Rate Of Variceal Bleeding Research Articles

A modified Hassab’s operation for portal hypertension: experience with 562 cases

BackgroundMany patients with portal hypertension require surgical treatment each year, and Hassab’s operation, or esophagogastric devascularization and splenectomy, is an elective procedure. However, it is difficult to devascularize all the vessels of the upper half of the stomach and distal esophagus when hyperblastosis, edema, extensive vein conglobation, and conglutination are present during the operation. These increase the postoperative risk of repeat bleeding. Patients and methodsWe modified Hassab’s operation to address the difficulties associated with devascularization in these cases. All consecutive Chinese patients with liver cirrhosis and portal hypertension who underwent the modified Hassab operation in the Second Affiliated Hospital of Xi’an Jiaotong University from September 1995 to December 2010 were included in the present retrospective study. ResultsA total of 562 modified Hassab’s operations were performed, and all the emergency operations performed because of bleeding obtained hemostasis. Although the pressure and blood flow of the portal vein decreased slightly after surgery, it was still maintained at a high level. Overall, 21.8% of the patients had complications, and 4.6% of these patients died during the hospitalization period. Within the 12-month follow-up period, the overall improvement rate of varices was 98.5% and the variceal bleeding rate was 1%. The 5-year bleeding rate was 9.7%. ConclusionsThe modified Hassab operation is an effective procedure for the treatment of portal hypertension. Few early or late complications were observed among the patients.

Changes in the clinical outcomes of variceal bleeding in cirrhotic patients: a 10-year experience in gangwon province, South Korea.

Background/AimsVariceal rupture is one of the main causes of mortality in cirrhotic patients. However, there are limited data on the long-term outcomes of variceal bleeding.MethodsWe investigated the incidence and mortality of variceal bleeding at three endoscopic centers in Gangwon province during 3 periods (August 1996 to July 1997, August 2001 to July 2002, and August 2006 to July 2007).ResultsA total of 1,704 upper gastrointestinal (GI) bleedings occurred during the study periods. Peptic ulcers were found in 825 patients (48.5%), and variceal ruptures were found in 607 patients (35.6%). The variceal bleeding rate did not decrease in each period (26.0% vs 43.7% vs 33.9%, respectively). In the variceal bleeding group, the 6-week mortality rate steadily and significantly decreased (15.5% vs 10.8% vs 6.4%, respectively, p=0.027). In addition, the mortality rate was significantly higher in the variceal bleeding group than in the non-variceal bleeding group (10.4% vs 2.0%, p<0.001; odds ratio, 5.659; 95% confidence interval, 3.445 to 9.295).ConclusionsVariceal bleeding was still the major cause of upper GI bleedings and did not decrease in prevalence over the 10-year period in Gangwon province, South Korea. However, the mortality rate of variceal bleeding decreased significantly.

Randomized Controlled Trial of Carvedilol vs Variceal Band Ligation in the Primary Prophylaxis of Variceal Haemorrhage

Purpose: To compare the efficacy of carvedilol with endoscopic variceal ligation (EVL) for primary prophylaxis of first variceal bleed. Methods: Randomized, controlled, multicenter trial was conducted in three tertiary care hospitals of Karachi over a period of 5 years. Cirrhotic patients with grade II or larger esophageal varices were allocated to Carvedilol 12.5 mg once daily or EVL performed every 2 weeks until eradication. First visit was 6 weeks after initiation of treatment and 3 monthly thereafter. End points were esophageal variceal bleeding, death and transplant. Analyses were made on intention to treat basis. Results: 200 patients were evaluated, out of which 81 patients were enrolled in carvedilol arm and 78 in EVL arm. Mean age of study participants was 47±12.4 years. 120 (75.47%) were males. 89.3% had viral hepatitis; mean Child-Pugh score was 8.63±1.8 and median follow-up was 11.5±7.8 months (range 1-24 months). Both the treatment groups were comparable regarding baseline characteristics. Outcome measures analyses revealed EVL had a trend towards lower variceal bleeding rates (2.5% vs. 3.7%) as well as overall mortality rates (14.1%vs 18.5%) which were, however, statistically not significant. Bleeding related mortality comparing EVL and carvedilol was also similar; 4.9% vs. 5.1%, respectively. No serious adverse events were recorded in either group. Conclusion: Carvedilol was found to be equally effective and safe compared to esophageal variceal ligation in preventing first bleed as well as mortality in patients with esophageal varices, who have not previously bled.

