The recent reduction in mortality from bleeding oesophageal varices is primarily observed from Days 1 to 5

Cirrhosis epidemiology in Denmark 1998-2022, and 2030 forecast

Background & Aims

The incidence of cirrhosis resulting from alcohol-related liver disease (ALD) is decreasing in Denmark, whereas the incidence of obesity is increasing, driving an increase in metabolic dysfunction-associated steatotic liver disease (MASLD). We aimed to perform an up-to-date study of the epidemiology of cirrhosis in Denmark, including etiologies, and a forecast through to 2030.

Methods

We identified all patients diagnosed with cirrhosis between 1998 and 2022, categorized into ALD and non-ALD cirrhosis, in nationwide Danish healthcare registries. Cirrhosis prevalence and incidence were computed. We used an age-period-cohort model to visualize impacts of age, calendar year, and birthyear on etiology-specific cirrhosis incidence rates (alcohol or non-alcohol, interpreted as mainly the result of MASLD), with predicted incidence rates for 2023-2030. The Kaplan-Meier function was used for survival probabilities.

Results

We included 30,747 (76%) patients with ALD cirrhosis and 9,548 (24%) with non-ALD cirrhosis. Patients with non-ALD cirrhosis were older and had more comorbidities compared with patients with ALD cirrhosis; median age at diagnosis was 66 vs. 59 years, increasing in both groups overall, from 56 years in 1998 to 66 years in 2022. The ALD cirrhosis proportion was stable at around 80% from 1998 to the end of 2014, and gradually declined to 58% in 2022. Overall cirrhosis prevalence will have peaked in 2024, and non-ALD cirrhosis will outnumber ALD cirrhosis from 2027. Thus, mortality among patients with cirrhosis is declining owing to fewer deaths the first year after cirrhosis diagnosis.

Conclusions

We forecast a change in cirrhosis epidemiology affecting hepatology practice in Denmark: patients will be older, fewer will have ALD, more will have MASLD, and their longer life expectancy and comorbidities will be more burdensome for healthcare systems.

Impact and implications

Alcohol-related liver (ALD) cirrhosis poses a substantial and growing burden on hospitals worldwide. Information about the current and imminent epidemiology of cirrhosis is important for our understanding of the public health, for researchers designing trials of interventions, and for planning of future assignments of healthcare systems. In the current study, we used Danish nationwide healthcare registries to study past, current, and future trends in the epidemiology of cirrhosis. Our results forecast a change in cirrhosis epidemiology and thereby a change in hepatology practice in Denmark. We expect that patients with ALD cirrhosis will be outnumbered by increasingly older patients who present in the outpatient clinic with cirrhosis from MASLD and a higher burden of comorbidities.

Time trends in mortality and life expectancy in 22,658 patients hospitalized with alcohol-associated cirrhosis: A nationwide cohort study

BACKGROUND

The management of alcohol-associated cirrhosis has improved in the last decades, but whether the prognosis has changed over time is uncertain. We aimed to assess time trends in mortality and life expectancy in patients hospitalized with alcohol-associated cirrhosis.

METHODS

In this population-based cohort study, we used the Swedish national population and health registers to identify all patients with a first episode of in-hospital alcohol-associated cirrhosis from 1969 to 2019 (n = 22,658). Time trends in 1-year mortality were assessed with multivariable Cox regression. A flexible parametric model was fitted to evaluate loss in life expectancy.

RESULTS

Crude mortality was similar in the 2010s and 1980s (unadjusted HR = 1.00, 95% CI = 0.93-1.08, ptrend = 0.767). However, when adjusting for baseline characteristics, mortality was lower in the 2010s than in the 1980s (adjusted HR = 0.74, 95% CI = 0.68-0.80), including both liver- and nonliver-related mortalities. These results were consistent in men but not in women, where only nonliver mortality had decreased. The average loss in life expectancy for patients with alcohol-associated cirrhosis compared with the general population was similar throughout the study period (in the 2010s: 14.3 y shorter (95% CI = 13.7-14.9) in men and 15.8 years shorter (95% CI = 14.9-16.7) in women).

CONCLUSION

Mortality in patients hospitalized with alcohol-associated cirrhosis has improved somewhat when accounting for baseline characteristics, but the loss in life expectancy remains substantial. This underscores the need for new therapeutic options and health policy interventions to further improve the dismal prognosis and life expectancy of patients with alcohol-associated cirrhosis.

