including vertiges, headache, and orthostatic hypertension. Conclusion: Carvedilol combined with EVL appeared as a relatively safe and effective in the prevention of recurrent variceal bleeding in patients of cirrhosis. Key words: carvedilol, variceal bleeding, EVL

Carvedilol vs. esophageal variceal band ligation in the primary prophylaxis of variceal hemorrhage: A multicentre randomized controlled trial

Esophageal variceal bleed is a major problem in patients with cirrhosis. Endoscopic variceal ligation (EVL) has been shown to be equal to or better than propranolol in preventing first bleed. Carvedilol is a non-selective β blocker with alpha-1 adrenergic blocker activity. Hemodynamic studies have shown carvedilol to be more effective than propranolol at reducing portal pressure. We compared efficacy of carvedilol with EVL for primary prophylaxis of esophageal variceal bleed. Cirrhotic patients with esophageal varices were randomized to carvedilol 12.5mg daily or EVL at three university hospitals of Pakistan. End points were esophageal variceal bleeding, death or liver transplant. Two hundred and nine patients were evaluated. Eighty two and eighty six patients were randomized in carvedilol and EVL arms respectively. Mean age was 48 ± 12.2 years; 122 (72.7%) were males; 89.9% had viral cirrhosis; mean Child-Pugh score was 7.3 ± 1.6 and mean follow up was 13.3 ± 12.1 months (range 1-50 months). Both EVL and carvedilol groups had comparable variceal bleeding rates (8.5% vs. 6.9%), bleed related mortality (4.6% vs. 4.9%) and overall mortality (12.8% vs. 19.5%) respectively. Adverse events in carvedilol group were hypotension (n=2), requiring cessation of therapy, while transient nausea (n=18) and dyspnea (n=30) resolved spontaneously. In the EVL arm, post banding ulcer bleed (n=1) and chest pain (n=17), were termed as serious adverse events while transient dysphagia (n=58) resolved without treatment. Although our study is underpowered, the findings suggest that carvedilol is probably not superior to EVL in preventing first variceal bleed in patients with viral cirrhosis.