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Ma AS, Thuluvath PJ. The Role of Endoscopy for Primary and Secondary Prophylaxis of Variceal Bleeding. Gastrointest Endosc Clin N Am 2024; 34:231-248. [PMID: 38395481 DOI: 10.1016/j.giec.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Cirrhosis is associated with a high morbidity and mortality. One of the most serious and unpredictable complication of cirrhosis, with a high mortality rate, is bleeding from esophagogastric varices. Endoscopic screening of varices followed by primary prophylactic treatment with beta blockers or band ligation in the presence of large esophageal varices will reduce the variceal bleeding rates and thereby reduce mortality risks in those with advanced cirrhosis. There is a paucity of data on primary prophylaxis of gastric varices but secondary prophylaxis includes glue injection, balloon-occluded retrograde transvenous obliteration, or transjugular intrahepatic portosystemic shunting with coil embolization.
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Affiliation(s)
- Andrew S Ma
- Institute for Digestive Health and Liver Disease Mercy Medical Center, Professional Office Building, 7th Floor 345 St. Paul Place, Baltimore, MD 21202, USA
| | - Paul J Thuluvath
- Institute for Digestive Health and Liver Disease Mercy Medical Center, Professional Office Building, 7th Floor 345 St. Paul Place, Baltimore, MD 21202, USA.
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2
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Wang CC, Kao JH. Letter to the Editor: Learning more about the safety of atezolizumab plus bevacizumab in patients with hepatocellular carcinoma. Hepatology 2023; 77:E82-E83. [PMID: 36626618 DOI: 10.1097/hep.0000000000000009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 10/04/2022] [Indexed: 01/12/2023]
Affiliation(s)
- Chia-Chi Wang
- Department of Gastroenterology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Jia-Horng Kao
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
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3
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Singh SP, Wadhawan M, Acharya SK, Bopanna S, Madan K, Sahoo MK, Bhat N, Misra SP, Duseja A, Mukund A, Anand AC, Goel A, Satyaprakash BS, Varghese J, Panigrahi MK, Tandan M, Mohapatra MK, Puri P, Rathi PM, Wadhwa RP, Taneja S, Thomas V, Bhatia V. Management of portal hypertensive upper gastrointestinal bleeding: Report of the Coorg Consensus workshop of the Indian Society of Gastroenterology Task Force on Upper Gastrointestinal Bleeding. Indian J Gastroenterol 2021; 40:519-540. [PMID: 34890020 DOI: 10.1007/s12664-021-01169-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/09/2021] [Indexed: 02/04/2023]
Abstract
Portal hypertensive bleeding is a major complication of portal hypertension (PHT) with high morbidity and mortality. A lot of advances have been made in our understanding of screening, risk stratification, and management strategies for portal hypertensive bleeding including acute variceal bleeding leading to improved overall outcomes in patients with PHT. A number of guidelines on variceal bleeding have been published by various societies in the past few years. The Indian Society of Gastroenterology (ISG) Task Force on Upper Gastrointestinal Bleeding (UGIB) felt that it was necessary to bring out a standard practice guidance document for the use of Indian health care providers especially physicians, gastroenterologists, and hepatologists. For this purpose, an expert group meeting was convened by the ISG Task Force to deliberate on this matter and write a consensus guidance document for Indian practice. The delegates including gastroenterologists, hepatologists, radiologists, and surgeons from different parts of the country participated in the consensus development meeting at Coorg in 2018. A core group was constituted which reviewed all published literature on portal hypertensive UGIB with special reference to the Indian scenario and prepared unambiguous statements on different aspects for voting and consensus in the whole group. This consensus was produced through a modified Delphi process and reflects our current understanding and recommendations for the diagnosis and management of portal hypertensive UGIB in Indians. Intended for use by the health care providers especially gastroenterologists and hepatologists, these consensus statements provide an evidence-based approach to risk stratification, diagnosis, and management of patients with portal hypertensive bleeding.
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Affiliation(s)
- Shivaram P Singh
- Department of Gastroenterology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, 753 001, India.
| | - Manav Wadhawan
- Department of Hepatology and Liver Transplant, Institute of Liver and Digestive Diseases, BLK Super Specialty Hospital, Delhi, 110 005, India
| | - Subrat K Acharya
- Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, 751 024, India
| | - Sawan Bopanna
- Department of Gastroenterology and Hepatology, Fortis Flt. Lt. Rajan Dhall Hospital, Aruna Asaf Ali Marg, Vasant Kunj, New Delhi, 110 070, India
| | - Kaushal Madan
- Department of Gastroenterology and Hepatology, Max Smart Super Specialty Hospital, Saket, New Delhi, 110 017, India
| | - Manoj K Sahoo
- Department of Medical Gastroenterology, IMS and SUM Hospital, K8 Kalinga Nagar, Shampur, Bhubaneswar, 751 003, India
| | - Naresh Bhat
- Department of Gastroenterology and Hepatology, Aster CMI Hospital, Bangalore, 560 092, India
| | - Sri P Misra
- Department of Gastroenterology and Hepatology, Moti Lal Nehru Medical College, Allahabad, 211 001, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Amar Mukund
- Department of Radiology, Institute of Liver and Biliary Sciences, Sector D-1, Vasant Kunj, New Delhi, 110 070, India
| | - Anil C Anand
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Patia, Bhubaneswar, 751 024, India
| | - Ashish Goel
- Department of Hepatology, Christian Medical College, Vellore, 632 004, India
| | | | - Joy Varghese
- Department of Hepatology and Transplant Hepatology, Institute of Liver Disease and Transplantation, Gleneagles Global Health City, 439, Cheran Nagar, Chennai, 600 100, India
| | - Manas K Panigrahi
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, 751 019, India
| | - Manu Tandan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Somajiguda, Hyderabad, 500 082, India
| | - Mihir K Mohapatra
- Department of Surgical Gastroenterology, Srirama Chandra Bhanja Medical College, Cuttack, 753 007, India
| | - Pankaj Puri
- Department of Gastroenterology and Hepatology, Fortis Escorts Liver and Digestive Diseases Institute, Okhla Road, New Delhi, 110 025, India
| | - Pravin M Rathi
- Department of Gastroenterology, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, 400 008, India
| | - Rajkumar P Wadhwa
- Department of Gastroenterology, Apollo BGS Hospital, Adichuchanagiri Road, Kuvempunagar, Mysore, 570 023, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Varghese Thomas
- Department of Gastroenterology, Malabar Medical College Hospital, Modakkallur, Calicut, 673 321, India
| | - Vikram Bhatia
- Department of Hepatology, Institute of Liver and Biliary Sciences, Sector D-1, Vasant Kunj, New Delhi, 110 070, India
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Yokoyama S, Ishizu Y, Ishigami M, Honda T, Kuzuya T, Ito T, Hinoki A, Sumida W, Shirota C, Tainaka T, Makita S, Yokota K, Uchida H, Fujishiro M. Factors associated with bleeding after endoscopic variceal ligation in children. Pediatr Int 2021; 63:1223-1229. [PMID: 33464654 DOI: 10.1111/ped.14614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/07/2021] [Accepted: 01/14/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Endoscopic variceal ligation (EVL) is a widely accepted treatment for esophagogastric varices in patients with portal hypertension (PHT). It is used for urgent treatment and prophylactic treatment of esophagogastric varices in pediatric as well as adult patients. However, major life-threatening adverse events such as early rebleeding can occur. Although early rebleeding after EVL among children and adolescents has been reported, the risk factors remain obscure. This study evaluated the risk factors for early rebleeding after EVL in children and adolescents. METHODS The subjects were children and adolescents (<18 years) with PHT who underwent EVL for esophagogastric varices. Early rebleeding was defined as hematemesis, active bleeding, or blood retention in the stomach, confirmed by esophagogastroduodenoscopy from 2 h to 5 days after EVL. RESULTS A total of 50 EVL sessions on 22 patients were eligible for this study. There were four episodes of early rebleeding. No other major adverse event has occurred. Multivariate analysis showed that EVL implemented at cardiac varices just below the esophagogastric junction (EGJ), within 5 mm from the EGJ, is the independent factor for a higher risk of early rebleeding: odds ratio 18.2 (95% confidence interval: 1.40-237.0), P = 0.02. CONCLUSIONS Children and adolescents who undergo EVL for cardiac varices just below the EGJ have a higher risk of early rebleeding than those who do not.
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Affiliation(s)
- Shinya Yokoyama
- Department of Gastroenterology and Hepatology, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Yoji Ishizu
- Department of Gastroenterology and Hepatology, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Masatoshi Ishigami
- Department of Gastroenterology and Hepatology, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Takashi Honda
- Department of Gastroenterology and Hepatology, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Teiji Kuzuya
- Department of Gastroenterology and Hepatology, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Takanori Ito
- Department of Gastroenterology and Hepatology, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Akinari Hinoki
- Department of Pediatric Surgery, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Wataru Sumida
- Department of Pediatric Surgery, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Chiyoe Shirota
- Department of Pediatric Surgery, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Takahisa Tainaka
- Department of Pediatric Surgery, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Satoshi Makita
- Department of Pediatric Surgery, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Kazuki Yokota
- Department of Pediatric Surgery, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Hiroo Uchida
- Department of Pediatric Surgery, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Nagoya University, Graduate School of Medicine, Nagoya-shi, Japan
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5
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Reiter FP, Hadjamu NJ, Nagdyman N, Zachoval R, Mayerle J, De Toni EN, Kaemmerer H, Denk G. Congenital heart disease-associated liver disease: a narrative review. Cardiovasc Diagn Ther 2021; 11:577-590. [PMID: 33968635 DOI: 10.21037/cdt-20-595] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Congenital heart diseases (CHD) can be associated with liver dysfunction. The cause for liver impairment can result out of a wide spectrum of different causes, including liver congestion, hypoxemia or low cardiac output. Fortunately, most CHD show a good long-term outcome from a cardiac perspective, but great attention should be paid on non-cardiac health problems that develop frequently in patients suffering from CHD. The treatment of liver dysfunction in CHD requires a close multidisciplinary management in a vulnerable patient collective. Unfortunately, structured recommendations on the management of liver dysfunction in patients with CHD are scarce. The objective of this review is to provide insights on the pathophysiology and etiologies of liver dysfunction as one of the most relevant non-cardiac problems related to CHD. Furthermore, we advise here on the management of liver disease in CHD with special attention on assessment of liver dysfunction, management of portal hypertension as well as on surveillance and management of hepatocellular carcinoma (HCC). A multidisciplinary perspective may help to optimize morbidity and mortality in the long-term course in these patients. However, as evidence is low in many aspects, we encourage the scientific community to perform prospective studies to gain more insights in the treatment of liver dysfunction in patients with CHD.