Meta-analysis: beta-blockers versus banding ligation for primary prophylaxis of esophageal variceal bleeding

To perform an updated meta-analysis comparing β-blockers (BB) with endoscopic variceal banding ligation (EVBL) in the primary prophylaxis of esophageal variceal bleeding. Randomized controlled trials were identified through electronic databases, article reference lists and conference proceedings. Analysis was performed using both fixed-effect and random-effect models. Heterogeneity and publication bias were systematically taken into account. Main outcomes were variceal bleeding rates and all-cause mortality, calculated overall and at 6, 12, 18 and 24 months. 19 randomized controlled trials were analyzed including a total of 1,483 patients. Overall bleeding rates were significantly lower for the EVBL group: odds ratio (OR) 2.06, 95% confidence interval (CI) [1.55-2.73], p < 0.0001, without evidence of publication bias. Bleeding rates were also significantly lower at 18 months (OR 2.20, 95% CI [1.04-4.60], P = 0.04), but publication bias was detected. When only high quality trials were taken into account, results for bleeding rates were no longer significant. No significant difference was found for either bleeding-related mortality or for all-cause mortality overall or at 6, 12, 18 or 24 months. BB were associated with more frequent severe adverse events (OR 2.61, 95% CI 1.60-4.40, P < 0.0001) whereas fatal adverse events were more frequent with EVBL (OR 0.14, 95% CI 0.02-0.99, P = 0.05). EVBL appears to be superior to BB in preventing the first variceal bleed, although this finding may be biased as it was not confirmed by high quality trials. No difference was found for mortality. Current evidence is insufficient to recommend EVBL over BB as first-line therapy.

Long-term outcome of angiographic partial splenectomy in patients with decompensated liver cirrhosis and hypersplenism

Background and study aims Hypersplenism is one of the serious complications of splenomegaly complicating liver cirrhosis. Although partial splenic embolization has been proposed in patients with cirrhosis and thrombocytopenia, there are limited data on long-term outcome. The aim of our study was prospective evaluation of the long-term effects of angiographic partial splenectomy (APS) using polyvinyl alcohol (PVA) or gelfoam particles in patients with decompensated liver cirrhosis and hypersplenism. Patients and methods This study was done at Radiology and Tropical Medicine of Tanta University hospitals. Sixty patients were randomly assigned to two equal groups, PVA group, and gelfoam group. Control group included 18 patients, who refused invasive procedures and treated conservatively. Informed consent was obtained from every patient. Results All groups were matched as regards age, sex, Child class, presence of oesophageal varices and complete blood count findings. APS was successfully performed in all 60 patients. Post-embolization syndrome was the most frequent side effect in both test groups while the need for repeated transfusions was significantly higher in the control group. No significant difference in mortality for all groups was detected. Variceal bleeding was significantly more in the control group. The procedure related complications were comparable in both test groups. All blood indices have significantly improved in comparison to the control group ( p < 0.05). In both test groups white blood cells (WBCs), platelets (PLT) and haemoglobin improved significantly in comparison to the pre-procedure values ( p < 0.05). Post-procedure WBCs and PLT were significantly higher in the gelfoam group than those in the PVA group ( p < 0.05). Conclusion APS is effective and has a favourable long-term outcome in the treatment of hypersplenism in Egyptian patients with decompensated post-hepatitis C cirrhosis. APS decreased the need for repeated transfusions. Both types of embolizing particles (PVA and gelfoam) were comparable as regards efficacy and post-procedure complications. APS may decrease the rate of variceal bleeding and future studies are needed to clarify its effects on portal hypertension.

