Review article: the relevance of portal pressure and other risk factors in acute gastro-oesophageal variceal bleeding

The Utility of the Platelet-Albumin-Bilirubin Score as a Non-invasive Predictor of Esophageal Varices and Variceal Hemorrhage in Patients With Liver Cirrhosis Compared to Child-Turcotte-Pugh and Model of End-Stage Liver Disease-Sodium Scores

Introduction Research on non-invasive tools for detecting gastro-esophageal varices is underway. We investigated the Platelet-Albumin-Bilirubin (PALBI) score in comparison with the Child-Turcotte-Pugh (CTP) and MELD-Na (MELD-Na) scores in patients with liver cirrhosis. Methods Three hundred and twenty-three patients with liver cirrhosis were studied. The PALBI, CTP and MELD-Na scores were calculated and analyzed for gastroesophageal varices and their characteristics using SPSS version 26 (IBM Corp., Armonk, NY, USA). Results Two hundred and sixty-four patients had esophageal varices and 102 presented with variceal hemorrhage. Mean PALBI, CTP and MELD-Na scores were significantly higher for patients with varices versus without varices (p < 0.05). Unlike the mean MELD-Na score, the mean PALBI and CTP scores were significantly higher in patients with large high-risk varices as compared to patients with small low-risk varices (p < 0.05). The mean CTP scores were significantly higher in patients with variceal hemorrhage than those without hemorrhage (p < 0.05), while the difference between mean PALBI and MELD-Na was insignificant, in this regard. The PALBI score had better sensitivity than the CTP and MELD-Na scores in indicating the presence of varices but was similar to the CTP score in predicting high-risk varices. Conclusion The PALBI score proves to have good utility and efficiency in predicting varices in comparison to CTP and MELD-Na scores. It can determine high-risk stigmata of variceal hemorrhage with similar performance as the CTP Score.

Analysis of Complications and Risk Factors Other than Bleeding before and after Endoscopic Treatment of Esophagogastric Variceal Bleeding in Patients with Liver Cirrhosis

Objective. To identify any concomitant complications other than bleeding (COTB) before and after endoscopic treatment of esophagogastric variceal bleeding (EGVB) in liver cirrhosis patients and explore the underlying risk factors. Materials and Methods. Cirrhotic patients complicated with EGVB, who underwent interventional endoscopic treatments in our hospital from November 2017 to August 2020, were enrolled in this study. Clinical data were retrospectively analyzed for COTB at admission and within 2 years of the first endoscopic treatment. Patients were screened for potential risk factors of COTB before and after the treatment. Univariate analysis was performed to identify clinical factors of secondary complications, and statistically significant factors were included in the multivariate Cox and logistic regression analyses. Results. Of the 547 patients with cirrhosis, 361 individuals had COTB in the first endoscopic treatment. In this cohort, the top 3 prevalent incidences were portal vein thrombosis (PVT) or spongiosis, cholelithiasis, and pathogenic infections. The COTB did not occur at admission in 171 liver cirrhosis patients but happened at the follow-up. Higher Child-Pugh scores indicated potential risks of multiple concurrent complications, including bleeding. Risk factors for concomitant PVT or cavernous changes after endoscopic treatment of EGVB, pathogenic infections, and cholelithiasis could prolong the cirrhosis symptoms, while noncholestatic cirrhosis patients might have a lower risk than posthepatitis B cirrhosis patients, in the context of a higher degree of EGV and serum level of D-D and a lower blood calcium level. Conclusions. Clinical treatment and interventions can be tailored to avoid other complications during and after EGVB treatment, which can affect the outcome and prognosis of bleeding symptoms.

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

Background

At the present time, in patients with liver cirrhosis and gastroesophageal varices, primary prophylaxis of variceal bleeding made with combination therapy with non-selective β-blockers (NSBBs) and endoscopic band ligation (EBL) is not recommended. The aim of this study was to evaluate if patients with worsening varices while on NSBBs regimen benefit, in terms of bleeding and survival, from adding treatment with EBL.

Methods

Patients with cirrhosis and endoscopic finding of gastroesophageal varices with high risk feature (increased variceal size and/or development of red signs) during primary prophylaxis with NSBBs, followed at the Unit of Internal Medicine and Hepatology, University and General Hospital of Padova, Italy, from 2012 to 2019, were retrospectively evaluated. When an increased bleeding risk of the varices was confirmed, patients maintained the pharmacological therapy alone or underwent also EBL. The primary endpoint of the study was the rate of variceal bleeding, the secondary endpoint was mortality at 30 months.

Results

Compared to patients treated only with NSBBs (n=56), in patients treated also with EBL (n=45), the 30‐month probability of variceal bleeding (29.1% vs 5.1%; P =0.036) was significantly reduced, while the probability of survival was similar (59.6% vs 65.7%; P=0.61). On multivariate analysis, treatment with EBL was found to be a weak protective factor for mortality (HR 0.47, P=0.044).