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Affiliation(s)
- Florian P Reiter
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Nino J Hadjamu
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Nicole Nagdyman
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Reinhart Zachoval
- Transplantation Center Munich, University Hospital, LMU Munich, Munich, Germany
| | - Julia Mayerle
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Enrico N De Toni
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Harald Kaemmerer
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Gerald Denk
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany.,Transplantation Center Munich, University Hospital, LMU Munich, Munich, Germany
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Cifuentes LI, Gattini D, Torres-Robles R, Gana JC. Band ligation versus sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis. Cochrane Database Syst Rev 2021; 1:CD011561. [PMID: 33522602 PMCID: PMC8094619 DOI: 10.1002/14651858.cd011561.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Portal hypertension commonly accompanies advanced liver disease and often gives rise to life-threatening complications, including bleeding (haemorrhage) from oesophageal and gastrointestinal varices. Variceal bleeding commonly occurs in children and adolescents with chronic liver disease or portal vein thrombosis. Prevention is, therefore, important. Randomised clinical trials have shown that non-selective beta-blockers and endoscopic variceal band ligation decrease the incidence of variceal bleeding in adults. In children and adolescents, band ligation, beta-blockers, and sclerotherapy have been proposed as primary prophylaxis alternatives for oesophageal variceal bleeding. However, it is unknown whether these interventions are of benefit or harm when used for primary prophylaxis in children and adolescents. OBJECTIVES To assess the benefits and harms of band ligation compared with sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, PubMed, Embase, and two other databases (April 2020). We scrutinised the reference lists of the retrieved publications, and we also handsearched abstract books of the two main paediatric gastroenterology and hepatology conferences from January 2008 to December 2019. We also searched clinicaltrials.gov, the United States Food and Drug Administration (FDA), the European Medicines Agency (EMA), and the World Health Organization (WHO) for ongoing clinical trials. We imposed no language or document type restrictions on our search. SELECTION CRITERIA We aimed to include randomised clinical trials irrespective of blinding, language, or publication status, to assess the benefits and harms of band ligation versus sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. If the search for randomised clinical trials retrieved quasi-randomised and other observational studies, then we read them through to extract information on harm. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology to perform this systematic review. We used GRADE to assess the certainty of evidence for each outcome. Our primary outcomes were all-cause mortality, serious adverse events and liver-related morbidity, and quality of life. Our secondary outcomes were oesophageal variceal bleeding and adverse events not considered serious. We used the intention-to-treat principle. We analysed data using Review Manager 5. MAIN RESULTS One conference abstract, describing a feasibility multi-centre randomised clinical trial, fulfilled our review inclusion criteria. We judged the trial at overall high risk of bias. This trial was conducted in three hospital centres in the United Kingdom. The aim of the trial was to determine the feasibility and safety of further larger randomised clinical trials of prophylactic band ligation versus no active treatment in children with portal hypertension and large oesophageal varices. Twelve children received prophylactic band ligation and 10 children received no active treatment. There was no information on the age of the children included, or about the diagnosis of any child included. All children were followed up for at least six months. Mortality was 8% (1/12) in the band ligation group versus 0% (0/10) in the no active intervention group (risk ratio (RR) 2.54, 95% confidence interval (CI) 0.11 to 56.25; very low certainty of evidence). The abstract did not report when the death occurred, but we assume it happened between the six-month follow-up and one year. No child (0%) in the band ligation group developed adverse events (RR 0.28, 95% CI 0.01 to 6.25; very low certainty of evidence) but one child out of 10 (10%) in the no active intervention group developed idiopathic thrombocytopaenic purpura. One child out of 12 (8%) in the band ligation group underwent liver transplantation versus none in the no active intervention group (0%) (RR 2.54, 95% CI 0.11 to 56.25; very low certainty of evidence). The trial reported no other serious adverse events or liver-related morbidity. Quality of life was not reported. Oesophageal variceal bleeding occurred in 8% (1/12) of the children in the band ligation group versus 30% (3/10) of the children in the no active intervention group (RR 0.28, 95% CI 0.03 to 2.27; very low certainty of evidence). No adverse events considered non-serious were reported. Two children were lost to follow-up by one-year. Ten children in total completed the trial at two-year follow-up. There was no information on funding. We found two observational studies on endoscopic variceal ligation when searching for randomised trials. One found no harm, and the other reported E nterobacter cloacae septicaemia in one child and mild, transient, upper oesophageal sphincter stenosis in another. We did not assess these studies for risk of bias. We did not find any ongoing randomised clinical trials of interest to our review. AUTHORS' CONCLUSIONS The evidence, obtained from only one feasibility randomised clinical trial at high risk of bias, is very scanty. It is very uncertain about whether prophylactic band ligation versus sham or no (active) intervention may affect mortality, serious adverse events and liver-related morbidity, or oesophageal variceal bleeding in children and adolescents with portal hypertension and large oesophageal varices. We have no data on quality of life. No adverse events considered non-serious were reported. The results presented in the trial need to be interpreted with caution. In addition, the highly limited data cover only part of our research question; namely, children with portal hypertension and large oesophageal varices. Data on children with portal vein thrombosis are lacking. Larger randomised clinical trials assessing the benefits and harms of band ligation compared with sham treatment for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis are needed. The trials should include important clinical outcomes such as death, quality of life, failure to control bleeding, and adverse events.
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Affiliation(s)
- Lorena I Cifuentes
- Division of Paediatrics, Evidence-based Health Care Programme, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Daniela Gattini
- Gastroenterology and Nutrition Department, Division of Paediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Romina Torres-Robles
- Sistema de Bibliotecas UC, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Juan Cristóbal Gana
- Gastroenterology and Nutrition Department, Division of Paediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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Gana JC, Cifuentes LI, Gattini D, Torres-Robles R. Band ligation versus sclerotherapy for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. Cochrane Database Syst Rev 2020; 11:CD011803. [PMID: 33164205 PMCID: PMC8078550 DOI: 10.1002/14651858.cd011803.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Portal hypertension commonly accompanies advanced liver disease and often gives rise to life-threatening complications, including haemorrhage from oesophageal and gastrointestinal varices. Variceal haemorrhage commonly occurs in children with chronic liver disease or portal vein obstruction. Prevention is therefore important. In adults, numerous randomised clinical trials have demonstrated benefits of non-selective beta-blockers and endoscopic variceal ligation as primary prevention in decreasing the risk of variceal haemorrhage. In children, band ligation, beta-blockers, and sclerotherapy have been proposed as alternatives for primary prophylaxis of oesophageal variceal bleeding. However, primary prophylaxis is not the current standard of care in children because it is unknown whether those treatments are of benefit or cause harm when used for primary prophylaxis of oesophageal variceal bleeding in children and adolescents. OBJECTIVES To determine the benefits and harms of band ligation versus sclerotherapy for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, PubMed, Embase, LILACS, and Science Citation Index Expanded (27 April 2020). We scrutinised the reference lists of retrieved publications, and performed a manual search from the main paediatric gastroenterology and hepatology conferences (NASPGHAN and ESPGHAN) abstract books from 2008 to 2019. We searched ClinicalTrials.gov, FDA, EMA, and WHO for ongoing clinical trials. There were no language or document type restrictions. SELECTION CRITERIA We planned to include randomised clinical trials irrespective of blinding, language, or publication status for assessment of benefits and harms. If the search for randomised clinical trials retrieved quasi-randomised and observational studies, then we read them through to extract information on harms. DATA COLLECTION AND ANALYSIS We planned to summarise data from randomised clinical trials by standard Cochrane methodologies. We planned to assess risk of bias and use GRADE to assess the certainty of evidence per outcome. Our primary outcomes were all-cause mortality, serious adverse events and liver-related morbidity, and quality of life. Our secondary outcomes were oesophageal variceal bleeding and adverse events not considered serious. We planned to analyse data with intention-to-treat. We planned to use Review Manager 5 to analyse the data. MAIN RESULTS We found no randomised clinical trials assessing band ligation versus sclerotherapy for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. AUTHORS' CONCLUSIONS Randomised clinical trials assessing the benefits or harms of band ligation versus sclerotherapy for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis are lacking. Therefore, trials with adequate power and proper design, assessing the benefits and harms of band ligation versus sclerotherapy on patient-relevant clinical outcomes such as mortality, quality of life, failure to control variceal bleeding, and adverse events are needed. Unless such trials are conducted and the results become published, we cannot make any conclusions regarding the benefits or harms of these two interventions.
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Affiliation(s)
- Juan Cristóbal Gana
- Gastroenterology and Nutrition Department, Division of Paediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Lorena I Cifuentes
- Division of Paediatrics, Evidence-based Health Care Programme, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Daniela Gattini
- Gastroenterology and Nutrition Department, Division of Paediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Romina Torres-Robles
- Sistema de Bibliotecas UC, Pontificia Universidad Católica de Chile, Santiago, Chile
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8
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Garbuzenko DV, Arefyev NO. Primary prevention of bleeding from esophageal varices in patients with liver cirrhosis: An update and review of the literature. J Evid Based Med 2020; 13:313-324. [PMID: 33037792 DOI: 10.1111/jebm.12407] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/19/2020] [Indexed: 12/12/2022]
Abstract
All patients with liver cirrhosis and portal hypertension should be stratified by risk groups to individualize different therapeutic strategies to increase the effectiveness of treatment. In this regard, the development of primary prophylaxis of variceal bleeding and its management according to the severity of portal hypertension may be promising. This paper is to describe the modern principles of primary prophylaxis of esophageal variceal bleeding in patients with liver cirrhosis. The PubMed and EMbase databases, Web of Science, Google Scholar, and the Cochrane Database of Systematic Reviews were used to search for relevant publications from 1999 to 2019. The results suggested that depending on the severity of portal hypertension, patients with cirrhosis should be divided into those who need preprimary prophylaxis, which aims to prevent the formation of esophageal varices, and those who require measures that aim to prevent esophageal variceal bleeding. In subclinical portal hypertension, therapy should be etiological and pathogenetic. Cirrhosis with clinically significant portal hypertension should receive nonselective β-blockers if they have small esophageal varices and risk factors for variceal bleeding. Nonselective β-blockers are the first-line drugs for the primary prevention of bleeding from medium to large-sized esophageal varices. Endoscopic band ligation is indicated for the patients who are intolerant to nonselective β-blockers or in the case of contraindications to pharmacological therapy. In summary, the stratification of cirrhotic patients by the severity of portal hypertension and an individual approach to the choice of treatment may increase the effectiveness of therapy as well as improve survival rate of these patients.
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Affiliation(s)
| | - Nikolay Olegovich Arefyev
- Department of Pathological Anatomy and Forensic Medicine, South Ural State Medical University, Chelyabinsk, Russia
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9
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Liu M, Li W, Li P, Ma F, Xue H. Ectopic duodenal variceal bleed successfully treated with TIPS and 2 years follow-up: A Case Report. Radiol Case Rep 2020; 15:1570-1574. [PMID: 32685071 PMCID: PMC7355383 DOI: 10.1016/j.radcr.2020.04.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/18/2020] [Accepted: 04/18/2020] [Indexed: 12/24/2022] Open
Abstract
Duodenal varices are an uncommon presentation of portal hypertension and can result in significant gastrointestinal bleeding with a high mortality. Diagnosis can be difficult and therapeutic options limited. We present a case of upper gastrointestinal bleeding in a woman aged 54 years with primary biliary cholangitis who was ultimately diagnosed with ectopic duodenal variceal bleed, which was successfully treated with transjugular intrahepatic portosystemic shunt. Transjugular intrahepatic portosystemic shunt provide an effective treatment for ectopic duodenal variceal bleed caused by liver cirrhosis, though interventional radiologists need to remain aware of and vigilant for the complications and risks of this treatment option.
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Vilar-Gomez E, Lou Z, Kong N, Vuppalanchi R, Imperiale TF, Chalasani N. Cost Effectiveness of Different Strategies for Detecting Cirrhosis in Patients With Nonalcoholic Fatty Liver Disease Based on United States Health Care System. Clin Gastroenterol Hepatol 2020; 18:2305-2314.e12. [PMID: 32289535 DOI: 10.1016/j.cgh.2020.04.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/31/2020] [Accepted: 04/03/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Several strategies are available for detecting cirrhosis in patients with nonalcoholic fatty liver disease (NAFLD), but their cost effectiveness is not clear. We developed a decision model to quantify the accuracy and costs of 9 single or combination strategies, including 3 noninvasive tests (fibrosis-4 [FIB-4], vibration-controlled transient elastography [VCTE], and magnetic resonance elastography [MRE]) and liver biopsy, for the detection of cirrhosis in patients with NAFLD. METHODS Data on the diagnostic accuracy, costs, adverse events, and cirrhosis outcomes over a 5-year period were obtained from publications. The diagnostic accuracy, per-patient cost per correct diagnosis of cirrhosis, and incremental cost-effectiveness ratios (ICERs) were calculated for each strategy for base cirrhosis prevalence values of 0.27%, 2%, and 4%. RESULTS The combination of the FIB-4 and VCTE identified patients with cirrhosis in NAFLD populations with a 0.27%, 2%, and 4% prevalence of cirrhosis with the lowest cost per person ($401, $690, and $1024, respectively) and highest diagnostic accuracy (89.3%, 88.5%, and 87.5% respectively). The combination of FIB-4 and MRE ranked second in cost per person ($491, $781, and $1114, respectively) and diagnostic accuracy (92.4%, 91.6%, 90.6%, respectively). Compared with the combination of FIB-4 and VCTE (least costly), the ICERs were lower for the combination of FIB-4 and MRE ($2864, $2918, and $2921) than the combination of FIB-4 and liver biopsy ($4454, $5156, and $5956) at the cirrhosis prevalence values tested. When the goal was to avoid liver biopsy, FIB-4 + VCTE and FIB-4 + MRE had similar diagnostic accuracies, ranging from 87.5% to 89.3% and 90.6% to 92.4% for a cirrhosis diagnosis, respectively, although FIB-4 + MRE had a slightly higher cost. CONCLUSIONS In our cost-effectiveness analysis based on the US health care system, we found that results from FIB-4, followed by either VCTE, MRE, or liver biopsy, detect cirrhosis in patients with NAFLD with a high level of accuracy and low cost. Compared with FIB-4 + VCTE, which was the least costly strategy, FIB-4 + MRE had a lower ICER than FIB-4 + LB.