Endoscopic variceal ligation for primary prophylaxis of esophageal variceal hemorrhage in pre-liver transplant patients

Endoscopic variceal ligation (EVL) is widely used to prevent esophageal variceal bleeding in patients with advanced cirrhosis. However, the safety and efficacy of EVL in this setting have not been clearly established. This study included 300 adult patients with cirrhosis on our liver transplant waitlist who underwent upper gastrointestinal endoscopy. Esophageal varices deemed to be at high risk of bleeding were banded until eradication or transplantation. A retrospective review of patient notes and endoscopy databases was undertaken, and the number of banding episodes, complications, and patient outcomes were recorded. Forty-two of 300 patients presented with or had previous variceal bleeding prior to referral and were excluded from the analysis. Of the remaining 258 patients, 101 underwent a total of 259 banding episodes (2.6 per patient) with a median follow-up post-banding of 18.4 months per patient (a total of 150 patient years). Failed prophylaxis occurred in 2 patients (2%), and there were 3 episodes (1.2%) of acute hematemesis from band-induced ulceration. One patient (1%) had mild esophageal stricturing post-banding without dysphagia. Four of 36 patients (11%) previously found to have moderately sized or larger varices that were not banded presented with hematemesis due to variceal bleeding and were subsequently banded. None of the patients that received banding died because of bleeding or failed to receive a transplant as a result of banding complications. This study shows that in liver transplant candidates, EVL is highly effective in preventing first variceal bleed. Although banding carries a small risk of band-induced bleeding, this rate is low in comparison with the predicted rate of variceal bleeding in this population.

Acute Myocardial Infarction and Gastrointestinal Bleeding in an African American Inner City Population

Purpose: Patients with concomitant gastrointestinal bleeding (GIB) and acute myocardial infarction (AMI) have been well described in literature; however the majority of these studies were performed in non-minority populations. The aim of our study was to characterize patients with GIB and AMI in a predominantly underserved, minority, African American inner city population. Methods: A retrospective chart review was conducted at two large teaching hospitals of a major university medical center in Brooklyn, NY. Patients were identified by using ICD-9 codes for GIB (occult and overt) and AMI, admitted 2001 through 2007. A total of 115 patients were identified, of which 102 (88.7%) were African American. This subset of patients was analyzed for patient characteristics, co-morbidities, endoscopy results as well as clinical outcomes. Results: The median age was 71.4 years, 59.8% were women. The co-morbidities most frequently identified were: arterial hypertension (73.5%), diabetes mellitus (35.3%), congestive heart failure (21.6%), history of CVA (16.7%), history of coronary artery disease (36.3%), and chronic kidney disease (22.5%). 36.3% of patients were taking aspirin, 22.6% plavix, and 4.9% coumadin. 74.5% of patients presented with overt GIB. Median peak troponin was 54.1 and the median of the lowest hemoglobin was 7.6 g/dl. 62 patients had endoscopic procedures (52 upper endoscopies and 18 colonoscopies). Endoscopy revealed 16.7% gastric ulcers, 6.7% duodenal ulcers, 3.3% Mallory Weiss tears, 16.7% esophagitis, 40% gastritis, 11.7% duodentitis, 1.7% gastric cancer, 1.7% variceal bleed and 1.7% Dieulafoy lesion were found. Ulcers were described as: clean base (62.5%), adherent clot (25.0%), visible vessel (6.3%), active bleeding (6.2%). 7 repeat endoscopies and 2 surgeries were required for rebleeding. The majority lesions found at colonoscopy included internal hemorrhoids, rectal ulcers, vascular malformations, diverticulosis. There were 19 cardiac catheterizations performed. Occult GIB was associated with significantly less mortality than overt GIB (3.8% versus 19.7%, P < 0.05). Although our patient population had a significant amount of chronic kidney disease, this did not affect the mortality rate (P-0.28). Conclusion: Inner city, African Americans presenting with acute MI and GIB have a significant amount of arterial hypertension and chronic kidney disease, but a surprising low rate of variceal bleeding. The type of GIB, rather than comorbid conditions significantly affected patient mortality. The endoscopic findings were consistent with the trend recorded in the literature showing a decrease in the prevalence of peptic ulcer disease.