The efficacy comparison of carvedilol plus endoscopic variceal ligation and traditional, nonselective β-blockers plus endoscopic variceal ligation in cirrhosis patients for the prevention of variceal rebleeding: a meta-analysis

BACKGROUND

Currently, the first-line treatment regimen in cirrhotic patients for variceal rebleeding prophylaxis is still under debate.

AIM

This study aimed to compare the efficacy and safety of carvedilol plus endoscopic variceal ligation (EVL) and traditional, nonselective β-blockers (NSBBs) plus EVL in preventing variceal rebleeding.

PATIENTS AND METHODS

Studies were found in PubMed, the Cochrane Library, China National Knowledge Infrastructure, Wanfang Med Online, and Wiper Database. Review Manager 5.3 was used to analyze the relevant data.

RESULTS

Nine trials including 802 patients were identified (402 for carvedilol and 400 for traditional NSBBs). Carvedilol was more efficacious than traditional NSBBs in decreasing the variceal rebleeding rate [odds ratio (OR): 0.53; 95% confidence interval (CI): 0.38-0.75; P = 0.0003], lowering the degree of esophageal varices (OR: 4.40; 95% CI: 2.64-7.34; P < 0.00001), decreasing the mean arterial pressure (standard mean difference: - 0.35; 95% CI: - 0.56 to - 0.14; P = 0.0009), reducing the total adverse events occurrence (OR: 0.39; 95% CI: 0.28-0.53; P < 0.00001), and decreasing drug-related adverse events (OR: 0.37; 95% CI: 0.25-0.56; P < 0.00001). No difference was noted between carvedilol and traditional NSBBs with respect to mortality and heart rate (OR: 0.72; 95% CI: 0.43; 1.22; P = 0.22 and standard mean difference: 0.09; 95% CI: - 0.12 to 0.30; P = 0.40, respectively).

CONCLUSION

Combined with variceal ligation, carvedilol was more effective and safer than traditional NSBBs in the prevention of rebleeding in cirrhotic patients.

Band ligation versus beta-blockers for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis

BACKGROUND

Portal hypertension commonly accompanies advanced liver disease and often gives rise to life-threatening complications, including haemorrhage from oesophageal and gastrointestinal varices. Variceal haemorrhage commonly occurs in children with chronic liver disease or portal vein obstruction. Prevention is therefore important. Following numerous randomised clinical trials demonstrating efficacy of non-selective beta-blockers and endoscopic variceal ligation in decreasing the incidence of variceal haemorrhage, primary prophylaxis of variceal haemorrhage in adults has become the established standard of care. Hence, band ligation and beta-blockers have been proposed to be used as primary prophylaxis of oesophageal variceal bleeding in children.

OBJECTIVES

To determine the benefits and harms of band ligation compared with any type of beta-blocker for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis.

SEARCH METHODS

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register (February 2019), CENTRAL (December 2018), PubMed (December 2018), Embase Ovid (December 2018), LILACS (Bireme; January 2019), and Science Citation Index Expanded (Web of Science; December 2018). We scrutinised the reference lists of the retrieved publications and performed a manual search from the main paediatric gastroenterology and hepatology conferences (NASPGHAN and ESPGHAN) abstract books from 2009 to 2018. We searched ClinicalTrials.gov for ongoing clinical trials. There were no language or document type restrictions.

SELECTION CRITERIA

We planned to include randomised clinical trials irrespective of blinding, language, or publication status for assessment of benefits and harms. We planned to also include quasi-randomised and other observational studies retrieved with the searches for randomised clinical trials for report of harm.

DATA COLLECTION AND ANALYSIS

We planned to summarise data from randomised clinical trials using standard Cochrane methodologies.

MAIN RESULTS

We found no randomised clinical trials assessing band ligation versus beta-blockers for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis.

AUTHORS' CONCLUSIONS

Randomised clinical trials assessing the benefits or harms of band ligation versus beta-blockers for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis are lacking. There is a need for well-designed, adequately powered randomised clinical trials to assess the benefits and harms of band ligation versus beta-blockers for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. Those randomised clinical trials should include patient-relevant clinical outcomes such as mortality, failure to control bleeding, and adverse events.