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Affiliation(s)
- Eduardo Vilar-Gomez
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Zhouyang Lou
- School of Industrial Engineering, Purdue University, West Lafayette, Indiana
| | - Nan Kong
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana
| | - Raj Vuppalanchi
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Thomas F Imperiale
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Center for Innovation, Health Services Research and Development, Roudebush Veterans Affairs Medical Center; Regenstrief Institute, Inc, Indianapolis, Indiana
| | - Naga Chalasani
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
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Matsushima H, Fujiki M, Sasaki K, Cywinski JB, D’Amico G, Uso TD, Aucejo F, David Kwon CH, Eghtesad B, Miller C, Quintini C, Hashimoto K. Can pretransplant TIPS be harmful in liver transplantation? A propensity score matching analysis. Surgery 2020; 168:33-39. [DOI: 10.1016/j.surg.2020.02.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/10/2020] [Accepted: 02/18/2020] [Indexed: 12/31/2022]
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Goldis A, Goldis R, Chirila TV. Biomaterials in Gastroenterology: A Critical Overview. ACTA ACUST UNITED AC 2019; 55:medicina55110734. [PMID: 31726779 PMCID: PMC6915447 DOI: 10.3390/medicina55110734] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 10/30/2019] [Accepted: 11/08/2019] [Indexed: 02/07/2023]
Abstract
In spite of the large diversity of diagnostic and interventional devices associated with gastrointestinal endoscopic procedures, there is little information on the impact of the biomaterials (metals, polymers) contained in these devices upon body tissues and, indirectly, upon the treatment outcomes. Other biomaterials for gastroenterology, such as adhesives and certain hemostatic agents, have been investigated to a greater extent, but the information is fragmentary. Much of this situation is due to the paucity of details disclosed by the manufacturers of the devices. Moreover, for most of the applications in the gastrointestinal (GI) tract, there are no studies available on the biocompatibility of the device materials when in intimate contact with mucosae and other components of the GI tract. We have summarized the current situation with a focus on aspects of biomaterials and biocompatibility related to the device materials and other agents, with an emphasis on the GI endoscopic procedures. Procedures and devices used for the control of bleeding, for polypectomy, in bariatrics, and for stenting are discussed, particularly dwelling upon the biomaterial-related features of each application. There are indications that research is progressing steadily in this field, and the establishment of the subdiscipline of "gastroenterologic biomaterials" is not merely a remote projection. Upon the completion of this article, the gastroenterologist should be able to understand the nature of biomaterials and to achieve a suitable and beneficial perception of their significance in gastroenterology. Likewise, the biomaterialist should become aware of the specific tasks that the biomaterials must fulfil when placed within the GI tract, and regard such applications as both a challenge and an incentive for progressing the research in this field.
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Affiliation(s)
- Adrian Goldis
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania
- Correspondence:
| | | | - Traian V. Chirila
- Queensland Eye Institute, South Brisbane, QL 4101, Australia;
- Science & Engineering Faculty, Queensland University of Technology, Brisbane, QL 4000, Australia
- Faculty of Medicine, University of Queensland, Herston, QL 4029, Australia
- Australian Institute for Bioengineering and Nanotechnology, University of Queensland, St Lucia, 4072 QL, Australia
- Faculty of Science, University of Western Australia, Crawley, WA 6009, Australia
- University of Medicine, Pharmacy, Sciences and Technology, 540139 Targu Mures, Romania
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Gana JC, Cifuentes LI, Gattini D, Villarroel Del Pino LA, Peña A, Torres-Robles R. Band ligation versus beta-blockers for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. Cochrane Database Syst Rev 2019; 9:CD010546. [PMID: 31550050 PMCID: PMC6758973 DOI: 10.1002/14651858.cd010546.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Portal hypertension commonly accompanies advanced liver disease and often gives rise to life-threatening complications, including haemorrhage from oesophageal and gastrointestinal varices. Variceal haemorrhage commonly occurs in children with chronic liver disease or portal vein obstruction. Prevention is therefore important. Following numerous randomised clinical trials demonstrating efficacy of non-selective beta-blockers and endoscopic variceal ligation in decreasing the incidence of variceal haemorrhage, primary prophylaxis of variceal haemorrhage in adults has become the established standard of care. Hence, band ligation and beta-blockers have been proposed to be used as primary prophylaxis of oesophageal variceal bleeding in children. OBJECTIVES To determine the benefits and harms of band ligation compared with any type of beta-blocker for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. SEARCH METHODS We searched The Cochrane Hepato-Biliary Group Controlled Trials Register (February 2019), CENTRAL (December 2018), PubMed (December 2018), Embase Ovid (December 2018), LILACS (Bireme; January 2019), and Science Citation Index Expanded (Web of Science; December 2018). We scrutinised the reference lists of the retrieved publications and performed a manual search from the main paediatric gastroenterology and hepatology conferences (NASPGHAN and ESPGHAN) abstract books from 2009 to 2018. We searched ClinicalTrials.gov for ongoing clinical trials. There were no language or document type restrictions. SELECTION CRITERIA We planned to include randomised clinical trials irrespective of blinding, language, or publication status for assessment of benefits and harms. We planned to also include quasi-randomised and other observational studies retrieved with the searches for randomised clinical trials for report of harm. DATA COLLECTION AND ANALYSIS We planned to summarise data from randomised clinical trials using standard Cochrane methodologies. MAIN RESULTS We found no randomised clinical trials assessing band ligation versus beta-blockers for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. AUTHORS' CONCLUSIONS Randomised clinical trials assessing the benefits or harms of band ligation versus beta-blockers for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis are lacking. There is a need for well-designed, adequately powered randomised clinical trials to assess the benefits and harms of band ligation versus beta-blockers for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. Those randomised clinical trials should include patient-relevant clinical outcomes such as mortality, failure to control bleeding, and adverse events.
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Affiliation(s)
- Juan Cristóbal Gana
- Gastroenterology and Nutrition Department, Division of Pediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile, 85 Lira, Santiago, Region Metropolitana, Chile, 8330074
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Vadera S, Yong CWK, Gluud LL, Morgan MY. Band ligation versus no intervention for primary prevention of upper gastrointestinal bleeding in adults with cirrhosis and oesophageal varices. Cochrane Database Syst Rev 2019; 6:CD012673. [PMID: 31220333 PMCID: PMC6586251 DOI: 10.1002/14651858.cd012673.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The presence of oesophageal varices is associated with the risk of upper gastrointestinal bleeding. Endoscopic variceal ligation is used to prevent this occurrence but the ligation procedure may be associated with complications. OBJECTIVES To assess the beneficial and harmful effects of band ligation versus no intervention for primary prevention of upper gastrointestinal bleeding in adults with cirrhosis and oesophageal varices. SEARCH METHODS We combined searches in the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, and Science Citation Index with manual searches. The last search update was 9 February 2019. SELECTION CRITERIA We included randomised clinical trials comparing band ligation verus no intervention regardless of publication status, blinding, or language in the analyses of benefits and harms, and observational studies in the assessment of harms. Included participants had cirrhosis and oesophageal varices with no previous history of variceal bleeding. DATA COLLECTION AND ANALYSIS Three review authors extracted data independently. The primary outcome measures were all-cause mortality, upper gastrointestinal bleeding, and serious adverse events. We undertook meta-analyses and presented results using risk ratios (RRs) with 95% confidence intervals (CIs) and I2 values as a marker of heterogeneity. In addition, we calculated the number needed to treat to benefit (NNTTB) for the primary outcomes . We assessed bias control using the Cochrane Hepato-Biliary domains; determined the certainty of the evidence using GRADE; and conducted sensitivity analyses including Trial Sequential Analysis. MAIN RESULTS Six randomised clinical trials involving 637 participants fulfilled our inclusion criteria. One of the trials included an additional small number of participants (< 10% of the total) with non-cirrhotic portal hypertension/portal vein block. We classified one trial as at low risk of bias for the outcome, mortality and high risk of bias for the remaining outcomes; the five remaining trials were at high risk of bias for all outcomes. We downgraded the evidence to moderate certainty due to the bias risk. We gathered data on all primary outcomes from all trials. Seventy-one of 320 participants allocated to band ligation compared to 129 of 317 participants allocated to no intervention died (RR 0.55, 95% CI 0.43 to 0.70; I2 = 0%; NNTTB = 6 persons). In addition, band ligation was associated with reduced risks of upper gastrointestinal bleeding (RR 0.44, 95% CI 0.28 to 0.72; 6 trials, 637 participants; I2 = 61%; NNTTB = 5 persons), serious adverse events (RR 0.55, 95% CI 0.43 to 0.70; 6 trials, 637 participants; I2 = 44%; NNTTB = 4 persons), and variceal bleeding (RR 0.43, 95% CI 0.27 to 0.69; 6 trials, 637 participants; I² = 56%; NNTTB = 5 persons). The non-serious adverse events reported in association with band ligation included oesophageal ulceration, dysphagia, odynophagia, retrosternal and throat pain, heartburn, and fever, and in the one trial involving participants with either small or large varices, the incidence of non-serious side effects in the banding group was much higher in those with small varices, namely ulcers: small versus large varices 30.5% versus 8.7%; heartburn 39.2% versus 17.4%. No trials reported on health-related quality of life.Two trials did not receive support from pharmaceutical companies; the remaining four trials did not provide information on this issue. AUTHORS' CONCLUSIONS This review found moderate-certainty evidence that, in patients with cirrhosis, band ligation of oesophageal varices reduces mortality, upper gastrointestinal bleeding, variceal bleeding, and serious adverse events compared to no intervention. It is unlikely that further trials of band ligation versus no intervention would be considered ethical.
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Affiliation(s)
- Sonam Vadera
- Division of Medicine, Royal Free Campus, University College LondonUCL Institute for Liver & Digestive HealthRowland Hill StreetHampsteadLondonUKNW3 2PF
| | - Charles Wei Kit Yong
- Division of Medicine, Royal Free Campus, University College LondonUCL Institute for Liver & Digestive HealthRowland Hill StreetHampsteadLondonUKNW3 2PF
| | - Lise Lotte Gluud
- Copenhagen University Hospital HvidovreGastrounit, Medical DivisionKettegaards Alle 30HvidovreDenmark2650
| | - Marsha Y Morgan
- Division of Medicine, Royal Free Campus, University College LondonUCL Institute for Liver & Digestive HealthRowland Hill StreetHampsteadLondonUKNW3 2PF
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Irawan H, Mulyawan IM. Combination of modified Sugiura technique and proximal splenorenal shunt for the management of portal vein thrombosis in noncirrhotic portal hypertension. Clin Exp Gastroenterol 2019; 12:149-156. [PMID: 31114286 PMCID: PMC6497474 DOI: 10.2147/ceg.s188200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 03/05/2019] [Indexed: 11/23/2022] Open
Abstract
Background: Noncirrhotic portal hypertension (NCPH) is a condition when a high hepatic venous pressure gradient with preserved liver functions and the absence of parenchymal dysfunction. NCPH with portal vein thrombosis (PVT) is a rare condition. Surgery aims to reduce portal vein flow and alter portal vein circulation. Case: A male, 59 years old, complained of blackish stool in the last 2 weeks and enlarged abdomen. Physical examination revealed anemia and melena with splenomegaly and ascites. Laboratory findings were anemia, normal hepatobiliary function, and no liver infection. Abdominal Doppler ultrasonography and contrast-enhanced abdominal computed tomography scan revealed ascites, splenomegaly, noncirrhotic liver, dilatation of portal vein, low portal vein peak velocity, and PVT. Esophagogastroduodenoscopy revealed esophageal varices grade 3 with a positive red color sign and cardia stomach varices. We performed a modified Sugiura technique through the left subcostal incision and proximal splenorenal shunt. The procedures of the modified Sugiura technique are splenectomy, devascularization, transection, and end-to-end anastomosis of the lower esophagus above the gastroesophageal junction, devascularization of the upper 2/3 of the lesser and greater curvatures of the stomach, and pyloroplasty. Portal circulation alteration used the proximal splenorenal shunt with end-to-side anastomosis of the splenic vein to left renal vein. At the one-year follow-up after surgery, his physical condition was better and there was no sign of complications. Conclusion: Devascularization procedure using a modified Sugiura technique is useful to treat and avoid rupture of esophageal varices. Portal circulation alteration using the proximal splenorenal shunt is a good choice. The treatment in NCPH utilizing the combination of modified Sugiura technique and the proximal splenorenal shunt is proper without complication.
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Affiliation(s)
- Hendry Irawan
- General Surgery Department, Faculty of Medicine Udayana University, Sanglah General Hospital, Denpasar, Bali, Indonesia
| | - I Made Mulyawan
- Digestive Surgery Division, General Surgery Department, Faculty of Medicine Udayana University, Sanglah General Hospital, Denpasar, Bali, Indonesia
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Laine L. Interventions for Primary Prevention of Esophageal Variceal Bleeding. Hepatology 2019; 69:1382-1384. [PMID: 30561058 DOI: 10.1002/hep.30463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 10/24/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Loren Laine
- Yale School of Medicine, New Haven, CT.,VA Connecticut Healthcare System, West Haven, CT
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Abstract
Acute variceal bleeding is one of the most fatal complications of cirrhosis and is responsible for about one-third of cirrhosis-related deaths. Therefore, every effort should be made to emergently resuscitate the patients, start pharmacotherapy as soon as possible and do endoscopic therapy in a timely manner. Despite the recent advances in treatment, mortality rate is still high. We provide a comprehensive review of evaluation and management of variceal bleeding.
