Child-Turcotte-Pugh Class is Best at Stratifying Risk in Variceal Hemorrhage: Analysis of a US Multicenter Prospective Study

Full adherence to cirrhosis quality indicators is associated with lower mortality in acute variceal bleeding: Nationwide audit

BACKGROUND AND AIMS

Acute variceal bleeding (AVB) is a major complication in patients with cirrhosis. Using a nationwide AVB audit, we performed a nested cohort study to determine whether full adherence to the AVB quality indicator (QI) improves clinical outcomes in patients with cirrhosis and AVB.

APPROACH AND RESULTS

We assessed real-world adherence to AVB QI among patients with cirrhosis admitted for AVB in all public hospitals in Singapore between January 2015 and December 2020. Full adherence was considered when all 5 QIs were fulfilled: prophylactic antibiotics, vasoactive agents, timely endoscopy, endoscopic hemostasis during index endoscopy, and nonselective beta-blockers after AVB. We compare 6-week mortality between the full adherence and suboptimal adherence groups using a propensity-matched cohort.A total of 989 patients with AVB were included. Full adherence to all AVB QI was suboptimal (56.5%). Analysis of the propensity-matched cohort with comparable baseline characteristics showed that full adherence was associated with a lower risk of early infection (20.0% vs. 26.9%), early rebleeding (5.2% vs. 10.2%), and mortality at 6 weeks (8.2% vs. 19.7%) and 1 year (21.3% vs. 35.4%) ( p <0.05 for all). While full adherence was associated with a lower 6-week mortality regardless of the MELD score, nonadherence was associated with a higher 6-week mortality despite a lower predicted risk of 6-week mortality. Despite high adherence to the recommended process measures, patients with CTP-C remain at a higher risk of rebleeding, 6-week and 1-year mortality.

CONCLUSIONS

Full adherence to the AVB QI should be the target for quality improvement in patients with cirrhosis.

The impact of restrictive blood transfusion on the safety of patients with esophageal varices after endoscopic variceal ligation: A single-center retrospective study

An investigation was conducted to examine the impact of restrictive blood transfusion on the safety of early rebleeding following endoscopic variceal ligation (EVL) in patients with liver cirrhosis. Data were collected from patients with cirrhosis and esophageal varices who underwent EVL at the Affiliated Hospital of North Sichuan Medical College between September 2021 and March 2023. Clinical information, including serum albumin levels, hemoglobin (Hb) levels, liver function classification, and the occurrence of early rebleeding, was recorded. Patients were divided into 2 groups based on their Hb levels: 60 g/L to 90 g/L (restrictive blood transfusion) or Hb ≥ 90 g/L after EVL. The impact of restrictive transfusion on the post-ligation safety of EVL was observed. A total of 246 cirrhotic patients were included in the analysis. Significant differences were found in Hb levels, liver function classification, early rebleeding rates, length of hospital stay, and hospitalization expenses between the restrictive transfusion and Hb ≥ 90 g/L groups. The early rebleeding rate was significantly varied between the groups with different Hb levels after EVL. Multivariate logistic analysis revealed that restrictive blood transfusion (OR = 4.61, 95% CI: 1.06-19.99; P = .041), Hb (OR = 0.96, 95% CI: 0.95-0.97; P < .001), and Child-Pugh class C (OR = 6.37, 95% CI: 1.28-31.67; P = .024) were identified as independent factors influencing early rebleeding. Our findings suggest that the risk of early rebleeding in cirrhotic patients after EVL may be increased by restrictive blood transfusion, and this should be further investigated in future research.

A Novel Nomogram for Predicting Early Rebleeding After Endoscopic Treatment of Esophagogastric Variceal Hemorrhage

BACKGROUND

Early rebleeding is a significant complication of endoscopic treatment for esophagogastric variceal hemorrhage (EGVH). However, a reliable predictive model is currently lacking.

AIMS

To identify risk factors for rebleeding within 6 weeks and establish a nomogram for predicting early rebleeding after endoscopic treatment of EVGH.

METHODS

Demographic information, comorbidities, preoperative evaluation, endoscopic features, and laboratory tests were collected from 119 patients who were first endoscopic treatment for EGVH. Independent risk factors for early rebleeding were determined through least absolute shrinkage and selection operator logistic regression. The discrimination, calibration, and clinical utility of the nomogram were assessed and compared with the model for end-stage liver disease (MELD), Child-Pugh, and albumin-bilirubin (ALBI) scores using receiver-operating characteristic (ROC) curves, calibration plots, and decision curve analyses (DCA).

RESULTS

Early rebleeding occurred in 39 patients (32.8%) within 6 weeks after endoscopic treatment. Independent early rebleeding factors included gastric variceal hemorrhage (GVH), concomitant hepatocellular carcinoma (HCC), international normalized ratio (INR), and creatinine. The nomogram demonstrated exceptional calibration and discrimination capability. The area under the curve for the nomogram was 0.758 (95% CI 0.668-0.848), and it was validated at 0.71 through cross-validation and bootstrapping validation. The DCA and ROC curves demonstrated that the nomogram outperformed the MELD, Child-Pugh, and ALBI scores.

CONCLUSIONS

Compared with existing prediction scores, the nomogram demonstrated superior discrimination, calibration, and clinical applicability for predicting rebleeding in patients with EGVH after endoscopic treatment. Therefore, it may assist clinicians in the early implementation of aggressive treatment and follow-up.

Prognostic value of virtual portal pressure gradient response in compensated cirrhotic patients treated with carvedilol

AIM

This study aimed to assess the prognostic significance of virtual portal pressure gradient (vPPG) response to carvedilol in patients with compensated cirrhosis (CC).

METHODS

Compensated cirrhosis patients with high-risk varices were prospectively enrolled to receive carvedilol for prevention of first variceal hemorrhage (VH) and followed up for 1 year. The vPPG response was defined as a reduction of vPPG >10% from baseline after 1-month therapy. Logistic and Cox regression analyses were performed to identify independent predictors for vPPG response and first decompensation, respectively. Competitive risk models were constructed to predict disease progression, and validated using the C-index, Kaplan-Meier analysis, competitive risk analysis, and calibration curves.

RESULTS

A total of 129 patients completed this study, of whom 56 (43.4%) achieved vPPG response and were referred as vPPG responders. Baseline vPPG, red color sign, Model for End-stage Liver Disease score, serum monocyte chemoattractant protein-1 (MCP-1), and laminin levels significantly correlated with vPPG response, which itself was further documented as an independent predictor of VH, ascites, and overall decompensation events in CC. Moreover, the red color sign or Child-Turcotte-Pugh score effectively predicted VH, while ascites correlated well with portal flow velocity or MCP-1. The predictive models for VH and ascites showed a good discrimination with C-index values of 0.747 and 0.689 respectively, and the high consistency on calibration curves.

CONCLUSION

The vPPG response could be used as a noninvasive tool for prediction of disease progression in patients with CC.

Development and validation of a prognostic score to identify the optimal candidate for preemptive TIPS in patients with cirrhosis and acute variceal bleeding

BACKGROUND AND AIM

Baveno VII workshop recommends the use of preemptive TIPS (p-TIPS) in patients with cirrhosis and acute variceal bleeding (AVB) at high- risk of treatment failure. However, the criteria defining "high-risk" have low clinical accessibility or include subjective variables. We aimed to develop and externally validate a model for better identification of p-TIPS candidates.

APPROACH AND RESULTS

The derivation cohort included 1554 patients with cirrhosis and AVB who were treated with endoscopy plus drug (n = 1264) or p-TIPS (n = 290) from 12 hospitals in China between 2010 and 2017. We first used competing risk regression to develop a score for predicting 6-week and 1-year mortality in patients treated with endoscopy plus drugs, which included age, albumin, bilirubin, international normalized ratio, white blood cell, creatinine, and sodium. The score was internally validated with the bootstrap method, which showed good discrimination (6 wk/1 y concordance-index: 0.766/0.740) and calibration, and outperformed other currently available models. In the second stage, the developed score was combined with treatment and their interaction term to predicate the treatment effect of p-TIPS (mortality risk difference between treatment groups) in the whole derivation cohort. The estimated treatment effect of p-TIPS varied substantially among patients. The prediction model had good discriminative ability (6 wk/1 y c -for-benefit: 0.696/0.665) and was well calibrated. These results were confirmed in the validation dataset of 445 patients with cirrhosis with AVB from 6 hospitals in China between 2017 and 2019 (6-wk/1-y c-for-benefit: 0.675/0.672).

CONCLUSIONS

We developed and validated a clinical prediction model that can help to identify individuals who will benefit from p-TIPS, which may guide clinical decision-making.

An imaging-based machine learning model outperforms clinical risk scores for prognosis of cirrhotic variceal bleeding

OBJECTIVES

To develop and validate a machine learning model based on contrast-enhanced CT to predict the risk of occurrence of the composite clinical endpoint (hospital-based intervention or death) in cirrhotic patients with acute variceal bleeding (AVB).

METHODS

This retrospective study enrolled 330 cirrhotic patients with AVB between January 2017 and December 2020 from three clinical centers. Contrast-enhanced CT and clinical data were collected. Centers A and B were divided 7:3 into a training set and an internal test set, and center C served as a separate external test set. A well-trained deep learning model was applied to segment the liver and spleen. Then, we extracted 106 original features of the liver and spleen separately based on the Image Biomarker Standardization Initiative (IBSI). We constructed the Liver-Spleen (LS) model based on the selected radiomics features. The performance of LS model was evaluated by receiver operating characteristics and calibration curves. The clinical utility of models was analyzed using decision curve analyses (DCA).

RESULTS

The LS model demonstrated the best diagnostic performance in predicting the composite clinical endpoint of AVB in patients with cirrhosis, with an AUC of 0.782 (95% CI 0.650-0.882) and 0.789 (95% CI 0.674-0.878) in the internal test and external test groups, respectively. Calibration curves and DCA indicated the LS model had better performance than traditional clinical scores.