Conclusion

In patients with liver cirrhosis, when varices show endoscopic feature of increased haemorrhagic risk, adding EBL to NSBBs is effective in reducing the probability of first bleeding.

Topical Issues in Diagnosis of Coagulopathies and Prevention of Thromboembolic Complications of Atrial Fibrillation in Patients with Liver Cirrhosis

Nowadays the comorbid pathology of liver cirrhosis and atrial fibrillation has been widely discussed and reported in the literature in the light of recent findings from the study of the effectiveness and safety of anticoagulants in this category of patients. The review is devoted to summarizing the existing data on the comorbid course of these diseases from the point of view of the impact of bleeding and thrombosis on the quality of life and mortality of patients and the possibility of using new methods of diagnosis and prevention of these complications. The purpose of the review is to focus the attention of physicians and researches on the relevance and prevalence of comorbid course of liver cirrhosis and atrial fibrillation, their complications, and discuss the benefits and possibilities of applying global methods of hemostasis assessment and anticoagulants in clinical practice. This article examines the main pathophysiological aspects of «rebalanced hemostasis» theory in liver coagulopathies, its effect on the onset of bleeding and thrombotic events, and considering the clinical benefit of the use of anticoagulants. The disadvantages of traditional coagulation assessment tests compared to the benefits of thromboelastometry (ROTEM) and thromboelastography (TEG), general fulfilling principles and evaluation of their indicators are discussed. Existing research findings on the safety and efficacy of warfarin and direct oral anticoagulants in patients with liver cirrhosis and atrial fibrillation compared with no treatment are highlighted.

Cirrhotic portal hypertension: From pathophysiology to novel therapeutics

Portal hypertension and bleeding from gastroesophageal varices is the major cause of morbidity and mortality in patients with cirrhosis. Portal hypertension is initiated by increased intrahepatic vascular resistance and a hyperdynamic circulatory state. The latter is characterized by a high cardiac output, increased total blood volume and splanchnic vasodilatation, resulting in increased mesenteric blood flow. Pharmacological manipulation of cirrhotic portal hypertension targets both the splanchnic and hepatic vascular beds. Drugs such as angiotensin converting enzyme inhibitors and angiotensin II type receptor 1 blockers, which target the components of the classical renin angiotensin system (RAS), are expected to reduce intrahepatic vascular tone by reducing extracellular matrix deposition and vasoactivity of contractile cells and thereby improve portal hypertension. However, these drugs have been shown to produce significant off-target effects such as systemic hypotension and renal failure. Therefore, the current pharmacological mainstay in clinical practice to prevent variceal bleeding and improving patient survival by reducing portal pressure is non-selective -blockers (NSBBs). These NSBBs work by reducing cardiac output and splanchnic vasodilatation but most patients do not achieve an optimal therapeutic response and a significant proportion of patients are unable to tolerate these drugs. Although statins, used alone or in combination with NSBBs, have been shown to improve portal pressure and overall mortality in cirrhotic patients, further randomized clinical trials are warranted involving larger patient populations with clear clinical end points. On the other hand, recent findings from studies that have investigated the potential use of the blockers of the components of the alternate RAS provided compelling evidence that could lead to the development of drugs targeting the splanchnic vascular bed to inhibit splanchnic vasodilatation in portal hypertension. This review outlines the mechanisms related to the pathogenesis of portal hypertension and attempts to provide an update on currently available therapeutic approaches in the management of portal hypertension with special emphasis on how the alternate RAS could be manipulated in our search for development of safe, specific and effective novel therapies to treat portal hypertension in cirrhosis.

Management of gastroesophageal varices in cirrhotic patients: current status and future directions

Bleeding from gastroesophageal varices (GEV) is a serious event in cirrhotic patients and can cause death. According to the explosion theory, progressive portal hypertension is the primary mechanism underlying variceal bleeding. There are two approaches for treating GEV: primary prophylaxis to manage bleeding or emergency treatment for bleeding followed by secondary prophylaxis. Treatment methods can be classified into two categories: 1) Those used to decrease portal pressure, such as medication (i.e., nonselective β-blockers), radiological intervention [transjugular intrahepatic portosystemic shunt (TIPS)] or a surgical approach (i.e., portacaval shunt), and 2) Those used to obstruct GEV, such as endoscopy [endoscopic variceal ligation (EVL), endoscopic injection sclerotherapy (EIS), and tissue adhesive injection] or radiological intervention [balloon-occluded retrograde transvenous obliteration (BRTO)]. Clinicians should choose a treatment method based on an understanding of its efficacy and limitations. Furthermore, elastography techniques and serum biomarkers are noninvasive methods for estimating portal pressure and may be helpful in managing GEV. The impact of these advances in cirrhosis therapy should be evaluated for their effectiveness in treating GEV.