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Affiliation(s)
- Obada Tayyem
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Mohammad Bilal
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX.
| | - Ronald Samuel
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Sheharyar K Merwat
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX
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19
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Abstract
Bleeding from gastroesophageal varices is a serious complication in patients with liver cirrhosis and portal hypertension. Although there has been significance improvement in the prognosis of variceal bleeding with advancement in diagnostic and therapeutic modalities for its management, mortality rate still remains high. Therefore, appropriate prevention and rapid, effective management of bleeding from gastroesophageal varices is very important. Recently, various studies about management of gastoesophageal varices, including prevention of development and aggravation of varices, prevention of first variceal bleeding, management of acute variceal bleeding, and prevention of variceal rebleeding, have been published. The present article reviews published articles and practice guidelines to present the most optimal management of patients with gastroesophageal varices.
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Affiliation(s)
- Yeon Seok Seo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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20
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Abstract
Acute esophageal variceal hemorrhage is a dreaded complication of portal hypertension. Its management has evolved rapidly in recent years. Endoscopic therapy is often employed to arrest bleeding varices as well as to prevent early rebleeding. The combination of vasoconstrictor and endoscopic therapy is superior to vasoconstrictor or endoscopic therapy alone for control of acute esophageal variceal hemorrhage. After control of acute variceal bleeding, combination of banding ligation and beta-blockers is generally recommended to prevent variceal rebleeding. To prevent the catastrophic event of acute variceal bleeding, endoscopic banding ligation is an important tool in the prophylaxis of first bleeding. Endoscopic obturation with cyanoacrylate is usually utilized to arrest acute gastric variceal hemorrhage as well as to prevent rebleeding. It can be concluded that endoscopic therapies play a pivotal role in management of portal hypertensive bleeding.
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Affiliation(s)
- Gin-Ho Lo
- Department of Medical Research, E-Da Hospital, Kaohsiung, School of Medicine for International Students, I-Shou University, 1, Yi-Da Road, Kaohsiung, 824, Taiwan.
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Colli A, Gana JC, Yap J, Adams‐Webber T, Rashkovan N, Ling SC, Casazza G. Platelet count, spleen length, and platelet count-to-spleen length ratio for the diagnosis of oesophageal varices in people with chronic liver disease or portal vein thrombosis. Cochrane Database Syst Rev 2017; 4:CD008759. [PMID: 28444987 PMCID: PMC6478276 DOI: 10.1002/14651858.cd008759.pub2] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Current guidelines recommend screening of people with oesophageal varices via oesophago-gastro-duodenoscopy at the time of diagnosis of hepatic cirrhosis. This requires that people repeatedly undergo unpleasant invasive procedures with their attendant risks, although half of these people have no identifiable oesophageal varices 10 years after the initial diagnosis of cirrhosis. Platelet count, spleen length, and platelet count-to-spleen length ratio are non-invasive tests proposed as triage tests for the diagnosis of oesophageal varices. OBJECTIVES Primary objectives To determine the diagnostic accuracy of platelet count, spleen length, and platelet count-to-spleen length ratio for the diagnosis of oesophageal varices of any size in paediatric or adult patients with chronic liver disease or portal vein thrombosis, irrespective of aetiology. To investigate the accuracy of these non-invasive tests as triage or replacement of oesophago-gastro-duodenoscopy. Secondary objectives To compare the diagnostic accuracy of these same tests for the diagnosis of high-risk oesophageal varices in paediatric or adult patients with chronic liver disease or portal vein thrombosis, irrespective of aetiology.We aimed to perform pair-wise comparisons between the three index tests, while considering predefined cut-off values.We investigated sources of heterogeneity. SEARCH METHODS The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Hepato-Biliary Group Diagnostic Test Accuracy Studies Register, the Cochrane Library, MEDLINE (OvidSP), Embase (OvidSP), and Science Citation Index - Expanded (Web of Science) (14 June 2016). We applied no language or document-type restrictions. SELECTION CRITERIA Studies evaluating the diagnostic accuracy of platelet count, spleen length, and platelet count-to-spleen length ratio for the diagnosis of oesophageal varices via oesophago-gastro-duodenoscopy as the reference standard in children or adults of any age with chronic liver disease or portal vein thrombosis, who did not have variceal bleeding. DATA COLLECTION AND ANALYSIS Standard Cochrane methods as outlined in the Cochrane Handbook for Diagnostic Test of Accuracy Reviews. MAIN RESULTS We included 71 studies, 67 of which enrolled only adults and four only children. All included studies were cross-sectional and were undertaken at a tertiary care centre. Eight studies reported study results in abstracts or letters. We considered all but one of the included studies to be at high risk of bias. We had major concerns about defining the cut-off value for the three index tests; most included studies derived the best cut-off values a posteriori, thus overestimating accuracy; 16 studies were designed to validate the 909 (n/mm3)/mm cut-off value for platelet count-to-spleen length ratio. Enrolment of participants was not consecutive in six studies and was unclear in 31 studies. Thirty-four studies assessed enrolment consecutively. Eleven studies excluded some included participants from the analyses, and in only one study, the time interval between index tests and the reference standard was longer than three months. Diagnosis of varices of any size. Platelet count showed sensitivity of 0.71 (95% confidence interval (CI) 0.63 to 0.77) and specificity of 0.80 (95% CI 0.69 to 0.88) (cut-off value of around 150,000/mm3 from 140,000 to 150,000/mm3; 10 studies, 2054 participants). When examining potential sources of heterogeneity, we found that of all predefined factors, only aetiology had a role: studies including participants with chronic hepatitis C reported different results when compared with studies including participants with mixed aetiologies (P = 0.036). Spleen length showed sensitivity of 0.85 (95% CI 0.75 to 0.91) and specificity of 0.54 (95% CI 0.46 to 0.62) (cut-off values of around 110 mm, from 110 to 112.5 mm; 13 studies, 1489 participants). Summary estimates for detection of varices of any size showed sensitivity of 0.93 (95% CI 0.83 to 0.97) and specificity of 0.84 (95% CI 0.75 to 0.91) in 17 studies, and 2637 participants had a cut-off value for platelet count-to-spleen length ratio of 909 (n/mm3)/mm. We found no effect of predefined sources of heterogeneity. An overall indirect comparison of the HSROCs of the three index tests showed that platelet count-to-spleen length ratio was the most accurate index test when compared with platelet count (P < 0.001) and spleen length (P < 0.001). Diagnosis of varices at high risk of bleeding. Platelet count showed sensitivity of 0.80 (95% CI 0.73 to 0.85) and specificity of 0.68 (95% CI 0.57 to 0.77) (cut-off value of around 150,000/mm3 from 140,000 to 160,000/mm3; seven studies, 1671 participants). For spleen length, we obtained only a summary ROC curve as we found no common cut-off between studies (six studies, 883 participants). Platelet count-to-spleen length ratio showed sensitivity of 0.85 (95% CI 0.72 to 0.93) and specificity of 0.66 (95% CI 0.52 to 0.77) (cut-off value of around 909 (n/mm3)/mm; from 897 to 921 (n/mm3)/mm; seven studies, 642 participants). An overall indirect comparison of the HSROCs of the three index tests showed that platelet count-to-spleen length ratio was the most accurate index test when compared with platelet count (P = 0.003) and spleen length (P < 0.001). DIagnosis of varices of any size in children. We found four studies including 277 children with different liver diseases and or portal vein thrombosis. Platelet count showed sensitivity of 0.71 (95% CI 0.60 to 0.80) and specificity of 0.83 (95% CI 0.70 to 0.91) (cut-off value of around 115,000/mm3; four studies, 277 participants). Platelet count-to-spleen length z-score ratio showed sensitivity of 0.74 (95% CI 0.65 to 0.81) and specificity of 0.64 (95% CI 0.36 to 0.84) (cut-off value of 25; two studies, 197 participants). AUTHORS' CONCLUSIONS Platelet count-to-spleen length ratio could be used to stratify the risk of oesophageal varices. This test can be used as a triage test before endoscopy, thus ruling out adults without varices. In the case of a ratio > 909 (n/mm3)/mm, the presence of oesophageal varices of any size can be excluded and only 7% of adults with varices of any size would be missed, allowing investigators to spare the number of oesophago-gastro-duodenoscopy examinations. This test is not accurate enough for identification of oesophageal varices at high risk of bleeding that require primary prophylaxis. Future studies should assess the diagnostic accuracy of this test in specific subgroups of patients, as well as its ability to predict variceal bleeding. New non-invasive tests should be examined.
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Affiliation(s)
- Agostino Colli
- A Manzoni Hospital ASST LeccoDepartment of Internal MedicineVia dell'Eremo, 9/11LeccoItaly23900
| | - Juan Cristóbal Gana
- Division of Pediatrics, Escuela de Medicina, Pontificia Universidad Católica de ChileGastroenterology and Nutrition Department85 LiraSantiagoRegion MetropolitanaChile8330074
| | - Jason Yap
- University of AlbertaDivision of Pediatric Gastroenterology, Hepatology and Nutrition, Dept. of Pediatrics, Stollery Children's Hospital, Faculty of MedicineAberhart Centre 111402 University AveEdmontonABCanadaT6G 2J3
| | | | - Natalie Rashkovan
- Sunnybrook Health Sciences CentreDepartment of Neurology2075 Bayview ave., room A448TorontoONCanadaM4N 3M5
| | - Simon C Ling
- The Hospital for Sick ChildrenDivision of Gastroenterology, Hepatology and Nutrition555 University AvenueTorontoONCanadaM5G 1X8
| | - Giovanni Casazza
- Università degli Studi di MilanoDipartimento di Scienze Biomediche e Cliniche "L. Sacco"via GB Grassi 74MilanItaly20157
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Abstract
Primary prophylaxis in portal hypertension in children is controversial, because there are few studies documenting its efficacy on the risk of bleeding. Twenty-eight centres out of the 38 we contacted returned a completed questionnaire about their clinical practices. More than 75% of the centres use endoscopy to screen patients diagnosed with portal cavernoma, biliary atresia, cystic fibrosis, and other fibrotic chronic liver diseases with suspected portal hypertension. In cases of grade 2 varices with red marks and grade 3 varices >90% of centres perform sclerotherapy or endoscopic variceal ligation. Noncardioselective beta-blockers were used by approximately 20% of centres. In conclusion, despite the absence of scientific recommendations there is a tacit consensus concerning the need to screen children with clinical signs of portal hypertension, and to provide primary prophylaxis in cases of endoscopic patterns of high-risk varices.
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Carvedilol versus propranolol effect on hepatic venous pressure gradient at 1 month in patients with index variceal bleed: RCT. Hepatol Int 2016; 11:181-187. [PMID: 27624505 DOI: 10.1007/s12072-016-9765-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 08/25/2016] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND AIMS Endoscopic variceal ligation (EVL) plus beta blocker is the mainstay treatment after index bleed to prevent rebleed. Primary objective of this study was to compare EVL plus propranolol versus EVL plus carvedilol on reduction of HVPG after 1 month of therapy. METHODS Patients of cirrhosis presenting with index esophageal variceal bleed received standard treatment (Somatostatin therapy f/b EVL) following which HVPG was measured and patients were randomized to propranolol or carvedilol group if HVPG was >12 mmHg. Standard endotherapy protocol was continued in both groups. HVPG was again measured at 1 month of treatment. RESULTS Out of 129 patients of index esophageal variceal bleed, 59 patients were eligible and randomized into carvedilol (n = 30) and propranolol (n = 29). At 1 month of treatment, decrease in heart rate, mean arterial blood pressure (MAP) and HVPG was significant within each group (p = 0.001). Percentage decrease in MAP was significantly more in carvedilol group as compared to propranolol group (p = 0.04). Number of HVPG responders (HVPG decrease >20 % or below 12 mmHg) was significantly more in carvedilol group (22/29) as compared to propranolol group (14/28), p = 0.04. CONCLUSION Carvedilol is more effective in reducing portal pressure in patients with cirrhosis with esophageal bleed. Though a larger study is required to substantiate this, the results in this study are promising for carvedilol. Clinical trials online government registry (CTRI/2013/10/004119). Trial registration number CTRI/2013/10/004119.
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Unnewehr M, Stich A. Fighting Hepatitis B in North Korea: Feasibility of a Bi-modal Prevention Strategy. J Korean Med Sci 2015; 30:1584-8. [PMID: 26539001 PMCID: PMC4630473 DOI: 10.3346/jkms.2015.30.11.1584] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 08/07/2015] [Indexed: 12/27/2022] Open
Abstract
In North Korea, the prevalence of hepatitis B is high due to natural factors, gaps in vaccination, and the lack of antiviral treatment. Aid projects are urgently needed, however impeded by North Korea's political and economical situation and isolation. The feasibility of a joint North Korean and German humanitarian hepatitis B prevention program was assessed. Part 1: Hepatitis B vaccination catch-up campaign. Part 2: Implementation of endoscopic ligation of esophageal varices (EVL) by trainings in Germany and North Korea. By vaccinating 7 million children between 2010 and 2012, the hepatitis B vaccination gap was closed. Coverage of 99.23% was reached. A total of 11 hepatitis B-induced liver cirrhosis patients (mean age 41.1 yr) with severe esophageal varices and previous bleedings were successfully treated by EVL without major complications. A clinical standard operating procedure, a feedback system and a follow-up plan were developed. The bi-modal preventive strategy was implemented successfully. Parts of the project can serve as an example for other low-income countries, however its general transferability is limited due to the special circumstances in North Korea.