CONCLUSION

A novel machine learning model outperforms previously known clinical risk scores in assessing the prognosis of cirrhotic patients with AVB CLINICAL RELEVANCE STATEMENT: The Liver-Spleen model based on contrast-enhanced CT has proven to be a promising tool to predict the prognosis of cirrhotic patients with acute variceal bleeding, which can facilitate decision-making and personalized therapy in clinical practice.

KEY POINTS

• The Liver-Spleen machine learning model (LS model) showed good performance in assessing the clinical composite endpoint of cirrhotic patients with AVB (AUC ≥ 0.782, sensitivity ≥ 80%). • The LS model outperformed the clinical scores (AUC ≤ 0.730, sensitivity ≤ 70%) in both internal and external test cohorts.

MELD, MELD 3.0, versus Child score to predict mortality after acute variceal hemorrhage: A multicenter US cohort

BACKGROUND

Acute variceal hemorrhage is a major decompensating event in patients with cirrhosis and is associated with high 6-week mortality risk. Many prognostic models based on clinical and laboratory parameters have been developed to risk stratify patients on index bleeding presentation, including those based on the Model for End-Stage Liver Disease (MELD) and Child-Turcotte-Pugh (CTP). However, consensus on model performance remains unclear.

METHODS

Using a large US multicenter cohort of hospitalized patients with cirrhosis who presented with acute variceal hemorrhage, this study evaluates, recalibrates, and compares liver severity index-based models, including the more recent MELD 3.0 model, to investigate their predictive performance on 6-week mortality. Models were also recalibrated and externally validated using additional external centers.

RESULTS

All recalibrated MELD-based and CTP-based models had excellent discrimination to identify patients at higher risk for 6-week mortality on initial presentation. The recalibrated CTP score model maintained the best calibration and performance within the validation cohort. Patients with low CTP scores (Class A, score 5-6) were strongly associated with < 5% mortality, while high CTP score (Class C, score > 9) were associated with > 20% mortality.

CONCLUSION

Use of liver severity index-based models accurately predict 6-week mortality risk for patients admitted to the hospital with acute variceal hemorrhage and supports the utilization of these models in future clinical trials as well as their use in clinical practice.

Management of the acute on chronic liver failure in the intensive care unit

Acute on chronic liver failure (ACLF) reflects the development of organ failure(s) in a patient with cirrhosis and is associated with high short-term mortality. Given that ACLF has many different 'phenotypes', medical management needs to take into account the relationship between precipitating insult, organ systems involved and underlying physiology of chronic liver disease/cirrhosis. The goals of intensive care management of patients suffering ACLF are to rapidly recognize and treat inciting events (e.g. infection, severe alcoholic hepatitis and bleeding) and to aggressively support failing organ systems to ensure that patients may successfully undergo liver transplantation or recovery. Management of these patients is complex since they are prone to develop new organ failures and infectious or bleeding complications. ICU therapy parallels that applied in the general ICU population in some complications but differs in others. Given that liver transplantation in ACLF is an emerging and evolving field, multidisciplinary teams with expertise in critical care and transplant medicine best accomplish management of the critically ill ACLF patient. The focus of this review is to identify the common complications of ACLF and to describe the proper management in critically ill patients awaiting liver transplantation in our centres, including organ support, prognostic assessment and how to assess when recovery is unlikely.

Risk stratification based on acute-on-chronic liver failure in cirrhotic patients hospitalized for acute variceal bleeding

BACKGROUND AND AIMS

Acute variceal bleeding (AVB) is a life-threatening complication of cirrhosis. Acute-on-chronic liver failure (ACLF) is a syndrome characterized by acute decompensation of cirrhosis, multiple organ failures and high short-term mortality. This study aimed to evaluate the role of ACLF in the risk stratification of cirrhotic patients with AVB.

METHODS

Prospective data of 335 cirrhotic patients hospitalized for AVB were retrospectively extracted from Medical Information Mart for Intensive Care (MIMIC)-IV database. ACLF was defined by European Association for the Study of Liver-Chronic Liver Failure Consortium and diagnosed/graded with chronic liver failure-organ failure (CLIF-OF) score. Cox-proportional hazards regression analysis was performed to identify the risk factors for 6-week morality in AVB patients. Discrimination and calibration of prognostic scores were evaluated by plotting the receiver operating characteristics (ROC) curve and calibration curve, respectively. Overall performance was assessed by calculating the Brier score and R² value.

RESULTS

A total of 181 (54.0%) patients were diagnosed with ACLF (grade 1: 18.2%, grade 2: 33.7%, grade 3: 48.1%) at admission. The 6-week mortality in patients with ACLF was significantly higher than that in patients without ACLF (43.6% vs. 8.4%, P < 0.001) and increased in line with the severity of ACLF (22.5%, 34.2% and 63.8% for ACLF grade 1, 2 and 3, P < 0.001). In multivariate analysis, presence of ACLF remained as an independent risk factor for 6-week mortality after adjusting for confounding factors (HR = 2.12, P = 0.03). The discrimination, calibration and overall performance of CLIF-C ACLF and CLIF-C AD were superior to the traditional prognostic scores (CTP, MELD and MELD-Na) in the prediction of 6-week mortality of patients with and without ACLF, respectively.

CONCLUSION

The prognosis of cirrhotic patients with AVB is poor when accompanied by ACLF. ACLF at admission is an independent predictor for the 6-week mortality in cirrhotic patients with AVB. CLIF-C ACLF and CLIF-C AD are the best prognostic scores in AVB patients with and without ACLF, respectively, and can be used for the risk stratification of these two distinct entities.

Diagnosis and Management of Esophagogastric Varices

Acute variceal bleeding (AVB) is a potentially fatal complication of clinically significant portal hypertension and is one of the most common causes of acute upper gastrointestinal bleeding. Thus, esophagogastric varices represent a major economic and population health issue. Patients with advanced chronic liver disease typically undergo an upper endoscopy to screen for esophagogastric varices. However, upper endoscopy is not recommended for patients with liver stiffness < 20 KPa and platelet count > 150 × 10⁹/L as there is a low probability of high-risk varices. Patients with high-risk varices should receive primary prophylaxis with either nonselective beta-blockers or endoscopic band ligation. In cases of AVB, patients should receive upper endoscopy within 12 h after resuscitation and hemodynamic stability, whereas endoscopy should be performed as soon as possible if patients are unstable. In cases of suspected variceal bleeding, starting vasoactive therapy as soon as possible in combination with endoscopic treatment is recommended. On the other hand, in cases of uncontrolled bleeding, balloon tamponade or self-expandable metal stents can be used as a bridge to more definitive therapy such as transjugular intrahepatic portosystemic shunt. This article aims to offer a comprehensive review of recommendations from international guidelines as well as recent updates on the management of esophagogastric varices.

Development and validation of a practical prognostic nomogram for evaluating inpatient mortality of cirrhotic patients with acute variceal hemorrhage

INTRODUCTION AND OBJECTIVES

Cirrhotic patients with acute variceal hemorrhage (AVH) have high short-term mortality. Established prognostic scores are seldom applicable clinically, partially because they need external validation or contain subjective variables. We aimed to develop and validate a practical prognostic nomogram based on objective predictors to predict prognosis for cirrhotic patients with AVH.

PATIENTS AND METHODS

We enrolled 308 AVH patients with cirrhosis from our center as the derivation cohort to develop a new nomogram using logistic regression and validated it in cohorts of patients from Medical Information Mart for Intensive Care (MIMIC) III (n = 247) and IV (n = 302).

RESULTS

International normalized ratio (INR), albumin (ALB) and estimated glomerular filtration rate (eGFR) were identified as predictors for inpatient mortality and a nomogram was constructed based on them. The nomogram discriminated well in both derivation and MIMIC-III/-IV validation cohorts with the area under the receiver operating characteristic curves (AUROCs) of 0.846 and 0.859/0.833, respectively and showed a better agreement between expected and observed outcomes (Hosmer-Lemeshow tests, all comparisons, P > 0.05) than other scores in all cohorts. Our nomogram had the lowest Brier scores (0.082/0.114/0.119 in training/MIMIC-III/MIMIC-IV) and highest R² (0.367/0.393/0.346 in training/MIMIC-III/MIMIC-IV) compared to the recalibrated model for end-stage liver disease (MELD), MELD-hepatic encephalopathy (MELD-HE) and cirrhosis acute gastrointestinal bleeding (CAGIB) scores in all cohorts.

CONCLUSIONS

We developed a practical prognostic nomogram using easily verified indicators available in initial patient evaluation, which may serve as a reliable tool to accurately predict inpatient mortality for cirrhotic patients with AVH.

Anticoagulation therapy early is safe in portal vein thrombosis patients with acute variceal bleeding: a multi-centric randomized controlled trial

Portal vein thrombosis (PVT) and acute variceal bleeding (AVB) are frequent complications of cirrhosis. The efficacy, safety, and timing of anticoagulant treatment in cirrhotic patients with PVT and AVB are contentious issues. We aimed to establish the safety and efficacy of initiating nadroparin calcium-warfarin sequential (NWS) anticoagulation therapy early after esophageal variceal band ligation within PVT patients having cirrhosis and AVB. Cirrhotic patients having AVB and PVT who underwent EVL were included and randomly allocated to either the NWS therapy group (1-month nadroparin calcium by subcutaneous injection following 5-month warfarin through oral administration, n = 43) or the control group (without any anticoagulation therapy, n = 43). The primary endpoint was the rate of PVT recanalization. Secondary endpoints included major bleeding events mainly referring to variceal rebleeding (5-day failure, 14-day, 4-week, 6-week, and 6-month rebleeding rates) and mortality after EVL. The overall recanalization (complete and partial) rate in the NWS therapy group was significantly higher than that in the control group (67.4% vs. 39.5%, P = 0.009). Low Child-Pugh score (P = 0.039, OR: 0.692, 95% CI 0.488-0.982), D-dimer < 2.00 ug/mL (P = 0.030, OR: 3.600, 95% CI 1.134-11.430), and NWS anticoagulation therapy (P = 0.002, OR: 4.189, 95% CI 1.660-10.568) were the predictors of PVT recanalization through univariate analysis of binary logistic regression. NWS anticoagulation therapy (P = 0.003, OR: 4.506, 95% CI 1.687-12.037) was the independent factor of recanalization through multivariate analysis. Nobody bled except for variceal rebleeding. Five-day failure and 14-day rebleeding were zero. There were no significantly different in 4-week (2.3% vs. 4.7%, P = 1.000), 6-week (4.7% vs. 9.3%, P = 0.672) and 6-month rebleeding (18.6% vs. 20.9%, P = 0.787) between the two groups. There was no mortality during six months follow-up. Low serum albumin (P = 0.011, OR: 0.844, 95% CI 0.741-0.962), high MELD score (P = 0.003, OR: 1.564, 95% CI 1.167-2.097) and Child-Pugh score (P = 0.006, OR: 1.950, 95% CI 1.206-3.155) were predictors of rebleeding by univariate analysis of binary logistic regression analysis. The Child-Pugh score (7 [6-8] vs. 6 [5-7], P = 0.003) and albumin levels (33.93 ± 5.30 vs. 37.28 ± 4.32, P = 0.002) were improved in the NWS therapy group at six months. In PVT patients with cirrhosis and AVB, starting NWS anticoagulation therapy early after EVL was safe and effective. It has the potential to raise albumin levels and improve liver function.