Venous thromboembolism in cirrhosis

The cirrhosis population represents a unique subset of patients who are at risk for both bleeding and developing venous thromboembolic events (VTEs). It has been commonly misunderstood that these patients are naturally protected from thrombosis by deficiencies in coagulation factors. As a result, the cirrhosis population is often falsely perceived to be "autoanticoagulated." However, the concept of "autoanticoagulation" conferring protection from thrombosis is a misnomer. While patients with cirrhosis may have a bleeding predisposition, not uncommonly they also experience thrombotic events. The concern for this increased bleeding risk often makes anticoagulation a difficult choice. Prophylactic and therapeutic management of VTE in patients with cirrhosis is a difficult clinical problem with the lack of clear established guidelines. The elucidation of laboratory and/or clinical predictors of VTE will be useful in this setting. This review serves to examine VTE and the use of anticoagulation in the cirrhosis population.

Lack of a correlation between portal vein flow and pressure: toward a shared interpretation of hemodynamic stress governing inflow modulation in liver transplantation

The portal vein flow (PVF), portal vein pressure (PVP), and hepatic venous pressure gradient (HVPG) were prospectively assessed to explore their relationships and to better define hyperflow and portal hypertension (PHT) during liver transplantation (LT). Eighty-one LT procedures were analyzed. No correlation between PVF and PVP was observed. Increases in the central venous pressure (CVP) were transmitted to the PVP (58%, range = 25%-91%, P = 0.001). Severe PHT (HVPG ≥ 15 mm Hg) showed a significant reciprocal association with high PVF (P = 0.023) and lower graft survival (P = 0.04). According to this initial experience, an HVPG value ≥ 15 mm Hg is a promising tool for the evaluation of hemodynamic stress potentially influencing outcomes. An algorithm for graft inflow modulation based on flows, gradients, and systemic hemodynamics is provided. In conclusion, the evaluation of PHT severity with PVP could be delusive because of the influence of CVP. PVF and PVP do not correlate and should not be used individually to assess hyperflow and PHT during LT.

Avaliação do volume de fluxo portal em pacientes esquistossomóticos: estudo comparativo entre ressonância magnética e ultrassom Doppler

OBJETIVO: Avaliar a concordância entre o ultrassom Doppler e a ressonância magnética e a reprodutibilidade interobservador desses métodos na quantificação do volume de fluxo portal em indivíduos esquistossomóticos. MATERIAIS E MÉTODOS: Foi realizado estudo transversal, observacional e autopareado, avaliando 21 pacientes portadores de esquistossomose hepatoesplênica submetidos a mensuração do fluxo portal por meio de ressonância magnética (utilizando-se a técnica phase-contrast) e ultrassom Doppler. RESULTADOS: Observou-se baixa concordância entre os métodos (coeficiente de correlação intraclasse: 34,5% [IC 95%]). A reprodutibilidade interobservador na avaliação pela ressonância magnética (coeficiente de correlação intraclasse: 99,2% [IC 95%] / coeficiente de correlação de Pearson: 99,2% / média do fluxo portal = 0,806) e pelo ultrassom Doppler (coeficiente de correlação intraclasse: 80,6% a 93,0% [IC 95%] / coeficiente de correlação de Pearson: 81,6% a 92,7% / média do fluxo portal = 0,954, 0,758 e 0,749) foi excelente. CONCLUSÃO: Há uma baixa concordância entre o ultrassom Doppler e a ressonância magnética na mensuração do volume de fluxo na veia porta. A ressonância magnética e o ultrassom Doppler são métodos reprodutíveis na quantificação do fluxo portal em pacientes portadores de hipertensão porta de origem esquistossomótica, apresentando boa concordância interobservador

Prospective evaluation of intraoperative hemodynamics in liver transplantation with whole, partial and DCD grafts

The interaction of systemic hemodynamics with hepatic flows at the time of liver transplantation (LT) has not been studied in a prospective uniform way for different types of grafts. We prospectively evaluated intraoperative hemodynamics of 103 whole and partial LT. Liver graft hemodynamics were measured using the ultrasound transit time method to obtain portal (PVF) and arterial (HAF) hepatic flow. Measurements were recorded on the native liver, the portocaval shunt, following reperfusion and after biliary anastomosis. After LT HAF and PVF do not immediately return to normal values. Increased PVF was observed after graft implantation. Living donor LT showed the highest compliance to portal hyperperfusion. The amount of liver perfusion seemed to be related to the quality of the graft. A positive correlation for HAF, PVF and total hepatic blood flow with cardiac output was found (p = 0.001). Portal hypertension, macrosteatosis >30%, warm ischemia time and cardiac output, independently influence the hepatic flows. These results highlight the role of systemic hemodynamic management in LT to optimize hepatic perfusion, particularly in LDLT and split LT, where the highest flows were registered.