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Affiliation(s)
- Markus Unnewehr
- Medizinische Klinik Nord, Klinikum Dortmund, Dortmund (Academic Teaching Hospital of the Westfälische Wilhelms-Universität Muenster, Muenster, Germany) and Medical Mission Institute, Wuerzburg, Germany
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Maruyama H, Kondo T, Sekimoto T, Kiyono S, Shimada T, Takahashi M, Okugawa H, Yokosuka O. Hyponatremia: a significant factor in a poor prognosis for cirrhosis with Child A/B after variceal eradication. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015. [PMID: 26202665 DOI: 10.1002/jhbp.282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND To identify prognostic factors prospectively in cirrhosis after the eradication of esophageal varices (EV). METHODS There were 52 cirrhosis patients (Child-Pugh A 24, B 28) who showed the eradication of EV after the endoscopic sclerotherapy (median observation period, 25.5 months). RESULTS Eighteen patients showed a recurrence of EV. The cumulative overall survival rate was 92.2% at 1 year, 70.9% at 3 years, and 47.2% at 5 years. Univariate analysis showed that serum sodium concentration (hazard ratio [HR] 0.724, P = 0.0006), serum aspartate transaminase (HR 1.019, P = 0.0075), serum alanine transaminase (HR 1.025, P = 0.0239), and serum creatinine (HR 11.311, P = 0.044) levels before treatment were significant factors for a poor prognosis. Multivariate analysis revealed that serum sodium concentration (HR 0.711, P = 0.0022) was the only significant factor. The cumulative survival rate was lower in patients with hyponatremia (<135 mEq/l, a best cut-off value; 83.3% at 1 year, and 33.3% at 3 years), than in those without (93.3% at 1 year, 77.3% at 3 years and 47.2% at 5 years). CONCLUSIONS Pre-treatment hyponatremia is a significant prognostic factor in cirrhosis with Child A/B after the eradication of EV by the endoscopic sclerotherapy.
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Affiliation(s)
- Hitoshi Maruyama
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Takayuki Kondo
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Tadashi Sekimoto
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Soichiro Kiyono
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Taro Shimada
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Masanori Takahashi
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Hidehiro Okugawa
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Osamu Yokosuka
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
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Gana JC, Cifuentes LI, Cerda J, Villarroel del Pino LA, Peña A, Torres-Robles R. Banding ligation versus sclerotherapy for primary prophylaxis of oesophageal varices in children. Hippokratia 2015. [DOI: 10.1002/14651858.cd011803] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Juan Cristóbal Gana
- Division of Pediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile; Gastroenterology and Nutrition Department; 85 Lira Santiago Region Metropolitana Chile 8330074
| | - Lorena I Cifuentes
- Escuela de Medicina, Pontificia Universidad Católica de Chile; Division of Paediatrics, Evidence-based Health Care Programme; Lira 85, 5º piso Santiago Metroplitana Chile 833-0074
| | - Jaime Cerda
- Faculty of Medicine, Pontificia Universidad Católica de Chile; Department of Public Health; Marcoleta 434, Santiago Centro Santiago Chile
| | - Luis A Villarroel del Pino
- Faculty of Medicine, Pontificia Universidad Católica de Chile; Department of Public Health; Marcoleta 434, Santiago Centro Santiago Chile
| | - Alfredo Peña
- Pontificia Universidad Católica de Chile; Division of Paediatrics; Lira 85, 5º piso Santiago Region Metropolitana of Santiago Chile
| | - Romina Torres-Robles
- Pontificia Universidad Católica de Chile; Sistema de Bibliotecas UC; Santiago Región Metropolitana Chile 8330074
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Bozic MA, Puri K, Molleston JP. Screening and Prophylaxis for Varices in Children with Liver Disease. Curr Gastroenterol Rep 2015; 17:27. [PMID: 26122248 DOI: 10.1007/s11894-015-0450-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Esophageal varices in children with portal hypertension are quite common. Bleeding from these varices frequently occurs. Prophylactic measures to prevent such bleeding can be undertaken either before ("primary," prompted by a screening endoscopy) or after ("secondary") an initial variceal bleed. There are no clear pediatric guidelines for primary or secondary prophylaxis of esophageal varices. Adult studies clearly support the use of pharmacologic (beta blockers) and endoscopic (endoscopic band ligation, EBL) management for both primary and secondary prophylaxis of esophageal varices in patients with portal hypertension. Pediatric studies are limited. There are inadequate data to recommend use of beta blockers to prevent variceal bleeding or rebleeding in children with portal hypertension. There is very limited support for EBL for primary prophylaxis in children and more compelling support for EBL for secondary prophylaxis. Further randomized controlled studies are needed but are difficult to implement in this vulnerable population.
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Affiliation(s)
- Molly A Bozic
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Indiana University School of Medicine, 705 Riley Hospital Drive, ROC 4210, Indianapolis, IN, 46202, USA
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Abstract
Primary prophylaxis is advisable for all patients with moderate-sized or large esophageal varices. After the first episode of bleeding, secondary prophylaxis should be initiated to prevent rebleeding. Multiple treatment modalities are available for each circumstance. Optimal regimens have not yet been established but are under investigation. At present, nonselective beta-blockers are the drugs of choice for primary prophylaxis. In patients with actively bleeding varices, octreotide or, in rare cases, a combination of vasopressin and nitroglycerin is used in conjunction with endoscopic band ligation of the varices. Either a beta-blocker, band ligation, or a combination of the two is appropriate for secondary prophylaxis. The combination is often the better choice for patients for whom primary prophylaxis with beta-blockers has failed. As in any treatment situation, the specific approach must be tailored to clinical circumstances. The patient's preferences and willingness or ability to comply with the therapy must be taken into account as well as the physician's expertise. Interventions for hepatic encephalopathy predominantly focus on reducing the amount of ammonia absorbed or endogenously generated in the body. They include correction of precipitating factors, bowel cleansing, and lactulose therapy. In difficult cases, a combination of lactulose and neomycin, metronidazole, or rifaximin is recommended. Because the prognosis for patients with hepatic encephalopathy is generally poor, orthotopic liver transplantation should be considered.
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Affiliation(s)
- Vijay H Shah
- Department of Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Harman DJ, Ryder SD, James MW, Jelpke M, Ottey DS, Wilkes EA, Card TR, Aithal GP, Guha IN. Direct targeting of risk factors significantly increases the detection of liver cirrhosis in primary care: a cross-sectional diagnostic study utilising transient elastography. BMJ Open 2015; 5:e007516. [PMID: 25941185 PMCID: PMC4420978 DOI: 10.1136/bmjopen-2014-007516] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES To assess the feasibility of a novel diagnostic algorithm targeting patients with risk factors for chronic liver disease in a community setting. DESIGN Prospective cross-sectional study. SETTING Two primary care practices (adult patient population 10,479) in Nottingham, UK. PARTICIPANTS Adult patients (aged 18 years or over) fulfilling one or more selected risk factors for developing chronic liver disease: (1) hazardous alcohol use, (2) type 2 diabetes or (3) persistently elevated alanine aminotransferase (ALT) liver function enzyme with negative serology. INTERVENTIONS A serial biomarker algorithm, using a simple blood-based marker (aspartate aminotransferase:ALT ratio for hazardous alcohol users, BARD score for other risk groups) and subsequently liver stiffness measurement using transient elastography (TE). MAIN OUTCOME MEASURES Diagnosis of clinically significant liver disease (defined as liver stiffness ≥8 kPa); definitive diagnosis of liver cirrhosis. RESULTS We identified 920 patients with the defined risk factors of whom 504 patients agreed to undergo investigation. A normal blood biomarker was found in 62 patients (12.3%) who required no further investigation. Subsequently, 378 patients agreed to undergo TE, of whom 98 (26.8% of valid scans) had elevated liver stiffness. Importantly, 71/98 (72.4%) patients with elevated liver stiffness had normal liver enzymes and would be missed by traditional investigation algorithms. We identified 11 new patients with definite cirrhosis, representing a 140% increase in the number of diagnosed cases in this population. CONCLUSIONS A non-invasive liver investigation algorithm based in a community setting is feasible to implement. Targeting risk factors using a non-invasive biomarker approach identified a substantial number of patients with previously undetected cirrhosis. TRIAL REGISTRATION NUMBER The diagnostic algorithm utilised for this study can be found on clinicaltrials.gov (NCT02037867), and is part of a continuing longitudinal cohort study.
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Affiliation(s)
- David J Harman
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Stephen D Ryder
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Martin W James
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Matthew Jelpke
- NHS Rushcliffe Clinical Commissioning Group, Nottingham, UK
| | | | - Emilie A Wilkes
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Timothy R Card
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - Guruprasad P Aithal
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Indra Neil Guha
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit (NDDBRU), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
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Gana JC, Cifuentes LI, Cerda J, Villarroel del Pino LA, Peña A, Rivera-Cornejo M. Banding ligation versus sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children. Cochrane Database Syst Rev 2015. [DOI: 10.1002/14651858.cd011561] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Juan Cristóbal Gana
- Division of Pediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile; Gastroenterology and Nutrition Department; 85 Lira Santiago Region Metropolitana Chile 8330074
| | - Lorena I Cifuentes
- Escuela de Medicina, Pontificia Universidad Católica de Chile; Division of Paediatrics, Evidence-based Health Care Programme; Lira 85, 5º piso Santiago Metroplitana Chile 833-0074
| | - Jaime Cerda
- Faculty of Medicine, Pontificia Universidad Católica de Chile; Department of Public Health; Marcoleta 434, Santiago Centro Santiago Chile
| | - Luis A Villarroel del Pino
- Faculty of Medicine, Pontificia Universidad Católica de Chile; Department of Public Health; Marcoleta 434, Santiago Centro Santiago Chile
| | - Alfredo Peña
- Pontificia Universidad Católica de Chile; Division of Paediatrics; Lira 85, 5º piso Santiago Region Metropolitana of Santiago Chile
| | - Marcela Rivera-Cornejo
- Pontificia Universidad Católica de Chile; Sistema de Bibliotecas UC; Santiago Región Metropolitana Chile 8330074
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Hua J, Liu GQ, Bao H, Sheng L, Guo CJ, Li H, Ma X, Shen JL. The role of liver stiffness measurement in the evaluation of liver function and esophageal varices in cirrhotic patients. J Dig Dis 2015; 16:98-103. [PMID: 25385497 DOI: 10.1111/1751-2980.12210] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We aimed to evaluate the efficacy of liver stiffness measurement (LSM) in predicting the presence and severity of esophageal varices (EV) and investigating its association with liver function (LF) in patients with liver cirrhosis. METHODS Medical records of 90 cirrhotic patients who underwent LSM by transient elastography were retrospectively reviewed. The relationship between LSM and the presence and severity of EV was evaluated by esophagogastroduodenoscopy (EGD) and multislice spiral computed tomography (MSCT). Another 25 healthy individuals were included as controls. RESULTS LSM was significantly associated with the Child-Pugh score in cirrhotic patients, with the highest LSM in those with Child-Pugh C. Patients with clinically decompensated cirrhosis had a higher LSM than those with compensated cirrhosis (36.75 ± 16.54 kPa vs 17.65 ± 10.87 kPa, P < 0.01). However, there was no significant difference in LSM value between patients with severe EV and those with no or non-severe EV determined by endoscopy (28.18 ± 17.44 kPa vs 31.00 ± 18.44 kPa) or MSCT (29.71 ± 18.39 kPa vs 24.90 ± 14.80 kPa). The diagnostic value of LSM for predicting severe EV was low in unselected cirrhotic patients. The presence of EV examined by EGD and MSCT was similar to each other. CONCLUSIONS LSM could be used to evaluate the progression of liver cirrhosis continuously. However, its role in assessing EV grades in advanced cirrhosis needs further confirmation. MSCT can assess EV accurately and may serve as an alternative to endoscopy in the assessment of portal hypertension.