External validation of Chronic Liver Failure-Consortium Acute Decompensation score in the risk stratification of cirrhotic patients hospitalized with acute variceal bleeding

BACKGROUND AND OBJECTIVE

Acute variceal bleeding (AVB) is a serious life-threatening complication of cirrhosis. This study aimed to validate the predictive value of Chronic Liver Failure-Consortium Acute Decompensation score (CLIF-C ADs) in the risk stratification of cirrhotic patients hospitalized with AVB.

METHODS

A total of 235 cirrhotic patients with AVB and without acute-on-chronic liver failure (ACLF) were retrospectively enrolled. The discrimination, calibration, overall performance and clinical utility of CLIF-C AD were evaluated and compared with traditional prognostic scores.

RESULTS

The area under the receiver operating characteristics curve of CLIF-C AD was significantly or numerically higher than that of Child-Turcotte-Pugh (CTP) (0.871 vs. 0.737, P  = 0.03), Model for End-stage Liver Disease (MELD) (0.871 vs. 0.757, P  = 0.1) and MELD-Sodium (MELD-Na) (0.871 vs. 0.822, P  = 0.45). The calibration of CLIF-C AD was excellent and superior to that of CTP, MELD and MELD-Na. The brier score/ R2 value for CLIF-C AD, CTP, MELD and MELD-Na were 0.045/0.278, 0.051/0.090, 0.050/0.123 and 0.046/0.207, respectively, suggesting a superior overall performance of CLIF-C AD to traditional scores. In decision curve analysis, the standardized net benefit of CLIF-C AD was higher to that of traditional scores. Patients with CLIF-C ADs ≤48, 49-59 and ≥60 were, respectively, stratified into low, moderate and high-risk groups (6-week mortality: 2.7% vs. 12.5% vs. 37.5%, P  < 0.001).

CONCLUSION

The prediction performance and clinical utility of CLIF-C AD for 6-week mortality in cirrhotic patients with AVB and without ACLF are excellent and superior to traditional prognostic scores. The new risk stratification with CLIF-C ADs may be useful in guiding rational management of AVB.

Liver Cirrhosis and Portal Hypertension

The understanding of pathogenesis of portal hypertension in patients with liver cirrhosis continues to evolve. In addition to progressive fibrosis, cirrhosis is characterized by parenchymal extinction and vascular remodelling, causing architectural distortion. Existence of prothrombotic state and more recently, intestinal bacterial dysbiosis are recently described in the pathogenesis of portal hypertension. Clinically significant portal hypertension (CSPH) is an important prognostic milestone in patients with liver cirrhosis. This is a pre-symptomatic phase that predicts the development of varices, ascites and importantly increased risk of Hepatocellular carcinoma (HCC). CSPH is associated with significantly reduced survival. Endoscopic surveillance is necessary in these patients. Non-selective Beta-blocker is the preferred therapy for primary prophylaxis in the management of portal hypertension. Patients with acute variceal bleed should be resuscitated appropriately, followed by vasoactive drugs and endoscopic therapy. Early TIPS should be considered in those with refractory bleed or in endoscopic treatment failure. Application of artificial intelligence and machine learning may be useful in future for identifying patients at risk of variceal hemorrhage.

Review article: the safety of anticoagulants and antiplatelet agents in patients with cirrhosis

Patients with cirrhosis were long thought to be coagulopathic. However, this paradigm has changed in recent years and currently, cirrhosis is recognised as a prothrombotic state. Due to the increasing incidence of cirrhosis from nonalcoholic steatohepatitis which is closely associated with cardiac disease, patients with cirrhosis increasingly require therapy with anticoagulants and antiplatelet agents. However, their potential for causing catastrophic and life-threatening bleeding in patients with cirrhosis leads to hesitancy about their use in patients with cirrhosis. Overall, traditional anticoagulation is safe for all Child-Pugh classes while newer direct oral anticoagulants (DOACs) are mostly safe in Child-Pugh class A/B and contraindicated in severe hepatic impairment. For different indications, published data to date suggest that anticoagulation is overall safe for patients with cirrhosis who have venous thromboembolism, atrial fibrillation and portal vein thrombosis, and does not increase the risk of variceal bleeding. Moreover, DOACs appear to have similar safety profiles as traditional anticoagulants. Finally, most studies suggest that antiplatelet agents are also safe to use in patients with cirrhosis although they are mostly contraindicated in severe hepatic impairment. For both anticoagulants and antiplatelet agents, severe thrombocytopaenia presents a relative contraindication to their use. More prospective trials and large cohort studies are needed to advance our understanding of the safety and nuances of DOACs and antiplatelet agents in patients with advanced cirrhosis.

Acute gastrointestinal bleeding: A comparison between variceal and nonvariceal gastrointestinal bleeding

Acute upper gastrointestinal bleeding (UGIB) is a typical medical emergency, with an incidence of 84 to 160 cases per 100,000 individuals and a mortality rate of approximately 10%. This study aimed to identify all cases of UGIB hospitalized in a tertiary gastroenterology department, to identify possible predictive factors involved in rebleeding and mortality, potential associations between different elements and the severity of bleeding, and the differences between the upper digestive hemorrhage due to nonvariceal and variceal bleeding. This was an observational, retrospective study of patients with UGIB admitted to the tertiary Department of Gastroenterology between January 2013 and December 2020. A total of 1499 patients were enrolled in the study. One thousand four hundred and ninety-nine patients were hospitalized for 7 years with active upper digestive hemorrhage, 504 variceal bleeding, and 995 nonvariceal bleeding. When comparing variceal with nonvariceal bleeding, in nonvariceal bleeding, the mean age was higher, similar sex, higher mortality rate, higher rebleeding rate, and higher hemorrhagic shock rate. Endoscopy treatment was also performed more frequently in variceal bleeding than in nonvariceal bleeding. Severe anemia was found more frequently in patients with variceal bleeding. The mortality rate was 10% in the entire study group, which was not significantly different between the 2 batches. However, the rebleeding rate is higher in patients with variceal gastrointestinal bleeding.

Child-Pugh Score, MELD Score and Glasgow Blatchford Score to Predict the In-Hospital Outcome of Portal Hypertensive Patients Presenting with Upper Gastrointestinal Bleeding: An Experience from Tertiary Healthcare System

The two most familiar scores used for prognostication of liver cirrhosis are the Model for End-stage Liver Disease (MELD) and Child-Turcotte-Pugh (CTP), while the Glasgow-Blatchford (GB) score is used for sorting non-variceal upper gastrointestinal hemorrhage into high- or low-risk categories. This study evaluates the validity of the CTP, MELD, and GB scoring systems in prognosticating the in-hospital outcome of bleeding portal hypertensive patients. In this study, the ROC curve and Younden index determine the efficacy of three scoring systems. The results indicate that CTP was the most efficient score as the predictor of outcome (AUC = 0.9, cut-off value > 7); followed by MELD (AUC = 0.8, cut-off value > 18) and then the GB score (AUC = 0.64, cut-off value > 14) (p < 0.05). In pair-wise comparison, the difference between CTP and MELD was insignificant (p > 0.05). Patients with a CTP score of >7 had notably higher in-hospital mortality (19.8% vs. 0.9%, p < 0.0001). Similarly, mortality with a MELD score > 18 was significant (14.8% vs. 5.9% (p < 0.0001). The GB score was not a good indicator of the outcome. Platelets, albumin, CTP, and MELD scores were the independent contributors to mortality. Thus, as liver cirrhosis prognosticators, CTP and MELD scores can also both be used as predictive scores of the in-hospital outcomes of bleeding patients due to portal hypertension. Compared to the GB score, CTP and MELD scores are fairly efficient predictors in these patients.

Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

1: ESGE recommends that patients with compensated advanced chronic liver disease (ACLD; due to viruses, alcohol, and/or nonobese [BMI < 30 kg/m²] nonalcoholic steatohepatitis) and clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] > 10 mmHg and/or liver stiffness by transient elastography > 25 kPa) should receive, if no contraindications, nonselective beta blocker (NSBB) therapy (preferably carvedilol) to prevent the development of variceal bleeding.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in those patients unable to receive NSBB therapy with a screening upper gastrointestinal (GI) endoscopy that demonstrates high risk esophageal varices, endoscopic band ligation (EBL) is the endoscopic prophylactic treatment of choice. EBL should be repeated every 2-4 weeks until variceal eradication is achieved. Thereafter, surveillance EGD should be performed every 3-6 months in the first year following eradication.Strong recommendation, moderate quality evidence. 3: ESGE recommends, in hemodynamically stable patients with acute upper GI hemorrhage (UGIH) and no history of cardiovascular disease, a restrictive red blood cell (RBC) transfusion strategy, with a hemoglobin threshold of ≤ 70 g/L prompting RBC transfusion. A post-transfusion target hemoglobin of 70-90 g/L is desired.Strong recommendation, moderate quality evidence. 4 : ESGE recommends that patients with ACLD presenting with suspected acute variceal bleeding be risk stratified according to the Child-Pugh score and MELD score, and by documentation of active/inactive bleeding at the time of upper GI endoscopy.Strong recommendation, high quality of evidence. 5 : ESGE recommends the vasoactive agents terlipressin, octreotide, or somatostatin be initiated at the time of presentation in patients with suspected acute variceal bleeding and be continued for a duration of up to 5 days.Strong recommendation, high quality evidence. 6 : ESGE recommends antibiotic prophylaxis using ceftriaxone 1 g/day for up to 7 days for all patients with ACLD presenting with acute variceal hemorrhage, or in accordance with local antibiotic resistance and patient allergies.Strong recommendation, high quality evidence. 7 : ESGE recommends, in the absence of contraindications, intravenous erythromycin 250 mg be given 30-120 minutes prior to upper GI endoscopy in patients with suspected acute variceal hemorrhage.Strong recommendation, high quality evidence. 8 : ESGE recommends that, in patients with suspected variceal hemorrhage, endoscopic evaluation should take place within 12 hours from the time of patient presentation provided the patient has been hemodynamically resuscitated.Strong recommendation, moderate quality evidence. 9 : ESGE recommends EBL for the treatment of acute esophageal variceal hemorrhage (EVH).Strong recommendation, high quality evidence. 10 : ESGE recommends that, in patients at high risk for recurrent esophageal variceal bleeding following successful endoscopic hemostasis (Child-Pugh C  ≤ 13 or Child-Pugh B > 7 with active EVH at the time of endoscopy despite vasoactive agents, or HVPG > 20 mmHg), pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours (preferably within 24 hours) must be considered.Strong recommendation, high quality evidence. 11 : ESGE recommends that, for persistent esophageal variceal bleeding despite vasoactive pharmacological and endoscopic hemostasis therapy, urgent rescue TIPS should be considered (where available).Strong recommendation, moderate quality evidence. 12 : ESGE recommends endoscopic cyanoacrylate injection for acute gastric (cardiofundal) variceal (GOV2, IGV1) hemorrhage.Strong recommendation, high quality evidence. 13: ESGE recommends endoscopic cyanoacrylate injection or EBL in patients with GOV1-specific bleeding.Strong recommendations, moderate quality evidence. 14: ESGE suggests urgent rescue TIPS or balloon-occluded retrograde transvenous obliteration (BRTO) for gastric variceal bleeding when there is a failure of endoscopic hemostasis or early recurrent bleeding.Weak recommendation, low quality evidence. 15: ESGE recommends that patients who have undergone EBL for acute EVH should be scheduled for follow-up EBLs at 1- to 4-weekly intervals to eradicate esophageal varices (secondary prophylaxis).Strong recommendation, moderate quality evidence. 16: ESGE recommends the use of NSBBs (propranolol or carvedilol) in combination with endoscopic therapy for secondary prophylaxis in EVH in patients with ACLD.Strong recommendation, high quality evidence.

Validating the prognostic value of Freiburg index of posttransjugular intrahepatic portosystemic shunt survival score and classic scores in Chinese patients with implantation of transjugular intrahepatic portosystemic shunt

BACKGROUND AND AIMS

It is important and challenging to evaluate the survival of cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt (TIPS). We aimed to validate the Freiburg index of post-TIPS survival (FIPS) score and classic scores for predicting mortality in Chinese patients after TIPS creation.

METHODS

A total of 709 consecutive patients with cirrhosis from December 2011 to July 2018 who underwent TIPS placement were retrospectively reviewed. The prognostic value of the FIPS score, the model for end-stage liver disease (MELD) score, Child-Pugh score and Chronic Liver Failure Consortium Acute Decompensation score was validated with the receiver operating characteristic (ROC) curve and DeLong et al. test.

RESULTS

The MELD-Na score was superior to the FIPS score in predicting 1-month mortality [AUROC, 0.727 (0.692-0.759) vs. 0.588 (0.551-0.625); P = 0.048]. The MELD and MELD-Na scores were significant superior to the FIPS score in predicting 3-month mortality [AUROC, 0.730 (0.696-0.762) vs. 0.598 (0.561-0.634); P = 0.044 and 0.740 (0.706-0.772) vs. 0.598 (0.561-0.634); P = 0.028]. Subgroup analyses revealed that Child-Pugh score was better than FIPS score in predicting 3-month mortality [AUROC, 0.797 (0.745-0.843) vs. 0.578 (0.517-0.637); P = 0.049] in nonviral cirrhosis group.

CONCLUSION

Classic scores still had good risk stratification and predictive ability of post-TIPS mortality. The FIPS score was not superior to the classic scores in the current Chinese cohort. The MELD and MELD-Na scores were significantly superior to the FIPS score in predicting 3-month mortality.

Effect of Direct-Acting Antiviral Agents on Gastroesophageal Varices in Patients with Hepatitis C Virus-Related Cirrhosis

Aim: In patients with hepatitis C virus-related liver cirrhosis (LC) who achieve sustained virological responses (SVRs) through treatment with direct-acting antiviral agents (DAAs), it remains unclear whether there are improvements in gastroesophageal varices (GEVs) and portal hypertension. We investigated changes in liver function and GEVs that occurred after DAA therapy. Materials and Methods: We evaluated the medical records of 195 patients with hepatitis C virus-related LC who received DAAs. A total of 171 patients achieved SVRs, among whom 36 had GEVs before or after receiving DAA therapy. The liver function, fibrosis, and GEVs were re-evaluated every 6 months after receiving DAA therapy. The risk factors for progressive GEVs were investigated. Results: DAA therapy resulted in improvements in liver function (indicated by aspartate transaminase, alanine transaminase, and serum albumin levels) and fibrosis (indicated by type IV collagen levels and the Fibrosis-4 index). After receiving DAA therapy, 27 patients had stable GEVs and 9 had progressive GEVs. With respect to GEV grades before DAA therapy, there was a significant difference between patients with stable and progressive GEVs (p = 0.027). Presence of grade-2 GEVs before starting DAA therapy was a risk factor for GEV progression (odds ratio: 5.83; p = 0.04). Patients with grade-2 GEVs had significantly shorter progression-free periods than those with grade < 2 GEVs (p = 0.025). Conclusions: DAA therapy does not ameliorate GEVs. Furthermore, grade-2 GEVs can worsen after DAA therapy. Therefore, patients with GEVs of grades ≥ 2 should undergo endoscopic surveillance after receiving DAAs.

[Current Interventional Management of Acute Upper Gastrointestinal Bleeding]

Upper gastrointestinal bleeding (UGIB), a common medical emergency, causes significant morbidity and mortality. Endoscopic evaluation and treatment remain the standard care in patients who can be hemodynamically stabilized. However, severe bleeding despite conservative medication treatment or medication combined with endoscopic intervention occurs in 5%-10% of patients, requiring interventional or surgical treatment. Endovascular embolization has emerged as an alternative to emergency operative intervention for high-risk patients with non-variceal UGIB and is now commonly considered the first-line therapy for refractory bleeding after endoscopic treatment. Child-Pugh class C or class B cirrhosis patients who have varicosity or active bleeding detected in endoscopy are at high risks for treatment failure, rebleeding, and death. A preemptive transjugular intrahepatic portosystemic shunt has been shown to reduce treatment failure and mortality significantly. Herein, we reviewed the current role of interventional treatment in the management of massive UGIB on the basis of years of clinical experience of the Department of Gastroenterology, West China Hospital, Sichuan University.

ω-3 fatty acid-enriched parenteral nutrition shortens hospital stay in acute variceal bleeding cirrhotic patients

Acute variceal bleeding, a crucial complication of liver cirrhosis requires high energy expenditures but gastrointestinal bleeding limits enteral feeding in the acute stage. We investigated the safety and efficacy of ω-3 fatty acid-enriched parenteral nutrition in acute variceal bleeding patients.In this retrospective study, a total of 208 cirrhotic patients with acute variceal bleeding who underwent parenteral nutrition in the absence of enteral nutrition were enrolled. Among the patients, 86 patients received ω-3 fatty-acid-enriched parenteral nutrition. The primary endpoint was to evaluate the duration of hospital stay and the presence of clinical complications of liver cirrhosis.The mean age of the patients enrolled was 54.9 years-old and 185 patients (88.9%) were male. The cause of liver cirrhosis, Child-Pugh score and comorbidities were statistically not different. Patients with ω-3 enriched parenteral nutrition had a significantly lower systolic blood pressure and total bilirubin levels. The difference in the in-hospital mortality (P = .813) or rate of complications (P = .880) was not statistically significant. The duration of hospital stay was significantly shorter in the patients who underwent ω-3 fatty acid-enriched parenteral nutrition (10.7 ± 7.3 vs 7.9 ± 4.2 days, P = .001).In liver cirrhosis patients with acute variceal bleeding, ω-3 fatty acid-enriched parenteral nutrition significantly decreased the length of hospital stay. Further prospective studies to consolidate these findings are warranted.

Study of the effect of vascular endothelial growth factor (VEGF) C(+405)G (rs2010963) single nucleotide polymorphism on the development of esophageal and gastric varices and risk of variceal bleeding in cirrhotic hepatitis C virus (HCV) patients (VEGF) C(+405)G IN esophageal and gastric varices

Background

HCV infection is a major worldwide cause of chronic liver diseases. Esophageal and gastric varices are common in cirrhotic patients due to concomitant portal hypertension. Variceal hemorrhage is a major decompensating event with high morbidity and mortality. Endothelial dysfunction, occurring in cirrhosis, facilitates the development of liver cirrhosis, portal hypertension and contributes to increased intrahepatic vascular resistance..VEGF family members are major regulators of blood vessel development and function.

Results

The study was conducted on 90 subjects admitted to Tropical Medicine Department, Alexandria Main University Hospital: 30 cirrhotic patients with endoscopically proven varices (group A), 30 cirrhotic patients without varices (group B), and 30 healthy controls (group C). All patients was subjected to detailed history taking and thorough clinical examination, laboratory investigations, ultrasound abdomen, upper gastrointestinal endoscopy, and genotyping for VEGF C(+405)G (rs2010963) by 5′ nuclease assay. The VEGF C(+405)G (rs2010963) GG genotype was associated with higher prevalence of esophageal and gastric varices and higher bleeding risk.