Decision analysis of prophylactic treatment for patients with high-risk esophageal varices

Background: Clinical decision analyses were conducted to quantify the uncertainty and to identify important factors in selection of prophylactic therapy for patients with esophageal varices. Methods: A Markov model compared variceal ligation, β-blockers, and “watchful waiting” strategies in terms of bleeding-free life years. Transition probabilities were obtained from meta-analyses of published data. A hypothetical 50-year-old white man with high-risk esophageal varices and cirrhosis served as the prototypical baseline case. Traditional n-way sensitivity analyses were applied to clarify the influence of each factor, and Monte Carlo probabilistic sensitivity analyses were used to investigate clinical uncertainty. Results: Probabilistic sensitivity analyses demonstrated that 77.0% of hypothetical cases had more bleeding-free life years after variceal ligation, whereas 23% had more when treated with β-blockers. On the basis of one-way sensitivity analyses, only 2 factors (variceal bleeding rates after ligation and treatment with β-blockers) influenced the strategy choice. Conclusions: Variceal ligation is an effective prophylactic therapy in many cases, but nearly one quarter of patients with high-risk esophageal varices and cirrhosis may benefit more from prophylactic treatment with β-blockers. Additional clinical studies identifying key variceal bleeding risk factors may lead to more effective clinical decision making for these patients. (Gastrointest Endosc 2000;52:707-14.)

Cost-effectiveness analysis of transjugular intrahepatic portosystemic shunt (TIPS) versus endoscopic therapy for the prevention of recurrent esophageal variceal bleeding.

For the prevention of recurrent esophageal variceal bleeding, studies show that patients treated with transjugular intrahepatic portosystemic shunt (TIPS) have lower rebleeding rates compared with endoscopic therapy. However, TIPS is associated with higher rates of portosystemic encephalopathy and possibly higher costs. The aim of this study was to conduct a cost-effectiveness analysis comparing TIPS with endoscopic sclerotherapy and endoscopic ligation for the prevention of recurrent esophageal variceal bleeding. Data for rates of rebleeding, death, complications, and crossover from endoscopy to TIPS were obtained from the literature. Costs for procedures and hospitalizations were obtained from two medical centers. Sensitivity analyses were performed varying probabilities of key variables. The patient population consisted of a hypothetical cohort of cirrhotic patients successfully treated for esophageal variceal bleeding with endoscopic sclerotherapy who received prophylactic sclerotherapy, ligation, or TIPS over 1 year. Endoscopic patients would receive propranolol. Mortality was similar for the three groups. The number of bleeds per patient for sclerotherapy, ligation, and TIPS would be 0.39, 0.32, and 0.07, respectively. The total annual costs per patient for sclerotherapy, ligation, and TIPS were $23,459, $23,111, and $26,275, respectively. The incremental cost per bleed prevented for TIPS compared with sclerotherapy and ligation was $8,803 and $12, 660, respectively. The incremental cost per bleed prevented for TIPS compared with sclerotherapy or ligation was sensitive to the cost of TIPS and the TIPS stenosis rate. Ligation had lower costs and lower recurrent bleeding rates than sclerotherapy. Compared with endoscopic therapy, TIPS leads to lower recurrent variceal bleeding rates and it is more cost effective in the short term for the prevention of recurrent esophageal variceal bleeding.