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Affiliation(s)
- Jing Hua
- Key Laboratory of Gastroenterology & Hepatology, Ministry of Health, Division of Gastroenterology and Hepatology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
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Propranolol associated with endoscopic band ligation reduces recurrence of esophageal varices for primary prophylaxis of variceal bleeding: a randomized-controlled trial. Eur J Gastroenterol Hepatol 2015; 27:84-90. [PMID: 25397691 DOI: 10.1097/meg.0000000000000227] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of this study was to compare the recurrence of esophageal varices (EVs) after endoscopic band ligation (EBL) associated with propranolol (PP) versus EBL alone. PATIENTS AND METHODS Sixty-six cirrhotic outpatients (EBL group, n=32 and EBL+PP group, n=34) with high-risk EVs without previous bleeding were studied. MAIN OUTCOME MEASUREMENTS The primary outcome was recurrence of EV. The secondary outcomes were EV eradication, bleeding before EV eradication, mortality, and adverse events. RESULTS Demographic characteristics and the initial endoscopic findings were similar. EV eradication was achieved in all patients. Three patients presented gastrointestinal bleeding before variceal eradication, two in the EBL group and one in the EBL+PP group (P=0.13). Six patients died (liver failure), two in the EBL group and four in the EBL+PP group (P=0.27). Twelve (38%) patients in the EBL group and three (9%) patients in the EBL+PP group had variceal recurrence. The risk of recurrence of EVs after eradication was significantly higher among patients in the EBL group (P=0.003). CONCLUSION EBL alone and EBL+PP were effective in the primary prophylaxis of bleeding from EVs in cirrhotic patients (EV eradication, bleeding before EV eradication, mortality, and adverse events were similar in both groups). However, variceal recurrence was lower in the EBL+PP group than band ligation alone.
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Abstract
Gastroesophageal varices are present in almost half of patients with cirrhosis at the time of initial diagnosis. Variceal bleeding occurs in 25% to 35% of patients with cirrhosis. Effective and timely care can prevent variceal bleeding (primary prophylaxis). For example, clinical studies demonstrate that both beta-blockers and endoscopic variceal ligation are effective in preventing a first episode of variceal bleeding. The major challenge is to screen patients in a timely manner and institute a form of therapy that has the highest chance of success in terms of patient compliance and effectiveness.
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Colli A, Gana JC, Turner D, Yap J, Adams‐Webber T, Ling SC, Casazza G. Capsule endoscopy for the diagnosis of oesophageal varices in people with chronic liver disease or portal vein thrombosis. Cochrane Database Syst Rev 2014; 2014:CD008760. [PMID: 25271409 PMCID: PMC7173747 DOI: 10.1002/14651858.cd008760.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Current guidelines recommend performance of oesophago-gastro-duodenoscopy at the time of diagnosis of hepatic cirrhosis to screen for oesophageal varices. These guidelines require people to undergo an unpleasant invasive procedure repeatedly with its attendant risks, despite the fact that half of the people do not have identifiable oesophageal varices 10 years after the initial diagnosis of cirrhosis. Video capsule endoscopy is a non-invasive test proposed as an alternative method for the diagnosis of oesophageal varices. OBJECTIVES To determine the diagnostic accuracy of capsule endoscopy for the diagnosis of oesophageal varices in children or adults with chronic liver disease or portal vein thrombosis, irrespective of the aetiology. To investigate the accuracy of capsule endoscopy as triage or replacement of oesophago-gastro-duodenoscopy. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Diagnostic Test Accuracy Studies Register (October 2013), MEDLINE (Ovid SP) (1950 to October 2013), EMBASE (Ovid SP) (1980 to October 2013), ACP Journal Club (Ovid SP) (1991 to October 2013), Database of Abstracts of Reviews of Effects (DARE) (Ovid SP) (third quarter), Health Technology Assessment (HTA) (Ovid SP) (third quarter), NHS Economic Evaluation Database (NHSEED) (Ovid SP) (third quarter), and Science Citation Index Expanded (SCI-EXPANDED) (ISI Web of Knowledge) (1955 to October 2013). We applied no language or document type restrictions. SELECTION CRITERIA Studies that evaluated the diagnostic accuracy of capsule endoscopy for the diagnosis of oesophageal varices using oesophago-gastro-duodenoscopy as the reference standard in children or adults of any age, with chronic liver disease or portal vein thrombosis. DATA COLLECTION AND ANALYSIS We followed the available guidelines provided in the Cochrane Handbook for Diagnostic Test of Accuracy Reviews. We calculated the pooled estimates of sensitivity and specificity using the bivariate model due to the absence of a negative correlation in the receiver operating characteristic (ROC) space and of a threshold effect. MAIN RESULTS The search identified 16 eligible studies, in which only adults with cirrhosis were included. In one study, people with portal thrombosis were also included. We classified most of the studies at high risk of bias for the 'Participants selection' and the 'Flow and timing' domains. One study assessed the accuracy of capsule endoscopy for the diagnosis of large (high-risk) oesophageal varices. In the remaining15 studies that assessed the accuracy of capsule endoscopy for the diagnosis of oesophageal varices of any size in people with cirrhosis, 936 participants were included; the pooled estimate of sensitivity was 84.8% (95% confidence interval (CI) 77.3% to 90.2%) and of specificity 84.3% (95% CI 73.1% to 91.4%). Eight of these studies included people with suspected varices or people with already diagnosed or even treated varices, or both, introducing a selection bias. Seven studies including only people with suspected but unknown varices were at low risk of bias; the pooled estimate of sensitivity was 79.7% (95% CI 73.1% to 85.0%) and of specificity 86.1% (95% CI 64.5% to 95.5%). Six studies assessed the diagnostic accuracy of capsule endoscopy for the diagnosis of large oesophageal varices, associated with a higher risk of bleeding; the pooled sensitivity was 73.7% (95% CI 52.4% to 87.7%) and of specificity 90.5% (95% CI 84.1% to 94.4%). Two studies also evaluated the presence of red marks, which are another marker of high risk of bleeding; the estimates of sensitivity and specificity varied widely. Two studies obtained similar results with the use of a modified device as index test (string capsule). Due to the absence of data, we could not perform all planned subgroup analyses. Interobserver agreement in the interpretation of capsule endoscopy results and any adverse event attributable to capsule endoscopy were poorly assessed and reported. Only four studies evaluated the interobserver agreement in the interpretation of capsule endoscopy results: the concordance was moderate. The participants' preferences for capsule endoscopy or oesophago-gastro-duodenoscopy were reported differently but seemed in favour of capsule endoscopy in nine of 10 studies. In 10 studies, participants reported some minor discomfort on swallowing the capsule. Only one study identified other significant adverse events, including impaction of the capsule due to previously unidentified oesophageal strictures in two participants. No adverse events were reported as a consequence of the reference standard. AUTHORS' CONCLUSIONS We cannot support the use of capsule endoscopy as a triage test in adults with cirrhosis, administered before oesophago-gastro-duodenoscopy, despite the low incidence of adverse events and participant reports of being better tolerated. Thus, we cannot conclude that oesophago-gastro-duodenoscopy can be replaced by capsule endoscopy for the detection of oesophageal varices in adults with cirrhosis. We found no data assessing capsule endoscopy in children and in people with portal thrombosis.
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Affiliation(s)
- Agostino Colli
- Ospedale "A Manzoni" LeccoDepartment of Internal MedicineVia dell'Eremo, 9/11LeccoItaly23900
| | - Juan Cristóbal Gana
- Division of Paediatrics, Escuela de Medicina, Pontificia Universidad Católica de ChileGastroenterology, Hepatology, and Nutrition Unit85 LiraSantiagoRegion MetropolitanaChile8330074
| | - Dan Turner
- Shaare Zedek Medical CenterPediatric Gastroenterology UnitP.O.B 3235JerusalemIsrael91031
| | - Jason Yap
- University of AlbertaDivision of Pediatric Gastroenterology, Hepatology and Nutrition, Dept. of Pediatrics, Stollery Children's Hospital, Faculty of MedicineAberhart Centre 111402 University AveEdmontonABCanadaT6G 2J3
| | | | - Simon C Ling
- The Hospital for Sick ChildrenDivision of Gastroenterology, Hepatology & Nutrition555 University AvenueTorontoONCanadaM5G 1X8
| | - Giovanni Casazza
- Università degli Studi di MilanoDipartimento di Scienze Biomediche e Cliniche "L. Sacco"via GB Grassi 74MilanItaly20157
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Je D, Paik YH, Gwak GY, Choi MS, Lee JH, Koh KC, Paik SW, Yoo BC. The comparison of esophageal variceal ligation plus propranolol versus propranolol alone for the primary prophylaxis of esophageal variceal bleeding. Clin Mol Hepatol 2014; 20:283-90. [PMID: 25320732 PMCID: PMC4197177 DOI: 10.3350/cmh.2014.20.3.283] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 08/08/2014] [Accepted: 08/11/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS To investigate the efficacy and longterm outcome of esophageal variceal ligation (EVL) plus propranolol in comparison with propranolol alone for the primary prophylaxis of esophageal variceal bleeding. METHODS A total of 504 patients were retrospectively enrolled in this study. 330 patients were in propranolol group (Gr1) and 174 patients were in EVL plus propranolol group (Gr2). The endpoints of this study were esophageal variceal bleeding and mortality. Association analyses were performed to evaluate bleeding and mortality between Gr1 and Gr2. RESULTS EVL was more applied in patients with high risk, such as large-sized varices (F2 or F3) or positive red color signs. Total 38 patients had bleeds, 32 in Gr1 and 6 in Gr2. The cumulative probability of bleeding at 120 months was 13% in Gr1 versus 4% in Gr2 (P=0.04). The predictive factors of variceal bleeding were red color signs (OR 2.962, P=0.007) and the method of propranolol plus EVL (OR 0.160, P=0.000). 20 patients died in Gr1 and 12 in Gr2. Mortality rates are similar in the two groups compared, 6.7% in Gr1 and 6.9% in Gr2. The cumulative probability of mortality at 120 months was not significantly different in the two groups (7% in Gr1, 12% in Gr2, P=0.798). The prognostic factors for mortality were age over 50 (OR 5.496, P=0.002), Child-Pugh class B (OR 3.979, P=0.001), and Child-Pugh class C (OR 10.861, P=0.000). CONCLUSIONS EVL plus propranolol is more effective than propranolol alone in the prevention of the first variceal bleeding in patients with liver cirrhosis.
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Affiliation(s)
- Dongmo Je
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong-Han Paik
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Geum-Youn Gwak
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Moon Seok Choi
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon Hyeok Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Cheol Koh
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Woon Paik
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung Chul Yoo
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Lim N, Desarno MJ, Lidofsky SD, Ganguly E. Hospitalization for variceal hemorrhage in an era with more prevalent cirrhosis. World J Gastroenterol 2014; 20:11326-32. [PMID: 25170218 PMCID: PMC4145772 DOI: 10.3748/wjg.v20.i32.11326] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 03/11/2014] [Accepted: 05/23/2014] [Indexed: 02/06/2023] Open
Abstract
AIM To examine hospitalization rates for variceal hemorrhage and relation to cause of cirrhosis during an era of increased cirrhosis prevalence. METHODS We performed a retrospective review of patients with cirrhosis and gastroesophageal variceal hemorrhage who were admitted to a tertiary care referral center from 1998 to 2009. Subjects were classified according to the etiology of their liver disease: alcoholic cirrhosis and non-alcoholic cirrhosis. Rates of hospitalization for variceal bleeding were determined. Data were also collected on total hospital admissions per year and cirrhosis-related admissions per year over the same time period. These data were then compared and analyzed for trends in admission rates. RESULTS Hospitalizations for cirrhosis significantly increased from 611 per 100000 admissions in 1998-2001 to 1232 per 100000 admissions in 2006-9 (P value for trend < 0.0001). This increase was seen in admissions for both alcoholic and non-alcoholic cirrhosis (P values for trend < 0.001 and < 0.0001 respectively). During the same time period, there were 243 admissions for gastroesophageal variceal bleeding (68% male, mean age 54.3 years, 62% alcoholic cirrhosis). Hospitalizations for gastroesophageal variceal bleeding significantly decreased from 96.6 per 100000 admissions for the time period 1998-2001 to 70.6 per 100000 admissions for the time period 2006-2009 (P value for trend = 0.01). There were significant reductions in variceal hemorrhage from non-alcoholic cirrhosis (41.6 per 100000 admissions in 1998-2001 to 19.7 per 100000 admissions in 2006-2009, P value for trend = 0.007). CONCLUSION Hospitalizations for variceal hemorrhage have decreased, most notably in patients with non-alcoholic cirrhosis, and this may reflect broader use of strategies to prevent bleeding.