Conclusion

VEGF C(+405)G (rs2010963) is an important genetic determinant of esophageal varices, gastric varices, and correlates with variceal bleeding risk. Genetic testing of this SNP would be useful in prediction of esophageal and gastric varices and bleeding risk.

Effect of aluminum phosphate gel on prevention of early rebleeding after ligation of esophageal variceal hemorrhage

BACKGROUND

Liver cirrhosis is the main cause of portal hypertension. The leading cause of death in patients with liver cirrhosis is its most common complication, esophageal variceal bleeding (EVB). Endoscopic variceal ligation (EVL) is recommended by many guidelines to treat EVB and prevent rebleeding; however, esophageal ulcers occur after treatment. Delayed healing of ulcers and unhealed ulcers lead to high rebleeding and mortality rates. Thus, the prevention of early postoperative rebleeding is of great significance in improving the quality of life and prognosis of patients.

AIM

To evaluate the efficacy of aluminum phosphate gel (APG) plus a proton pump inhibitor (PPI) in the prevention of early rebleeding after EVL in patients with EVB.

METHODS

The medical records of 792 patients who were diagnosed with EVB and in whom bleeding was successfully stopped by EVL at Shenzhen People’s Hospital, Guangdong Province, China from January 2015 to December 2020 were collected. According to the study inclusion and exclusion criteria, 401 cases were included in a PPI-monotherapy group (PPI group), and 377 cases were included in a PPI and APG combination therapy (PPI + APG) group. We compared the incidence rates of early rebleeding and other complications within 6 wk after treatment between the two groups. The two-sample t-test, Wilcoxon rank-sum test, and chi-squared test were adopted for statistical analyses.

RESULTS

No significant differences in age, sex, model for end-stage liver disease score, coagulation function, serum albumin level, or hemoglobin level were found between the two groups. The incidence of early rebleeding in the PPI + APG group (9/337; 2.39%) was significantly lower than that in the PPI group (30/401; 7.48%) (P = 0.001). Causes of early rebleeding in the PPI group were esophageal ulcer (3.99%, 16/401) and esophageal varices (3.49%, 14/401), while those in the PPI + APG group were also esophageal ulcers (5/377; 1.33%) and esophageal varices (4/377; 1.06%); such causes were significantly less frequent in the PPI + APG group than in the PPI group (P = 0.022 and 0.024, respectively). The early mortality rate within 6 wk in both groups was 0%, which was correlated with the timely rehospitalization of all patients with rebleeding and the conduct of emergency endoscopic therapy. The incidence of adverse events other than early bleeding in the PPI + APG group (28/377; 7.43%) was significantly lower than that in the PPI group (63/401; 15.71%) (P < 0.001). The incidence of chest pain in the PPI + APG group (9/377; 2.39%) was significantly lower than that in the PPI group (56/401; 13.97%) (P < 0.001). The incidence of constipation in the PPI + APG group (16/377; 4.24%) was significantly higher than that in the PPI group (3/401; 0.75%) (P = 0.002) but constipation was relieved after patients drank more water or took lactulose. In the PPI and PPI + APG groups, the incidence rates of spontaneous peritonitis within 6 wk after discharge were 0.50% (2/401) and 0.53% (2/377), respectively, and those of hepatic encephalopathy were 0.50% (2/401) and 0.27% (1/377), respectively, presenting no significant difference (P > 0.999).

CONCLUSION

PPI + APG combination therapy significantly reduces the incidence of early rebleeding and chest pain in patients with EVB after EVL.

Systematic review and meta-analysis of risk scores in prediction for the clinical outcomes in patients with acute variceal bleeding

BACKGROUND

Acute variceal bleeding (AVB) is a life-threatening condition that needs risk stratification to guide clinical treatment. Which risk system could reflect the prognosis more accurately remains controversial. We aimed to conduct a meta-analysis of the predictive value of GBS, AIMS65, Rockall (clinical Rockall score and full Rockall score), CTP and MELD.

METHOD

PubMed, Web of Science, Embase, Cochrane library, WANGFANG and CNKI were searched. Twenty-eight articles were included in the study. The Meta-DiSc software and MedCalc software were used to pool the predictive accuracy.

RESULTS

Concerning in-hospital mortality, CTP, AIMS65, MELD, Full-Rockall and GBS had a pooled AUC of 0.824, 0.793, 0.788, 0.75 and 0.683, respectively. CTP had the highest sensitivity of 0.910 (95% CI: 0.864-0.944) with a specificity of 0.666 (95% CI: 0.635-0.696). AIMS65 had the highest specificity of 0.774 (95% CI: 0.749-0.798) with a sensitivity of 0.679 (95% CI: 0.617-0.736). For follow-up mortality, MELD, AIMS65, CTP, Clinical Rockall, Full-Rockall and GBS showed a pooled AUC of 0.798, 0.77, 0.746, 0.704, 0.678 and 0.618, respectively. CTP had the highest specificity (0.806, 95% CI: 0.763-0.843) with a sensitivity of 0.722 (95% CI: 0.628-0.804). GBS had the highest sensitivity 0.800 (95% CI: 0.696-0.881) with a specificity of 0.412 (95% CI: 0.368-0.457). As for rebleeding, no score performed particularly well.

CONCLUSIONS

No risk scores were ideally identified by our systematic review. CTP was superior to other risk scores in identifying AVB patients at high risk of death in hospital and patients at low risk within follow-up. Guidelines have recommended the use of GBS to risk stratification of patients with upper gastrointestinal bleeding. However, if the cause of upper gastrointestinal bleeding is suspected oesophageal and gastric varices, extra care should be taken. Because in this meta-analysis, the ability of GBS was limited.Key messageCTP was superior in identifying AVB patients at high risk of death in hospital and low risk within follow-up.GBS, though recommended by the Guidelines, should be cautiously used when assessing AVB patients.

Role of early transjugular intrahepatic portosystemic stent-shunt in acute variceal bleeding: An update of the evidence and future directions

Variceal bleeding is a serious complication of cirrhosis and portal hypertension. Despite the improvement in management of acute variceal bleed (AVB), it still carries significant mortality. Portal pressure is the main driver of variceal bleeding and also a main predictor of decompensation. Reduction in portal pressure has been the mainstay of management of variceal bleeding. Transjugular intrahepatic porto-systemic stent shunt (TIPSS) is a very effective modality in reducing the portal hypertension and thereby, controlling portal hypertensive bleeding. However, its use in refractory bleeding (rescue/salvage TIPSS) is still associated with high mortality. “Early” use of TIPSS as a “pre-emptive strategy” in patients with AVB at high risk of failure of treatment has shown to be superior to standard treatment in several studies. While patients with Child C cirrhosis (up to 13 points) clearly benefit from early-TIPSS strategy, it’s role in less severe liver disease (Child B) and more severe disease (Child C > 13 points) remains less clear. Moreover, standard of care has improved in the last decade leading to improved 1-year survival in high-risk patients with AVB as compared to earlier “early” TIPSS studies. Lastly in the real world, only a minority of patients with AVB fulfil the stringent criteria for early TIPSS. Therefore, there is unmet need to explore role of early TIPSS in management of AVB in well-designed prospective studies. In this review, we have appraised the role of early TIPSS, patient selection and discussed future directions in the management of patients with AVB.

Prognosis of patients undergoing salvage TIPS is still poor in the preemptive TIPS era

BACKGROUND

Salvage transjugular intrahepatic portosystemic shunts (TIPS) are associated with poor prognosis, especially in patients with Child-Pugh C cirrhosis. Since preemptive TIPS improved prophylaxis of variceal bleeding in those patients, recourse to salvage TIPS may now affect patients with a better prognosis.

AIM

To assess the impact of the preemptive TIPS policy on outcomes after salvage TIPS placement.

METHODS

We conducted a retrospective monocentric study on cirrhotic patients undergoing salvage TIPS with polytetrafluoroethylene-covered stents from 2002 to 2017 (period 1 until February 2011; period 2 after the preemptive TIPS policy in March 2011). The primary endpoint was one-year transplant-free survival.

RESULTS

We included 106 patients (period 1/2 = 53/53 patients, male gender 82%, age 54 ± 9 years, alcoholic cirrhosis 70%, Child-Pugh score B/C 94%). One-year transplant-free survival was 46.0% during period 1 compared to 40.2% during period 2 (p = 0.65). Amongst 61 patients with history of variceal bleeding, 32 (52.5%) had an inadequate secondary prophylaxis, including 19 (59.4%) with a previous indication of preemptive TIPS. One-year transplant-free survival was 33.2% if inadequate secondary prophylaxis vs 65.2% if adequate (p = 0.008). Independent factors associated with survival were a lower Child-Pugh or MELD score, infection, failure to control bleeding, and hepatic encephalopathy after TIPS.

CONCLUSION

Prognosis after salvage TIPS remained poor in our series. Optimizing secondary prophylaxis, including preemptive TIPS placement, should be the main concern to improve prognosis.

Mortality, Risk Factors and Disparities Associated with Esophageal Variceal Bleeding in Children's Hospitals in the US

OBJECTIVES

To use a large administrative database to determine the mortality, risk factors, and comorbidities of esophageal variceal bleeding in children.

STUDY DESIGN

Retrospective cohort study using Pediatric Health Information System data from 50 tertiary children's hospitals in the US. International Classification of Diseases (ICD) codes (FY 2020 ICD-10 update and revision 10 of ICD-9) from 2004 through 2019 identified children 18 years and younger with variceal bleeding and complications. Univariate analyses used the Student t -test for continuous variables (age) and the χ² test for categorical variables (all others). A mixed-effects linear regression was performed for multiple variables.