Band ligation versus no intervention for primary prevention of upper gastrointestinal bleeding in adults with cirrhosis and oesophageal varices

BACKGROUND

The presence of oesophageal varices is associated with the risk of upper gastrointestinal bleeding. Endoscopic variceal ligation is used to prevent this occurrence but the ligation procedure may be associated with complications.

OBJECTIVES

To assess the beneficial and harmful effects of band ligation versus no intervention for primary prevention of upper gastrointestinal bleeding in adults with cirrhosis and oesophageal varices.

SEARCH METHODS

We combined searches in the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, and Science Citation Index with manual searches. The last search update was 9 February 2019.

SELECTION CRITERIA

We included randomised clinical trials comparing band ligation verus no intervention regardless of publication status, blinding, or language in the analyses of benefits and harms, and observational studies in the assessment of harms. Included participants had cirrhosis and oesophageal varices with no previous history of variceal bleeding.

DATA COLLECTION AND ANALYSIS

Three review authors extracted data independently. The primary outcome measures were all-cause mortality, upper gastrointestinal bleeding, and serious adverse events. We undertook meta-analyses and presented results using risk ratios (RRs) with 95% confidence intervals (CIs) and I² values as a marker of heterogeneity. In addition, we calculated the number needed to treat to benefit (NNTTB) for the primary outcomes . We assessed bias control using the Cochrane Hepato-Biliary domains; determined the certainty of the evidence using GRADE; and conducted sensitivity analyses including Trial Sequential Analysis.

MAIN RESULTS

Six randomised clinical trials involving 637 participants fulfilled our inclusion criteria. One of the trials included an additional small number of participants (< 10% of the total) with non-cirrhotic portal hypertension/portal vein block. We classified one trial as at low risk of bias for the outcome, mortality and high risk of bias for the remaining outcomes; the five remaining trials were at high risk of bias for all outcomes. We downgraded the evidence to moderate certainty due to the bias risk. We gathered data on all primary outcomes from all trials. Seventy-one of 320 participants allocated to band ligation compared to 129 of 317 participants allocated to no intervention died (RR 0.55, 95% CI 0.43 to 0.70; I² = 0%; NNTTB = 6 persons). In addition, band ligation was associated with reduced risks of upper gastrointestinal bleeding (RR 0.44, 95% CI 0.28 to 0.72; 6 trials, 637 participants; I² = 61%; NNTTB = 5 persons), serious adverse events (RR 0.55, 95% CI 0.43 to 0.70; 6 trials, 637 participants; I² = 44%; NNTTB = 4 persons), and variceal bleeding (RR 0.43, 95% CI 0.27 to 0.69; 6 trials, 637 participants; I² = 56%; NNTTB = 5 persons). The non-serious adverse events reported in association with band ligation included oesophageal ulceration, dysphagia, odynophagia, retrosternal and throat pain, heartburn, and fever, and in the one trial involving participants with either small or large varices, the incidence of non-serious side effects in the banding group was much higher in those with small varices, namely ulcers: small versus large varices 30.5% versus 8.7%; heartburn 39.2% versus 17.4%. No trials reported on health-related quality of life.Two trials did not receive support from pharmaceutical companies; the remaining four trials did not provide information on this issue.

AUTHORS' CONCLUSIONS

This review found moderate-certainty evidence that, in patients with cirrhosis, band ligation of oesophageal varices reduces mortality, upper gastrointestinal bleeding, variceal bleeding, and serious adverse events compared to no intervention. It is unlikely that further trials of band ligation versus no intervention would be considered ethical.

Carvedilol versus traditional, non-selective beta-blockers for adults with cirrhosis and gastroesophageal varices

BACKGROUND

Non-selective beta-blockers are recommended for the prevention of bleeding in people with cirrhosis, portal hypertension and gastroesophageal varices. Carvedilol is a non-selective beta-blocker with additional intrinsic alpha₁-blocking effects, which may be superior to traditional, non-selective beta-blockers in reducing portal pressure and, therefore, in reducing the risk of upper gastrointestinal bleeding.

OBJECTIVES

To assess the beneficial and harmful effects of carvedilol compared with traditional, non-selective beta-blockers for adults with cirrhosis and gastroesophageal varices.