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Karadsheh Z, Allison H. Primary prevention of variceal bleeding: pharmacological therapy versus endoscopic banding. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2014; 5:573-9. [PMID: 24350068 PMCID: PMC3842697 DOI: 10.4103/1947-2714.120791] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Variceal bleeding is one of the most feared complications in patients with liver cirrhosis. It continues to be a leading cause of death among patients with liver cirrhosis. Although its prognosis has improved over the last several decades, it still carries substantial mortality. Preventing variceal bleeding has been extensively studied and evaluated in several studies in the recent years and the comparison between the different modalities available to prevent variceal bleeding has been an area of discussion. Currently the two most widely used modalities to prevent variceal bleeding are pharmacologic (non-selective beta-blockers [NSBB]) and endoscopic (variceal band ligation [VBL]) which have replaced sclerotherapy in the recent years. In addition to NSBB and recent carvedilol, different other medications have been evaluated including isosorbide mononitrates, spironolactone and angiotensin blocking agents. Comparing the outcomes and adverse effects of these two modalities has been evaluated in different studies. Some studies have showed superiority of VBL until recently, when carvedilol has been included, however; overall mortality has been similar in most trials. Despite that, NSBB remain the first line treatment, as they are cheaper and relatively effective in preventing both esophageal and gastric bleeding. The following sections discuss the primary prevention of variceal bleeding with a focus on NSBB, carvedilol and VBL.
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Affiliation(s)
- Zeid Karadsheh
- Department of Medicine, Brockton Hospital, Brockton, USA
| | - Harmony Allison
- Division of Gastroenterology, Tufts Medical Center, Boston, MA, USA
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Laurain A, de Leusse A, Gincul R, Vanbiervliet G, Bramli S, Heyries L, Martane G, Amrani N, Serraj I, Saurin JC, Borentain P, Filoche B, Duburque C, Gaudric M, Sogni P, Dumortier J. Oesophageal capsule endoscopy versus oesophago-gastroduodenoscopy for the diagnosis of recurrent varices: a prospective multicentre study. Dig Liver Dis 2014; 46:535-40. [PMID: 24631032 DOI: 10.1016/j.dld.2014.02.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/22/2014] [Accepted: 02/04/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Oesophago-gastroduodenoscopy is the standard method for the diagnosis of recurrent oesophago-gastric varices after endoscopic treatment and eradication. The aim of this study was to evaluate the PillCam Eso capsule endoscopy in this setting. METHODS Prospective, multicentre study in which patients with history of oesophageal varices treated by band ligation underwent PillCam Eso capsule and oesophago-gastroduodenoscopy. Capsule recordings were blindly read by two endoscopists. Indication for a new prophylactic treatment and patient satisfaction were determined for both procedures. RESULTS 80 patients (80% males, mean age: 57±12 years) were included, after a median delay of 16 months from last endoscopic treatment. Recurrent oesophageal varices requiring a new prophylactic treatment were detected in 26 patients (32.5%). The mean oesophageal transit time of the capsule was 153 s (range 2-930 s). Capsule sensitivity, specificity, negative and positive predictive values for indication of new prophylactic treatments were 65%, 83%, 83%, and 65%, respectively. Capsule adequately classified 77.5% of the patients for prophylaxis indication. Inter-observer concordance for capsule readings was 88% for the prophylaxis indication. CONCLUSION This study demonstrates that accuracy of PillCam Eso capsule for the diagnosis of recurrent oesophageal varices after endoscopic eradication is suboptimal. PillCam Eso capsule might therefore be proposed in patients unable or unwilling to undergo oesophago-gastroduodenoscopy.
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Affiliation(s)
- Anne Laurain
- Edouard Herriot Hospital - HCL, Department of Digestive Diseases, Claude Bernard Lyon 1 University, Lyon, France
| | - Antoine de Leusse
- Edouard Herriot Hospital - HCL, Department of Digestive Diseases, Claude Bernard Lyon 1 University, Lyon, France; Jean Mermoz Hospital, Lyon, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Rodica Gincul
- Edouard Herriot Hospital - HCL, Department of Digestive Diseases, Claude Bernard Lyon 1 University, Lyon, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Geoffroy Vanbiervliet
- Archet II Hospital, Department of Digestive Diseases, Nice, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Slim Bramli
- Avignon Hospital, Department of Digestive Diseases, Avignon, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Laurent Heyries
- Conception Hospital - AP-HM, Department of Digestive Diseases, Marseille, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Gabriel Martane
- Avignon Hospital, Department of Digestive Diseases, Avignon, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Naima Amrani
- Ibn Sina Hospital, Department of Digestive Diseases, Rabat, Morocco; Société Française d'Endoscopie Digestive, Paris, France
| | - Ilham Serraj
- Ibn Sina Hospital, Department of Digestive Diseases, Rabat, Morocco
| | - Jean-Christophe Saurin
- Edouard Herriot Hospital - HCL, Department of Digestive Diseases, Claude Bernard Lyon 1 University, Lyon, France; Lyon Sud Hospital, Department of Digestive Diseases, Pierre Benite, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Patrick Borentain
- Conception Hospital - AP-HM, Department of Digestive Diseases, Marseille, France
| | - Bernard Filoche
- Saint Philibert Hospital, Department of Digestive Diseases, Lomme, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Clotilde Duburque
- Saint Philibert Hospital, Department of Digestive Diseases, Lomme, France
| | - Marianne Gaudric
- Cochin Hospital - AP-HP, Department of Digestive Endoscopy, Paris, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Philippe Sogni
- Cochin Hospital - AP-HP, Department of Digestive Endoscopy, Paris, France
| | - Jérôme Dumortier
- Edouard Herriot Hospital - HCL, Department of Digestive Diseases, Claude Bernard Lyon 1 University, Lyon, France.
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Abstract
Primary prevention of variceal bleeding is an important and long-debated topic in the management of patients with cirrhosis and esophageal varices. Prophylaxis is recommended for high-risk patients with small esophageal varices (advanced liver disease and/or presence of red wale marks) and those with medium/large varices. Nonselective β-blockers and endoscopic band ligation have been shown to be equally effective in primary prevention of variceal bleeding and are the only currently recommended therapies. Controversy still exists, however, regarding which one of these strategies is preferred. This article reviews the established recommendations and recent advances in the prevention of first esophageal variceal bleeding.
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Affiliation(s)
- Douglas A Simonetto
- Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Department of Physiology, Advanced Liver Disease Study Group, Fiterman Center for Digestive Diseases, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Vijay H Shah
- Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Department of Physiology, Advanced Liver Disease Study Group, Fiterman Center for Digestive Diseases, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Patrick S Kamath
- Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Department of Physiology, Advanced Liver Disease Study Group, Fiterman Center for Digestive Diseases, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Prophylactic impact of endoscopic treatment for esophageal varices in liver resection: a prospective study. J Gastroenterol 2014; 49:917-22. [PMID: 23775207 DOI: 10.1007/s00535-013-0841-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 05/21/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Prophylactic treatment for esophageal varices has been performed without adequate supporting evidence. We assessed the feasibility of prophylactic and follow-up treatment for high-risk esophageal varices in patients with hepatocellular carcinoma (HCC). METHODS Patients with HCC were screened prospectively and followed up for esophageal varices and gastroduodenal ulceration. High-risk esophageal varices (huge F3 varices or intermediate F2 varices positive for red color signs) were treated prophylactically. Follow-up endoscopy was performed to assess the impact of prophylaxis and changes in varices at 1 week, 1 month, and 6 months after operation. If high-risk varices were found during follow-up, secondary prophylaxis was performed according to the same criteria. RESULTS Among 251 patients with HCC, 81 (32.3 %) had esophageal varices on screening endoscopy. Prophylactic endoscopic treatment was required by 13 patients (1 with F3 varices and 12 with F2 varices positive for red color signs). Ten varices worsened, and 4 varices progressed to high-risk varices requiring endoscopic treatment. No F0 or F1 varices at screening endoscopy progressed to high-risk varices, and no bleeding event occurred during 6 months of preplanned follow-up. A preoperative platelet count of less than 10 × 10(4)/μL (odds ratio: 4.21, 95 % confidence interval 3.11-10.6; p < 0.001), the presence of splenomegaly (2.87, 2.16-21.8; p = 0.011), and an indocyanine green retention rate at 15 min of greater than 30 % (2.31, 1.88-24.6; p = 0.026) were independent predictors of worsening varices. CONCLUSIONS Our protocol for prophylactic and follow-up treatment of high-risk esophageal varices was feasible in patients with HCC.
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Bai M, Qi X, Yang M, Han G, Fan D. Combined therapies versus monotherapies for the first variceal bleeding in patients with high-risk varices: a meta-analysis of randomized controlled trials. J Gastroenterol Hepatol 2014; 29:442-52. [PMID: 24118091 DOI: 10.1111/jgh.12396] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM The effect of combined therapies (among non-selected beta-blockers [NSBB], endoscopic therapy, and other treatments) on the first variceal bleeding has been evaluated in several randomized controlled trials previously, and the results were controversial. We performed this meta-analysis to assess the effect of combined therapies in patients with high-risk varices without previous variceal bleeding. METHODS The Cochrane Library, The Cochrane Hepato-Biliary Group Controlled Trials Register, MEDLINE, and EMBASE were searched for eligible trials. Manual searches were also performed for additional studies. Upper gastrointestinal bleeding, variceal bleeding, mortality, and adverse events were evaluated as end-points by meta-analysis. RESULTS Twelve randomized controlled trials with 1571 patients were included. Compared with the NSBB (propranolol or nadolol) or endoscopic therapy alone, all of the combined therapies did not demonstrate significant improvements in variceal bleeding, total upper gastrointestinal bleeding, and mortality. Only the combinations of isosorbide-mononitrate or spironolactone with NSBB tended to decrease the risk of variceal bleeding when compared with the use of NSBB alone (isosorbide-mononitrate plus NSBB vs NSBB: odds ratio = 0.67, 95% confidence interval 0.40-1.13, P = 0.13; spironolactone plus NSBB vs NSBB: odds ratio = 0.41, 95% confidence interval 0.10-1.69, P = 0.22). Adverse events were more frequently observed in the combined therapy groups. CONCLUSIONS Based on the available evidences, no combined therapy can be recommended as the first-line treatment for the primary prevention of variceal bleeding currently. Further studies with large sample sizes and long-term follow up are warranted.
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Affiliation(s)
- Ming Bai
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
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Dell'Era A, Iannuzzi F, Fabris FM, Fontana P, Reati R, Grillo P, Aghemo A, de Franchis R, Primignani M. Impact of portal vein thrombosis on the efficacy of endoscopic variceal band ligation. Dig Liver Dis 2014; 46:152-6. [PMID: 24084343 DOI: 10.1016/j.dld.2013.08.138] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 08/11/2013] [Accepted: 08/20/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Influence of portal vein thrombosis on efficacy of endoscopic variceal banding in patients with cirrhosis or extrahepatic portal vein obstruction has never been evaluated. Aim of the study was to assess influence of thrombosis on rate and time to eradication in cirrhosis and extrahepatic portal vein obstruction undergoing banding, compared to cirrhotic patients without thrombosis. METHODS Retrospective analysis of 235 consecutive patients (192 with cirrhosis without thrombosis, 22 cirrhosis and thrombosis and 21 extrahepatic portal vein obstruction) who underwent banding. Banding was performed every 2-3 weeks until eradication; endoscopic follow-up was performed at 1, 3, 6 months, then annually. RESULTS Eradication was achieved in 233 patients. Median time to eradication in cirrhotic patients with portal vein thrombosis vs. cirrhotic patients without thrombosis was 50.9 days (12-440) vs. 43.4 days (13-489.4); log-rank: 0.04; patients with extrahepatic portal vein obstruction vs. cirrhotic patients without thrombosis 63.9 days (31-321.6) vs. 43.4 days (13.0-489.4); log-rank: 0.008. Thrombosis was shown to be the only risk factor for longer time to eradication. CONCLUSIONS Portal vein thrombosis per se appears to be the cause of a longer time to achieve eradication of varices but, once eradication is achieved, it does not influence their recurrence.
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Affiliation(s)
- Alessandra Dell'Era
- Department of Medical Sciences, Università degli Studi di Milano - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy; Gastroenterology 3 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy.
| | - Francesca Iannuzzi
- Department of Medical Sciences, Università degli Studi di Milano - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy; Gastroenterology 3 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Federica M Fabris
- Gastroenterology 3 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Paola Fontana
- Department of Medical Sciences, Università degli Studi di Milano - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy; Gastroenterology 3 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Raffaella Reati
- Department of Medical Sciences, Università degli Studi di Milano - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy; Gastroenterology 3 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Paolo Grillo
- Epidemiology Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Alessio Aghemo
- Gastroenterology 1 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Roberto de Franchis
- Department of Medical Sciences, Università degli Studi di Milano - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy; Gastroenterology 3 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Massimo Primignani
- Gastroenterology 3 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
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Liu X, Li M. Efficacy and safety of three different methods for primary prophylaxis of variceal bleeding in cirrhosis. Shijie Huaren Xiaohua Zazhi 2014; 22:253-258. [DOI: 10.11569/wcjd.v22.i2.253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the efficacy and safety of endoscopic variceal ligation (EVL), propranolol and EVL plus propranolol for the primary prophylaxis of first variceal bleeding in cirrhosis.
METHODS: We chose 90 patients with cirrhosis and esophageal varices at a high risk of bleeding and divided them into EVL (n = 30), propranolol (n = 30) and combination (n = 30) groups. Treatment effectiveness and side effects in the 3 groups were compared.