RESULTS

There were 1902 patients who had 3399 encounters for esophageal variceal bleeding. The mortality rate for variceal bleeding was 7.3%, increasing to 8.8% by 6 weeks; any mortality during the study was 20.1%. Transfusion was required in 54.7% of encounters, and 42.6% were admitted to the intensive care unit. Variceal bleeding encounters were complicated by peptic ulcer disease (6.9%), bacteremia (11.4%), acute renal failure (5.1%), mechanical ventilation (18%), ascites (21.3%), and peritonitis (3.3%). Multivariable mixed-effects logistic regression showed that Black race (OR, 2.59; P < .001) or Hispanic ethnicity (OR, 2.31; P = .001), but not sex, household income, or insurance type, were associated with increased mortality. Bacteremia, peritonitis, mechanical ventilation, acute renal failure, and transfusion were associated with higher mortality (ORs of 2.29, 2.18, 1.93, 6.33, and 1.81, respectively; P < .001, .005, .011, <.001, and .005, respectively).

CONCLUSIONS

The 6-week mortality rate for variceal bleeding in children is 8.8%. Black or Hispanic children are at higher risk of dying. Serious morbidities associated with variceal hemorrhage impact mortality. These data can inform consideration of prophylactic or therapeutic interventions for children at risk.

Mac-2 Binding Protein Glycosylation Isomer for Screening High-Risk Esophageal Varices in Liver Cirrhotic Patient

Background: Esophageal varices occur at middle to advanced stages of cirrhosis and are associated with increased mortality due to their potential for rupture and bleeding. The aim of this study is to examine the accuracy of a surrogate marker, Mac-2 binding protein glycosylation isomer (M2BPGi), for screening high-risk esophageal varices in cirrhotic patients. Methods: Ninety-four cirrhotic patients who underwent endoscopy screening at Cipto Mangunkusumo Hospital, Jakarta, Indonesia were included. Patients with a history of ligation, portal vein thrombosis, or hepatocellular carcinoma were excluded. All enrolled patients underwent ultrasonography, transient elastography, and laboratory tests. The HISCL-5000 Sysmex analyzer was used to measure M2BPGi levels. Results: Of these 94 patients, 27 had high-risk esophageal varices and 67 had non-high-risk esophageal varices. M2BPGi levels were higher in patients with high-risk esophageal varices compared with those with non-high-risk esophageal varices (cutoff index (COI) of 11.4 vs. 3.7, p < 0.001). The sensitivity, specificity, positive predictive value, and negative predictive value of M2BPGi with a cutoff value of 5 COI was 92.6%, 70.1%, 55.6%, and 95.9%, respectively. Conclusions: M2BPGi could be used as a non-invasive surrogate marker for ruling out high-risk esophageal varices in cirrhotic patients. This method is cheap and non-invasive and could be used as a screening tool in resource-limited settings.

Therapeutic strategies for refractory variceal bleeding due to percutaneous liver biopsy: A case report

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Intrahepatic arterioportal fistula is an unusual complication of liver biopsy.

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Intrahepatic arterioportal fistula can cause variceal bleeding.

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Angioembolization is an effective treatment of variceal bleeding.

Introduction and importance

Variceal bleeding due to intrahepatic arterioportal fistula is an unusual complication of percutaneous liver biopsy. As majority of variceal bleeding are cirrhotic in origin, the rare occurrence of an acquired intrahepatic arterioportal fistula presents a therapeutic dilemma.

Case presentation

We report the case of a 57-year-old female with refractory variceal bleeding that occurred six years after a percutaneous liver biopsy. As part of the workup for placement of Transjugular Intrahepatic Portosystemic Shunt, a computed tomography hepatic arteriography was performed. This revealed a large arterioportal fistula in left lobe of liver. Variceal bleeding was controlled following successful embolisation of the arterioportal fistula.

Clinical discussion

Persistent intrahepatic arterioportal fistula can result in portal hypertension and variceal bleeding. This is a rare complication of percutaneous liver biopsy that warrants consideration as an aetiology of portal hypertension with variceal bleeding. The therapeutic strategy for refractory bleeding due to intrahepatic arterioportal fistula is different from cirrhotic portal hypertension and requires trans-arterial embolisation of the fistula.

Conclusion

This case highlights the need to consider arterioportal fistula as an aetiology of portal hypertension as therapeutic strategy in refractory variceal bleeding is different from cirrhotic portal hypertension.

Risk Stratification Based on Chronic Liver Failure Consortium Acute Decompensation Score in Patients With Child-Pugh B Cirrhosis and Acute Variceal Bleeding

BACKGROUND AND AIMS

Optimal candidates for early transjugular intrahepatic portosystemic shunt (TIPS) in patients with Child-Pugh B cirrhosis and acute variceal bleeding (AVB) remain unclear. This study aimed to test the hypothesis that risk stratification using the Chronic Liver Failure Consortium Acute Decompensation score (CLIF-C ADs) may be useful to identify a subgroup at high risk of mortality or further bleeding that may benefit from early TIPS in patients with Child-Pugh B cirrhosis and AVB.

APPROACH AND RESULTS

We analyzed the pooled individual data from two previous studies of 608 patients with Child-Pugh B cirrhosis and AVB who received standard treatment between 2010 and 2017 in China. The concordance index values of CLIF-C ADs for 6-week and 1-year mortality (0.715 and 0.708) were significantly better than those of active bleeding at endoscopy (0.633 [P < 0.001] and 0.556 [P < 0.001]) and other prognostic models. With X-tile software identifying an optimal cutoff value, patients were categorized as low risk (CLIF-C ADs <48), intermediate risk (CLIF-C ADs 48-56), and high risk (CLIF-C ADs >56), with a 5.6%, 16.8%, and 25.4% risk of 6-week death, respectively. Nevertheless, the performance of CLIF-C ADs for predicting a composite endpoint of 6-week death or further bleeding was not satisfactory (area under the receiver operating characteristics curve [AUC], 0.588). A nomogram incorporating components of CLIF-C ADs and albumin, platelet, active bleeding, and ascites significantly improved the prediction accuracy (AUC, 0.725).

CONCLUSIONS

In patients with Child-Pugh B cirrhosis and AVB, risk stratification using CLIF-C ADs identifies a subgroup with high risk of death that may derive survival benefit from early TIPS. With improved prediction accuracy for 6-week death or further bleeding, the data-driven nomogram may help to stratify patients in randomized trials. Future external validation of these findings in patients with different etiologies is required.

Endoscopic ultrasound-guided cyanoacrylate injection to prevent rebleeding in hepatocellular carcinoma patients with variceal hemorrhage

BACKGROUND AND AIM

Secondary prophylaxis (SP) of variceal rebleeding was reported to improve outcomes of hepatocellular carcinoma (HCC) patients, but the optimal endoscopic approach is not well defined. We compared outcomes in HCC patients who underwent SP by endoscopic ultrasound-guided cyanoacrylate obturation (EUS-CYA) versus no SP.

METHODS

Between 2014 and 2018, 30 consecutive patients with inoperable HCC and recent endoscopically controlled variceal bleeding were prospectively recruited. Twenty-seven patients with persistent varices ≥ 3 mm on endoscopic ultrasound underwent EUS-CYA for SP. Thirty-three HCC patients treated by esophagogastroduodenoscopy-guided CYA obturation (EGD-CYA) alone for acute variceal bleeding between 2009 and 2013 were identified from a prospective gastrointestinal bleed registry as standard of care controls for comparison. Outcome measures were death-adjusted cumulative incidence of rebleeding, bleeding-free survival, technical success, and procedure-related adverse events of EUS-CYA.

RESULTS

The majority of patients in both groups had advanced HCC, portal vein thrombosis, and Child-Pugh B cirrhosis. EUS-CYA was successful in all 27 patients with no radiographic evidence of cyanoacrylate-lipiodol embolization. Significantly lower 30- and 90-day death-adjusted cumulative incidence of rebleeding (14.8% vs 42.4%, P = 0.023 and 18.5% vs 60.6%, P = 0.002, respectively) and significantly higher variceal bleeding-free survival at 3 and 6 months (51.9% vs 21.2%, P = 0.009, 40.7% vs 15.2%, P = 0.010, respectively) were observed in the EUS-CYA group when compared with standard of care group.

CONCLUSIONS

Secondary prophylaxis by EUS-CYA reduced rebleeding rate and improved variceal bleeding-free survival in patients with inoperable HCC and variceal bleeding when compared with no SP. Randomized studies are needed to confirm the benefits of EUS-CYA for this difficult-to-treat population.

A New Recalibrated Four-Category Child-Pugh Score Performs Better than the Original Child-Pugh and MELD Scores in Predicting In-Hospital Mortality in Decompensated Alcoholic Cirrhotic Patients with Acute Variceal Bleeding: a Real-World Cohort Analysis

BACKGROUND

There currently is no consensus on how to accurately predict early rebleeding and death after a major variceal bleed. This study investigated the relative predictive performances of the original Child-Pugh (CP), model for end-stage liver disease (MELD) and a four-category recalibrated Child-Pugh (rCP).

METHODS

This prospective study included all adult patients admitted to Groote Schuur Hospital with acute esophageal variceal bleeding secondary to alcoholic cirrhosis, between January 2000 and December 2017. CP and rCP grades and MELD score were calculated on admission, and the predictive ability in discriminating in-hospital rebleeding and death was compared by area under receiver-operating characteristic (AUROC) curves.

RESULTS

During the study period, 403 consecutive adult patients were treated for bleeding esophageal varices of whom 225 were secondary to alcoholic cirrhosis. Twenty-four (10.6%) patients were CP grade A, 88 (39.1%) grade B and 113 (50.2%) grade C on hospital admission. MELD scores ranged from 6 to 40. Thirty-one (13.8%) patients rebleed, and 41 (18.2%) patients died. There was no difference in the discriminatory capacity of the CP (AUROC 0.59, 95% CI 0.50-0.670) and MELD (AUROC 0.62, 95% CI 0.51-0.73) to predict rebleeding (p = 0.72), or between the Child-Pugh (AUROC 0.75, 95% CI 0.71-0.81) and MELD (AUROC 0.71, 95% CI 0.62-0.80) to predict death (p = 0.35). The rCP classification (A-D) had a significantly improved discriminatory capacity (AUROC 0.83 95% CI 0.77-0.89) compared to the CP score (A-C) and MELD to predict death (p = 0.004).