[Portosystemic shunt in the treatment of portal hypertension]

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Effects of modified splenocaval shunt plus devascularization on esophagogastric variceal bleeding: a comparative study of this treatment and devascularization only in cirrhotic portal hypertension

BACKGROUND

Pericardial devascularization (PCDV) and portosystemic shunt were reported to have favorable results for the management of portal hypertension in cirrhotic patients in China and the West, respectively. This study was undertaken to investigate the effects of a modified proximal splenocaval shunt plus PCDV on variceal bleeding in patients with portal hypertension.

METHODS

From January 1997 to December 2007, 168 patients with portal hypertension of cirrhotic origin received an operation for gastroesophageal variceal bleeding. Of these, 90 patients received a splenocaval shunt plus a PCDV procedure (Combined Group) and the other 78 patients received a PCDV procedure only (PCDV Group). The procedure-related morbidity and mortality, rebleeding, encephalopathy, and survival rates were analyzed.

RESULTS

Postoperative mortality was 3.3% in the combined group and 5.1% in the PCDV group (P > 0.05). Overall morbidity was 13.3% in the combined group and 15.4% in the PCDV group (P > 0.05). The rate for rebleeding, including variceal bleeding and gastropathy, was 5.1% in the combined group, which was significantly lower than that in the PCDV group, at 16.7% (P < 0.05). The incidence of encephalopathy was 6.63% in the combined group and 6.67% in the PCDV group (P > 0.05). The 1-, 3-, 5- and 10-year survival rates were 97.4, 91.7, 80.0, and 60.0% in the combined group and 96.7, 83.3, 73.3, and 53.3% in the PCDV group (P > 0.05).

CONCLUSIONS

The modified splenocaval shunt plus PCDV is a safe and effective procedure for the long-term control of variceal bleeding; the procedure may not only maintain the portal flow to the liver, but may also protect the liver function in cirrhotic patients. The better clinical outcome means that the procedure may be one of the best choices for treating portal hypertension of cirrhotic origin.

Management of Cirrhosis and Associated Complications

Liver cirrhosis is the encapsulation or replacement of injured tissue by collagen, resulting in end-stage liver disease and portal hypertension. The consequences of cirrhosis are impaired hepatocyte function, increase intrahepatic circulatory resistance, portal hypertension, and the development of hepatocellular carcinoma. Complications include encephalopathy, coagulopathy, varices, ascites, spontaneous bacterial peritonitis, epatorenal syndrome, and hepatopulmonary syndrome. Managing patients with acute or chronic liver failure is challenging, and liver failure may have profound effects on other organ systems. Most therapies are directed at managing the complications and bridging patients to liver transplantation. The clinician must be aware of the pathologic presentations and the appropriate management, including pharmacologic and nonpharmacologic therapies, goals and end points of therapy, and monitoring of therapy. This review focuses on the management of the complications directly associated with liver dysfunction (encephalopathy and coagulopathy) and portal hypertension (varices, ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, hepatopulmonary syndrome).

Hyperfibrinolysis in liver disease

The incidence of hyperfibrinolysis in patients with cirrhosis is still debated. The reasons for this uncertainty probably lie in the lack of appropriate laboratory tests for its evaluation. There is a relative consensus, however, that hyperfibrinolysis can complicate the clinical course of liver cirrhosis, especially in cases of moderate to severe liver failure. Hyperfibrinolysis correlates positively with the severity of underlying liver disease, and low-grade systemic fibrinolysis is found in 30% to 46% of patients who have end-stage liver disease. Accelerated intravascular coagulation with secondary hyperfibrinolysis has been reported in patients who have liver failure. Hyperfibrinolysis may delay primary hemostasis, thereby aggravating variceal bleeding and facilitating recurrence.

Current management of the complications of portal hypertension: variceal bleeding and ascites

Portal hypertension is one of the main consequences of cirrhosis. It results from a combination of increased intrahepatic vascular resistance and increased blood flow through the portal venous system. The condition leads to the formation of portosystemic collateral veins. Esophagogastric varices have the greatest clinical impact, with a risk of bleeding as high as 30% within 2 years of medium or large varices developing. Ascites, another important complication of advanced cirrhosis and severe portal hypertension, is sometimes refractory to treatment and is complicated by spontaneous bacterial peritonitis and hepatorenal syndrome. We describe the pathophysiology of portal hypertension and the current management of its complications, with emphasis on the prophylaxis and treatment of variceal bleeding and ascites.