Development of Gastroesophageal Varices and Risk of Variceal Bleeding in Patients With Cirrhosis

Abstract: We studied the relationships between portal pressure measured using the portal venous pressure gradient, the development of gastroesophageal varices, and the risk of variceal bleeding in 56 patients with cirrhosis. Portal pressure was higher in patients with varices than in those without (P&gt;0.01), and 11 mmHg was the lowest portal pressure measured in the patients with varices. The size of the varices was not associated with the portal pressure. There was no difference in the value of portal pressure measurements for the patients with variceal bleeding and those without and there was no linear‐relationship between the degree of portal hypertension and the rate of variceal bleeding. 12 mmHg was the lowest portal pressure measured in the patients with variceal bleeding. The size of the varices was related to the rate of variceal bleeding (P&gt;0.05). We conclude that (a) a portal pressure of 11 mmHg is necessary for the formation of varices, (b) 12 mmHg of portal pressure is necessary for variceal bleeding to occur but the degree of portal hypertension has no predictive value for the risk of variceal bleeding, and (c) the size of the varices does not depend on the degree of portal hypertension but is associated with the risk of variceal bleeding.

Improved Survival After Prophylactic Portal Nondecompression Surgery for Esophageal Varices: A Randomized Clinical Trial

To evaluate prophylactic surgery for esophageal varices, a prospective randomized controlled trial was begun in 1980 by the Japanese Research Society for Portal Hypertension. Methods of operation included selective shunts and nonshunting interruption procedures. One hundred and twelve Japanese patients, in whom endoscopic findings suggested risk of bleeding but who had no bleeding episode, were randomly allocated to the operated group of 60 patients or nonoperated group of 52 patients. Nine patients with idiopathic portal hypertension, histologically proven noncirrhotic disease, which all fell in the operated group, were excluded from the study and the remaining 103 patients (51 operated and 52 nonoperated) were analyzed. Long-term follow-up of patients for a median of 49 mo with a maximum of 73 mo showed a total of 11 (22%) deaths, including 2 operative deaths, in the operated group compared with 23 (49%) deaths in the nonoperated group. The cumulative survival rate at 5 yr in the operated group was 72%, which was significantly higher than the 45% of the nonoperated group (p less than 0.05). The cumulative variceal bleeding rate at 5 yr was 7% in the operated group, which was significantly lower than that of the nonoperated group of 46% (p less than 0.001). It was concluded that portal nondecompression surgery was effective in preventing the variceal bleeding and in improving survival.

Prospective controlled trial of elective endoscopic sclerotherapy in comparison with percutaneous transhepatic obliteration of esophageal varices in patients with nonalcoholic cirrhosis

The results of a prospective randomized controlled trial of elective endoscopic intravariceal sclerotherapy carried out over a 36-mo period in comparison with elective percutaneous transhepatic obliteration of varices (PTO, are presented. Sixty-six patients with nonalcoholic cirrhosis were randomized after they had stabilized, usually between 7 and 14 days after variceal bleeding had stopped following medical treatment (balloon tamponade and vasopressin infusion). Thirty-three patients were assigned to the sclerotherapy group and the other 33 patients were assigned to the PTO group. The mean follow-up period was similar in both groups. There was no significant difference in demographic, clinical, and laboratory data between the two groups. Six patients (18%) in the sclerotherapy group and 21 (64%) in the PTO group had at least one episode of gastrointestinal bleeding during the follow-up period (p < 0.005). Three patients in the sclerotherapy group and 1 patient in the PTO group bled from lesions other than varices; therefore the incidence of variceal bleeding was 9% in the former and 61% in the latter (p < 0.005). The cumulative variceal bleeding rate was significantly lower in the sclerotherapy group than the PTO group (p < 0.05). Five patients in the sclerotherapy group died during the follow-up period but none died of recurrent variceal bleeding. Nineteen patients in the PTO group died and 10 of them died of bleeding from varices. The cumulative survival rate was significantly better in the sclerotherapy group (p < 0.05). These results indicate that elective endoscopic intravariceal sclerotherapy is superior to elective PTO in the prevention of recurrent variceal hemorrhage and mortality in nonalcoholic cirrhosis.