CONCLUSION

A recalibrated Child-Pugh score outperforms the original Child-Pugh grade and MELD score in predicting in-hospital death in patients with bleeding esophageal varices secondary to alcoholic cirrhosis.

Defining the advantages and exposing the limitations of endoscopic variceal ligation in controlling acute bleeding and achieving complete variceal eradication

BACKGROUND

Bleeding esophageal varices (BEV) is a potentially life-threatening complication in patients with portal hypertension with mortality rates as high as 25% within six weeks of the index variceal bleed. After control of the initial bleeding episode patients should enter a long-term surveillance program with endoscopic intervention combined with non-selective β-blockers to prevent further bleeding and eradicate EV.

AIM

To assess the efficacy of endoscopic variceal ligation (EVL) in controlling acute variceal bleeding, preventing variceal recurrence and rebleeding and achieving complete eradication of esophageal varices (EV) in patients who present with BEV.

METHODS

A prospectively documented single-center database was used to retrospectively identify all patients with BEV who were treated with EVL between 2000 and 2018. Control of acute bleeding, variceal recurrence, rebleeding, eradication and survival were analyzed using Baveno assessment criteria.

RESULTS

One hundred and forty patients (100 men, 40 women; mean age 50 years; range, 21–84 years; Child-Pugh grade A = 32; B = 48; C = 60) underwent 160 emergency and 298 elective EVL interventions during a total of 928 endoscopy sessions. One hundred and fourteen (81%) of the 140 patients had variceal bleeding that was effectively controlled during the index banding procedure and never bled again from EV, while 26 (19%) patients had complicated and refractory variceal bleeding. EVL controlled the acute sentinel variceal bleed during the first endoscopic intervention in 134 of 140 patients (95.7%). Six patients required balloon tamponade for control and 4 other patients rebled in hospital. Overall 5-d endoscopic failure to control variceal bleeding was 7.1% (n = 10) and four patients required a salvage transjugular intrahepatic portosystemic shunt. Index admission mortality was 14.2% (n = 20). EV were completely eradicated in 50 of 111 patients (45%) who survived > 3 mo of whom 31 recurred and 3 rebled. Sixteen (13.3%) of 120 surviving patients subsequently had 21 EV rebleeding episodes and 10 patients bled from other sources after discharge from hospital. Overall rebleeding from all sources after 2 years was 21.7% (n = 26). Sixty-nine (49.3%) of the 140 patients died, mainly due to liver failure (n = 46) during follow-up. Cumulative survival for the 140 patients was 71.4% at 1 year, 65% at 3 years, 60% at 5 years and 52.1% at 10 years.

CONCLUSION

EVL was highly effective in controlling the sentinel variceal bleed with an overall 5-day failure to control bleeding of 7.1%. Although repeated EVL achieved complete variceal eradication in less than half of patients with BEV, of whom 62% recurred, there was a significant reduction in subsequent rebleeding.

Predictive value of insulin-like growth factor 1-Child-Turcotte-Pugh score for mortality in patients with decompensated cirrhosis

BACKGROUND

Previous studies have used a modified version of the Child-Turcotte-Pugh (CTP) score to include insulin-like growth factor 1 (IGF-1) concentrations, denoted the Insulin-like Growth Factor 1-Child-Turcotte-Pugh (IGF-CTP) system. We evaluated the predictive power of IGF-CTP for 1-year mortality in patients with decompensated cirrhosis (DC).

METHODS

A total of 386 patients with DC were retrospectively analyzed. Comparison of distribution of patients with decompensated cirrhosis according to Insulin-like Growth Factor-1-Child-Turcotte-Pugh and Child-Turcotte-Pugh scores were performed. Area under the receiver operating characteristic curves (AUROCs) for IGF-CTP, CTP and the Model for End-stage Liver Disease (MELD) scores were evaluated to compare predictive value. Univariate and multivariate analyses were carried out to determine potential risk factors for 1-y mortality.

RESULTS

During the 1-y follow-up, 94 patients died. Significantly more patients (both surviving and non-surviving) were classified as IGF-CTP stage C than CTP stage C. The AUROC of IGF-CTP was significantly higher than that of CTP and MELD in the training and validation cohorts. Multivariate analysis indicated IGF-CTP score and IGF-1 to be independently associated with mortality.

CONCLUSION

The IGF-CTP score is independently associated with mortality for patients with DC, and offers more accurate prediction of 1-y mortality than either CTP or MELD score for these patients.

A Quality Improvement Initiative Results in Improved Rates of Timely Postvariceal Bleeding Surveillance Endoscopy

OBJECTIVES

We performed a study to assess the effects of a quality improvement (QI) initiative on the rates of postvariceal bleeding surveillance upper endoscopy (EGD).

METHODS

We identified patients with cirrhosis hospitalized with variceal bleeding and assessed the rates of timely (≤4 weeks) EGD before and after a QI initiative.

RESULTS

Preintervention: 16% (5 of 32) of patients underwent timely surveillance EGD. We developed a standardized ordering template for gastroenterology fellows and reserved postvariceal EGD scheduling slots. Postintervention: 43% (12 of 28) of patients underwent timely surveillance EGD.

DISCUSSION

A QI intervention was associated with a 27% absolute increase in timely surveillance EGDs.

Validation of the AASLD recommendations for classification of oesophageal varices in clinical practice

BACKGROUND & AIMS

The American Association for the Study of Liver Diseases recommends the use of a 2-grade classification system (small and large) to describe the size of oesophageal varices (OV). Data on observer agreement (OA) on this system are currently lacking. We aimed to evaluate this classification and compare it to the widely used 3-grade classification (grade 1 'small', grade 2 'medium', grade 3 'large') among operators of variable experience.

METHODS

High-definition video recordings of 100 patients with cirrhosis were prospectively collected using standardised criteria. Nine observers of variable experience performed independent evaluations of the videos in random order. OV were scored using both systems. All assessments were repeated a year later by the same observers to assess intra-observer agreement.

RESULTS

Interobserver agreement (all observers) using the 2-grade and the 3-grade system was k = 0.71 (95% CI: 0.64-0.78) and k = 0.73 (95% CI: 0.66-0.79) respectively. When using the 2-grade system, intra-observer agreement between hepatologists (n = 3), luminal gastroenterologists (n = 3) and trainee gastroenterologists (n = 3) was k = 0.89 (95% CI: 0.86-0.91), k = 0.72 (95% CI: 0.67-0.77), and k = 0.74 (95% CI: 0.67-0.8) respectively. With the 3-grade system; intra-observer agreement between the same three subgroups were k = 0.9 (95% CI: 0.87-0.92), k = 0.73 (95% CI: 0.68-0.78), k = 0.77 (95% CI: 0.71-0.82) respectively.

CONCLUSIONS

There was no difference in OA between the 2-grade and 3-grade classification systems. Hepatologists had significantly higher levels of consistency in grading OV. This may have implications to create alternative training models for residents and fellows in the recognition and grading of OV.

Platelet-albumin-bilirubin score - a predictor of outcome of acute variceal bleeding in patients with cirrhosis

BACKGROUND

The albumin-bilirubin (ALBI) score was validated as a prognostic indicator in patients with liver disease and hepatocellular carcinoma. Incorporating platelet count in the platelet-albumin-bilirubin (PALBI) score improved validity in predicting outcome of patients undergoing resection and ablation.

AIM

To evaluate the PALBI score in predicting outcome of acute variceal bleeding in patients with cirrhosis.

METHODS

The data of 1517 patients with cirrhosis presenting with variceal bleeding were analyzed. Child Turcotte Pugh (CTP) class, Model of End-stage Liver Disease (MELD), ALBI and PALBI scores were calculated on admission, and were correlated to the outcome of variceal bleeding. Areas under the receiving-operator characteristic curve (AUROC) were calculated for survival and rebleeding.

RESULTS

Mean age was 52.6 years; 1176 were male (77.5%), 69 CTP-A (4.5%), 434 CTP-B (29.2%), 1014 CTP-C (66.8%); 306 PALBI-1 (20.2%), 285 PALBI-2 (18.8%), and 926 PALBI-3 (61.1%). Three hundred and thirty-two patients died during hospitalization (21.9%). Bleeding-related mortality occurred in 11% of CTP-B, 28% of CTP-C, in 21.8% of PALBI-2 and 34.4% of PALBI-3 patients. The AUROC for predicting survival of acute variceal bleeding was 0.668, 0.689, 0.803 and 0.871 for CTP, MELD, ALBI and PALBI scores, respectively. For predicting rebleeding the AUROC was 0.681, 0.74, 0.766 and 0.794 for CTP, MELD, ALBI and PALBI scores, respectively.

CONCLUSION

PALBI score on admission is a good prognostic indicator for patients with acute variceal bleeding and predicts early mortality and rebleeding.

Noninvasive evaluation of esophageal varices in cirrhotic patients based on spleen hemodynamics: a dual-energy CT study

OBJECTIVE

To evaluate noninvasively the severity of esophageal varices (EV) in cirrhotic patients using splenic hemodynamics obtained with dual-energy CT.

METHODS

We retrospectively analyzed 72 cirrhotic patients with EV between December 2018 and June 2019. Patients were divided into three groups: mild (EV1), medium (EV2), or severe (EV3) EV groups based on severity of EV assessed by endoscopy. An additional control group included 20 patients with normal liver CT. All patients underwent contrast-enhanced dual-energy CT. The iodine weight in spleen (IW-S) was calculated as IW-S = IC-S (iodine concentration in spleen) × V-S (spleen volume). Differences between EV and control groups were analyzed using one-way analysis of variance with Welch's correction. Games-Howell test made further pairwise comparison. The diagnostic value of IW-S on high-risk EV (EV2, EV3, or EV1 with red color sign) was evaluated using the ROC curve. p < 0.05 indicated statistical significance.

RESULTS

The overall difference of IW-S between the control and EV groups was statistically significant (p < 0.001). Patients with more severe EV had higher IW-S values. Pairwise comparisons showed that except for control vs. EV1 groups, the IW-S between any other two groups was significantly different (p < 0.05). With a cutoff value at 1087 mg, the AUC for using IW-S for the detection of high-risk EV was 0.87 (95% CI 0.77~0.94). Sensitivity and specificity were 84.9% and 84.2%, respectively.