RESULTS: The three groups of patients had comparable baseline characteristics and follow-up time (EVL: 19.9 mo ± 7.2 mo; propranolol: 19.3 mo ± 6.7 mo; combination: 21.4 mo ± 5.3 mo). There were no significant differences in average ligation times between the EVL group and combination group (2.2 ± 1.2 vs 2.0 ± 0.9, P > 0.05), mean daily propranolol dose between the propranolol group and combination group(75.6 mg ± 23.4 mg vs 68.8 mg ± 30.5 mg, P > 0.05), rate of first variceal bleeding and bleeding-related mortality (10.0%, 16.7% vs 6.6%, both P > 0.05) or incidence of portal hypertensive gastropathy between the three groups (16.7%, 6.6% vs 10.0%, both P > 0.05). The incidence of complications and adverse reactions was significantly different between the three groups (50.0%, 26.7% vs 56.7%, both P < 0.05), but no serious complications or adverse reactions occurred. The difference in variceal recurrence rate was significant between the EVL group and combination group (26.7% vs 6.6%, P = 0.04).
CONCLUSION: EVL, propranolol and EVL plus propranolol are effective and safe in primary prophylaxis of bleeding due to high-risk varices. The adverse effects caused by propranolol are minimal. The recurrence of varices is lower if propranolol is added to EVL, but without much more adverse reactions.
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de Franchis R, Dell’Era A. Pre-primary and Primary Prophylaxis of Variceal Hemorrhage. VARICEAL HEMORRHAGE 2014. [PMCID: PMC7121476 DOI: 10.1007/978-1-4939-0002-2_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Variceal hemorrhage is a life-threatening complication of portal hypertension. Thus, prevention of variceal formation (pre-primary prophylaxis) or at least prevention of variceal bleeding are important goals to improve life quality and—if possible—survival of patients with liver cirrhosis. Interruption of the underlying cause of liver disease is the most successful approach, which, however, often fails. For this situation interruption or modulation of different pathophysiological mechanisms leading to fibrosis, hyperdynamic circulation and portal hypertension have been shown effective in animal models. But few could be translated to humans. By contrast, different steps to prevent first bleeding from varices have proven successful in many clinical trials. These applied mainly drugs to lower portal pressure, such as nonselective β-blockers, or endoscopic obliteration of varices, while prophylactic shunt procedures are not advised.
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Affiliation(s)
| | - Alessandra Dell’Era
- Ospedale Universitario Luigi Sacco, Universitá degli Studi di Milano, UOC Gastroenterologia, Milano, Italy
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Ishigami M, Onishi Y, Kamei H, Kiuchi T, Katano Y, Itoh A, Hirooka Y, Goto H. Impact of recipient age and preoperative fasting blood glucose level as the risk factors of living donor liver transplantation in cirrhotic patients in the recent comprehensive era with knowledge of indications: Recent status in a Japanese single center. Hepatol Res 2013; 43:1148-55. [PMID: 23413786 DOI: 10.1111/hepr.12067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 12/17/2012] [Accepted: 01/03/2013] [Indexed: 12/15/2022]
Abstract
AIM Recently, knowledge for indications of living donor liver transplantation (LDLT) has been robustly accumulated in. For further improvement, risks should be reexamined in recent cases. In this study, we investigated preoperative risk factors in cirrhotic patients who underwent LDLT in recent era. METHODS Seventy-four cirrhotic patients who underwent LDLT at our institution between 2003 and 2011 were included. Recipient and donor age and sex, existence of hepatocellular carcinoma (HCC), preoperative Model for End-Stage Liver Disease score, fasting blood glucose (FBG), triglyceride, total cholesterol, serum creatinine, hemoglobin A1c, graft : recipient weight ratio, ABO compatibility and choice of calcineurin inhibitor were analyzed. A proportional hazard model was applied and P < 0.05 was considered statistically significant. RESULTS In multivariate analysis, recipient age (hazard ratio = 1.188, P = 0.011) and FBG (hazard ratio = 1.009, P = 0.016) showed as significant independent factors. Theoretical mortalities were 9.2%, 21.9% and 51.7% in patients with normal FBG at 55, 60 and 65 years old, respectively, and 34.3% and 53.6% in patients with FBG of 150 and 200 mg/dL, respectively, at 60 years old. CONCLUSION Recipient age and FBG remain important risk factors for LDLT in cirrhotic patients even in the recent era. These factors should be considered for selecting liver transplant candidates in cirrhotic patients.
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Affiliation(s)
- Masatoshi Ishigami
- Department of Gastroenterology, Nagoya University School of Medicine, Nagoya, Japan
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Reiberger T, Ulbrich G, Ferlitsch A, Payer BA, Schwabl P, Pinter M, Heinisch BB, Trauner M, Kramer L, Peck-Radosavljevic M. Carvedilol for primary prophylaxis of variceal bleeding in cirrhotic patients with haemodynamic non-response to propranolol. Gut 2013; 62:1634-41. [PMID: 23250049 DOI: 10.1136/gutjnl-2012-304038] [Citation(s) in RCA: 195] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Non-selective β-blockers or endoscopic band ligation (EBL) are recommended for primary prophylaxis of variceal bleeding in patients with oesophageal varices. Additional α-adrenergic blockade (as by carvedilol) may increase the number of patients with haemodynamic response (reduction in hepatic venous pressure gradient (HVPG) of ≥ 20% or to values <12 mm Hg). DESIGN Patients with oesophageal varices undergoing measurement of HVPG before and under propranolol treatment (80-160 mg/day) were included. HVPG responders were kept on propranolol (PROP group), while non-responders were placed on carvedilol (6.25-50 mg/day). Carvedilol responders continued treatment (CARV group), while non-responders to carvedilol underwent EBL. The primary aim was to assess haemodynamic response rates to carvedilol in propranolol non-responders. RESULTS 36% (37/104) of patients showed a HVPG response to propranolol. Among the propranolol non-responders 56% (38/67) eventually achieved a haemodynamic response with carvedilol, while 44% (29/67) patients were finally treated with EBL. The decrease in HVPG was significantly greater with carvedilol (median 12.5 mg/day) than with propranolol (median 100 mg/day): -19 ± 10% versus -12 ± 11% (p<0.001). During a 2 year follow-up bleeding rates for PROP were 11% versus CARV 5% versus EBL 25% (p=0.0429). Fewer episodes of hepatic decompensation (PROP 38%/CARV 26% vs EBL 55%; p=0.0789) and significantly lower mortality (PROP 14%/CARV 11% vs EBL 31%; p=0.0455) were observed in haemodynamic responders compared to the EBL group. CONCLUSIONS Carvedilol leads to a significantly greater decrease in HVPG than propranolol. Using carvedilol for primary prophylaxis a substantial proportion of non-responders to propranolol can achieve a haemodynamic response, which is associated with improved outcome with regard to prevention of variceal bleeding, hepatic decompensation and death.
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Affiliation(s)
- Thomas Reiberger
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, , Vienna, Austria
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Turon F, Casu S, Hernández-Gea V, Garcia-Pagán JC. Variceal and other portal hypertension related bleeding. Best Pract Res Clin Gastroenterol 2013; 27:649-64. [PMID: 24160925 DOI: 10.1016/j.bpg.2013.08.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 08/11/2013] [Indexed: 02/06/2023]
Abstract
Variceal bleeding is one of the commonest and most severe complications of liver cirrhosis. Even with the current best medical care, mortality from variceal bleeding is still around 20%. When cirrhosis is diagnosed, varices are present in about 30-40% of compensated patients and in 60% of those who present with ascites. Once varices have been diagnosed, the overall incidence of variceal bleeding is in the order of 25% at two years. Variceal size is the most useful predictor for variceal bleeding, other predictors are severity of liver dysfunction (Child-Pugh classification) and the presence of red wale marks on the variceal wall. The current consensus is that every cirrhotic patient should be endoscopically screened for varices at the time of diagnosis to detect those requiring prophylactic treatment. Non-selective beta-adrenergic blockers (NSBB) and endoscopic band ligation (EBL) have been shown effective in the prevention of first variceal bleeding. The current recommendation for treating acute variceal bleeding is to start vasoactive drug therapy early (ideally during the transferral or to arrival to hospital, even if active bleeding is only suspected) and performing EBL. Once bleeding is controlled, combination therapy with NSBB + EBL should be used to prevent rebleeding. In patients at high risk of treatment failure despite of using this approach, an early covered-TIPS within 72 h (ideally 24 h) should be considered. Data on management of gastric variceal bleeding is limited. No clear recommendation for primary prophylaxis can be done. In acute cardiofundal variceal bleeding, vasoactive agents together with cyanoacrylate (CA) injection seem to be the treatment of choice. Further CA injections and/or NSBB may be used to prevent rebleeding. TIPS or Balloon-occluded retrograde transvenous obliteration when TIPS is contraindicated may be used as a rescue therapy.
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Affiliation(s)
- Fanny Turon
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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Duché M, Ducot B, Ackermann O, Baujard C, Chevret L, Frank-Soltysiak M, Jacquemin E, Bernard O. Experience with endoscopic management of high-risk gastroesophageal varices, with and without bleeding, in children with biliary atresia. Gastroenterology 2013; 145:801-7. [PMID: 23792202 DOI: 10.1053/j.gastro.2013.06.022] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 06/05/2013] [Accepted: 06/15/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Biliary atresia, the most common cause of childhood cirrhosis, increases the risks for portal hypertension and gastrointestinal bleeding. We report the results from a single-center study of primary and secondary prophylaxis of bleeding in children with portal hypertension and high-risk varices. METHODS We collected data from 66 children with major endoscopic signs of portal hypertension, including grade 3 esophageal varices or grade 2 varices with red wale markings and/or gastric varices, treated consecutively from February 2001 through May 2011. Thirty-six children (mean age, 22 mo) underwent primary prophylaxis (sclerotherapy and/or banding, depending on age and weight). Thirty children (mean age, 24 mo) who presented with gastrointestinal bleeding received endoscopic treatment to prevent a relapse of bleeding (secondary prophylaxis). RESULTS In the primary prophylaxis group, a mean number of 4.2 sessions were needed to eradicate varices; no bleeding from gastroesophageal varices was observed after eradication. Varices reappeared in 37% of children, and 97% survived for 3 years. In the secondary prophylaxis group, a mean number of 4.6 sessions was needed to eradicate varices. Varices reappeared in 45%, and 10% had breakthrough bleeding; 84% survived for 3 years. There were no or only minor complications of either form of prophylaxis. CONCLUSIONS Endoscopic therapy as primary or secondary prophylaxis of bleeding appears to be well tolerated and greatly reduces the risk of variceal bleeding in children with biliary atresia and high-risk gastroesophageal varices. However, there is a risk that varices will recur, therefore continued endoscopic surveillance is needed.
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Affiliation(s)
- Mathieu Duché
- Hépatologie Pédiatrique and Centre de Référence National de l'Atrésie des Voies Biliaires, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France; Université Paris-Sud 11, Le Kremlin-Bicêtre, France; Radiologie Pédiatrique, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
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Dessouky BAM, Abdel Aal ESM. Multidetector CT oesophagography: an alternative screening method for endoscopic diagnosis of oesophageal varices and bleeding risk. Arab J Gastroenterol 2013; 14:99-108. [PMID: 24206737 DOI: 10.1016/j.ajg.2013.08.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 04/21/2013] [Accepted: 08/26/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND STUDY AIMS Variceal bleeding is a frequent and life-threatening complication of portal hypertension. The aim of this study was to evaluate multidetector computed tomographic (MDCT) oesophagography as an alternative to endoscopy for screening oesophageal varices (EVs) and predicting bleeding risk. PATIENTS AND METHODS A total of 137 cirrhotic patients underwent MDCT followed by endoscopy and EVs were graded independently. The screening ability of CT for EV was evaluated by comparing the grades of EV at CT and at endoscopy. Prediction of bleeding risk by CT was determined by correlating the CT variceal grades, diameters and palisade vein dilatation with the endoscopic red colour (RC) sign. Extra-oesophageal findings were assessed by CT. Patients' acceptance for both examinations were compared. RESULTS At endoscopy, 47 (34%) patients had grade 0 EV, 52 (38%) patients had grade 1 EV, 29 (21%) patients had grade 2 EV and nine (7%) patients had grade 3 EV. The sensitivity, specificity, positive and negative predictive values and accuracy of CT oesophagography for defining EV in all grades were 99%, 98%, 99%, 98% and 99%, respectively. The MDCT variceal grades, diameters and palisade vein dilatation were correlated with the severity of the RC sign. Important extra-oesophageal findings were determined by CT only. The acceptance of patients for CT oesophagography was significantly more than that for endoscopy (p<0.001). CONCLUSION MDCT is a reliable, preliminary or adjunctive method that can be used for routine screening for EVs and the prediction of variceal bleeding.
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