CONCLUSION

IW-S obtained with dual-energy CT can noninvasively predict EV severity.

KEY POINTS

• A higher iodine weight in spleen (IW-S) was observed in case of severe esophageal varices. • Cirrhotic patients have significantly higher IW-S than normal-liver patients. • IW-S in dual-energy CT maybe used to evaluate the severity of EV.

Hepatitis C eradication with direct-acting anti-virals reduces the risk of variceal bleeding

BACKGROUND

The real-world, long-term benefits of sustained virologic response (SVR) on the risk of variceal bleeding remain unclear.

AIM

To assess the association between DAA-induced SVR and post-treatment variceal bleeding METHODS: We identified patients who initiated DAA-only anti-viral treatments in the United States Veterans Affairs healthcare system from 2013 to 2015. We followed patients until 1 January 2019 for the development of gastro-oesophageal variceal bleeding defined by diagnostic codes. We used multivariable Cox proportional hazards regression to assess the association between SVR and development of variceal bleeding, adjusting for potential confounders.

RESULTS

Among 33 582 DAA-treated patients, 549 (1.6%) developed variceal bleeding after treatment (mean follow-up 3.1 years). Compared to no SVR, SVR was associated with a significantly lower incidence of variceal bleeding among all patients (0.46 vs 1.26 per 100 patient-years, adjusted hazard ratio [AHR] 0.66, 95% CI 0.52-0.83), among patients with pre-treatment cirrhosis (1.55 vs 2.96 per 100 patient-years, AHR 0.73, 95% CI 0.57-0.93) and among patients without pre-treatment cirrhosis (0.07 vs 0.29 per 100 patient-years, AHR 0.33, 95% CI 0.17-0.65). The risk of variceal bleeding after treatment was lower in those who achieved SVR vs no SVR among patients who had non-bleeding varices (3.5 vs 4.9 per 100 patient-years) or bleeding varices (12.9 vs 16.4 per 100 patient-years) diagnosed before treatment, but these differences were not statistically significant in adjusted analyses.

CONCLUSION

DAA-induced SVR is independently associated with a lower risk of variceal bleeding during long-term follow-up in patients with and without pre-treatment cirrhosis. These findings demonstrate an important real-world benefit of DAA treatment.

Remaining challenges for the noninvasive diagnosis of esophageal varices in liver cirrhosis

Although endoscopy is the recommended method for detecting esophageal varices, noninvasive methods for diagnosing esophageal varices are needed to avoid unnecessary invasive endoscopic examinations. In recent years, many studies have been performed to predict the presence of high-risk varices in noninvasive ways. The most widely used tools for noninvasive screening for esophageal varices are the Baveno VI and expanded Baveno VI criteria. Even these accepted criteria are not 100% accurate and have some limitations. Here, we summarize the current literature on the noninvasive diagnosis of esophageal varices in liver cirrhosis patients and highlight the remaining issues.

Selective versus non‐selective shunts for the prevention of variceal rebleeding

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess the benefits and harms of any type of selective shunt versus any type of non‐selective shunt for the prevention of oesophagogastric variceal rebleeding in people with portal hypertension.

Emergency Transjugular Intrahepatic Portosystemic Shunt: an Effective and Safe Treatment for Uncontrolled Variceal Bleeding

BACKGROUND

Uncontrolled variceal bleeding (VB) remains a great challenge for clinical treatment. Emergency transjugular intrahepatic portosystemic shunt (TIPS) is a salvage procedure, but unsatisfactory clinical outcomes and a high incidence of complications have been reported. This study aimed to investigate the effect and safety of emergency TIPS performed in our institution during recent years.

METHODS

Fifty-eight consecutive cirrhotic patients with uncontrolled VB who underwent emergency TIPS from March 2009 to November 2017 in our hospital were followed until the last clinical evaluation, liver transplantation (LT), or death.

RESULTS

Overall, 5, 36, and 17 patients belonged to Child-Pugh class A, B, and C, respectively. TIPS was successfully performed in 57 (98.3%) patients at 89.5 h (mean) after initial bleeding. After TIPS, bleeding ceased in 52 (91.2%) patients, and 51 (89.5%) patients had a portal pressure gradient below 12 mmHg. Only one (1.8%) major procedure-related complication occurred without any clinical consequences, and no procedure-related deaths occurred. During follow-up, 55 hepatic encephalopathy (HE) episodes occurred in 19 (33.3%) patients, and the median time of the first HE episode was 3.1 months. Seven (12.3%) patients experienced shunt dysfunction after 8.7 months (median). The 6-week, 1-year, and 2-year variceal rebleeding rates were 10.5%, 17.1%, and 20.0%, respectively. The LT-free survival rates at 6 weeks, 1 year, and 2 years were 87.7%, 81.8% and 73.6%, respectively.

CONCLUSION

Our study highlights the fact that emergency TIPS could be effective for patients with liver cirrhosis and uncontrolled VB with few potential complications.

Identifying optimal candidates for early TIPS among patients with cirrhosis and acute variceal bleeding: a multicentre observational study

OBJECTIVES

Early placement of transjugular intrahepatic portosystemic shunt (TIPS) has been shown to improve survival in high-risk patients (Child-Pugh B plus active bleeding at endoscopy or Child-Pugh C 10-13) with cirrhosis and acute variceal bleeding (AVB). However, early TIPS criteria may overestimate the mortality risk in a significant proportion of patients, and the survival benefit conferred by early TIPS in such patients has been questioned. Alternative criteria have been proposed to refine the criteria used to identify candidates for early TIPS. Nevertheless, the true survival benefit provided (or not) by early TIPS compared with standard treatment in the different risk categories has not been investigated in specifically designed comparative studies.

DESIGN

We collected data on 1425 consecutive patients with cirrhosis and AVB who were admitted to 12 university hospitals in China between December 2010 and June 2016. Of these, 206 patients received early TIPS, and 1219 patients received standard treatment. The Fine and Gray competing risk regression model was used to compare the outcomes between the two groups that were stratified based on the currently available risk stratification systems after adjusting for liver disease severity and other potential confounders.

RESULTS

Overall, early TIPS was associated with an 80% relative risk reduction (RRR) in mortality at 6 weeks (adjusted HR=0.20; 95% CI: 0.10 to 044; p<0.001) and 51% RRR at 1 year (adjusted HR=0.49, 95% CI: 0.32 to 0.73; p<0.001) compared with standard treatment. In stratification analyses, the RRRs in mortality did not significantly differ among the risk categories. However, the absolute risk reductions (ARRs) of mortality were more pronounced in high-risk patients. The ARRs at 6 weeks were -2.1%, -10.2% and -32.4% in Model for End-stage Liver Disease (MELD) ≤11, 12-18 and ≥19 patients and were -1.5%, -9.1% and -23.2% in Child-Pugh A, B and C patients, respectively (interaction tests, p<0.001 for both criteria). The ARRs for mortality at 1 year were -1.7%, -5.4% and -32.7% in MELD ≤11, 12-18 and ≥19 patients, respectively, and -3.6%, -5.2% and -20.3% in Child-Pugh A, B and C patients, respectively (interaction tests, p<0.001 for both criteria). After adjusting for liver disease severity and other potential confounders, a survival benefit was observed in MELD ≥19 or Child-Pugh C patients but not in MELD ≤11 or Child-Pugh A patients. In MELD 12-18 patients, a survival benefit was observed within 6 weeks but not at 1 year. In Child-Pugh B patients, a survival benefit was observed in those with active bleeding but not those without active bleeding. However, the evaluation of active bleeding was associated with a high interobserver variability. Furthermore, early TIPS was associated with a significantly reduced incidence of failure to control bleeding or rebleeding and new or worsening ascites, without increasing the risk of overt hepatic encephalopathy.

CONCLUSIONS

Early TIPS was associated with improved survival in patients with MELD ≥19 or Child-Pugh C cirrhosis but not in patients with MELD ≤11 or Child-Pugh A cirrhosis. For MELD 12-18 or Child-Pugh B patients, future studies addressing optimal selection criteria for early TIPS remain highly warranted.

Multicenter Retrospective Risk Assessment of Esophageal Variceal Bleeding in Patients with Cirrhosis: An Acoustic Radiation Force Impulse Elastography-Based Prediction Model

Background/Aims

Acoustic radiation force impulse (ARFI) elastography predicts the presence of esophageal varices (EVs). We investigated whether an ARFI-based prediction model can assess EV bleeding (EVB) risk in patients with cirrhosis.

Methods

The records of 262 patients with cirrhosis who underwent ARFI elastography and endoscopic surveillance at two institutions in 2008 to 2013 were retrospectively reviewed, and ARFI-spleen diameter-to-platelet ratio scores (ASPS) were calculated.

Results

The median patient age (165 men, 97 women) was 56 years. The median ARFI velocity, spleen diameter, platelet count, and ASPS were 1.7 m/sec, 10.1 cm, 145×10⁹/L, and 1.16, respectively. During the median 38-month follow-up, 61 patients experienced EVB. Among all patients (179 without EVs and 83 with EVs), the cutoff value that maximized the sum of the sensitivity (73.1%) and specificity (78.4%) (area under receiver operating characteristic curve [AUROC], 0.824) for predicting EVB was 2.60. The cumulative EVB incidence was significantly higher in patients with ASPS ≥2.60 than in those with ASPS <2.60 (p<0.001). Among patients with EVs (n=83), 49 had high-risk EVs (HEVs), and 22 had EVB. The cumulative EVB incidence was significantly higher in HEV patients than in low-risk EV patients (p=0.037). At an ASPS of 4.50 (sensitivity, 66.7%; specificity, 70.6%; AUROC, 0.691), the cumulative EVB incidence was significantly higher in patients with a high ASPS than in those with a low ASPS (p=0.045). A higher ASPS independently predicted EVB (hazard ratio, 4.072; p=0.047).

Conclusions

ASPS can assess EVB risk in patients with cirrhosis. Prophylactic management should be considered for patients with HEVs and ASPS ≥4.50.