SEARCH METHODS

We combined searches in the Cochrane Hepato-Biliary's Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, and Science Citation Index with manual searches. The last search update was 08 May 2018.

SELECTION CRITERIA

We included randomised clinical trials comparing carvedilol versus traditional, non-selective beta-blockers, irrespective of publication status, blinding, or language. We included trials evaluating both primary and secondary prevention of upper gastrointestinal bleeding in adults with cirrhosis and verified gastroesophageal varices.

DATA COLLECTION AND ANALYSIS

Three review authors (AZ, RJ and LH), independently extracted data. The primary outcome measures were mortality, upper gastrointestinal bleeding and serious adverse events. We undertook meta-analyses and presented results using risk ratios (RR) or mean differences (MD), both with 95% confidence intervals (CIs), and I² values as a marker of heterogeneity. We assessed bias control using the Cochrane Hepato-Biliary domains and the quality of the evidence with GRADE.

MAIN RESULTS

Eleven trials fulfilled our inclusion criteria. One trial did not report clinical outcomes. We included the remaining 10 randomised clinical trials, involving 810 participants with cirrhosis and oesophageal varices, in our analyses. The intervention comparisons were carvedilol versus propranolol (nine trials), or nadolol (one trial). Six trials were of short duration (mean 6 (range 1 to 12) weeks), while four were of longer duration (13.5 (6 to 30) months). Three trials evaluated primary prevention; three evaluated secondary prevention; while four evaluated both primary and secondary prevention. We classified all trials as at 'high risk of bias'. We gathered mortality data from seven trials involving 507 participants; no events occurred in four of these. Sixteen of 254 participants receiving carvedilol and 19 of 253 participants receiving propranolol or nadolol died (RR 0.86, 95% CI 0.48 to 1.53; I² = 0%, low-quality evidence). There appeared to be no differences between carvedilol versus traditional, non-selective beta-blockers and the risks of upper gastrointestinal bleeding (RR 0.77, 95% CI 0.43 to 1.37; 810 participants; 10 trials; I² = 45%, very low-quality evidence) and serious adverse events (RR 0.97, 95% CI 0.67 to 1.42; 810 participants; 10 trials; I² = 14%, low-quality evidence). Significantly more deaths, episodes of upper gastrointestinal bleeding and serious adverse events occurred in the long-term trials but there was not enough information to determine whether there were differences between carvedilol and traditional, non-selective beta-blockers, by trial duration. There was also insufficient information to detect differences in the effects of these interventions in trials evaluating primary or secondary prevention. There appeared to be no differences in the risk of non-serious adverse events between carvedilol versus its comparators (RR 0.55, 95% CI 0.23 to 1.29; 596 participants; 6 trials; I² = 88%; very low-quality evidence). Use of carvedilol was associated with a greater reduction in hepatic venous pressure gradient than traditional, non-selective beta-blockers both in absolute (MD -1.75 mmHg, 95% CI -2.60 to -0.89; 368 participants; 6 trials; I² = 0%; low-quality evidence) and percentage terms (MD -8.02%, 95% CI -11.49% to -4.55%; 368 participants; 6 trials; I² = 0%; low-quality evidence). However, we did not observe a concomitant reduction in the number of participants who failed to achieve a sufficient haemodynamic response (RR 0.76, 95% CI 0.57 to 1.02; 368 participants; 6 trials; I² = 42%; very low-quality evidence) or in clinical outcomes.

AUTHORS' CONCLUSIONS

We found no clear beneficial or harmful effects of carvedilol versus traditional, non-selective beta-blockers on mortality, upper gastrointestinal bleeding, serious or non-serious adverse events despite the fact that carvedilol was more effective at reducing the hepatic venous pressure gradient. However, the evidence was of low or very low quality, and hence the findings are uncertain. Additional evidence is required from adequately powered, long-term, double-blind, randomised clinical trials, which evaluate both clinical and haemodynamic outcomes.

Advances in the treatment of portal hypertension in cirrhosis

Non-selective beta-blockers and handling of esophageal varices has been key elements in the treatment of portal hypertension in recent decades. Liver vein catheterization has been essential in diagnosis and monitoring of portal hypertension, but ongoing needs for noninvasive tools has led to research in areas of both biomarkers, and transient elastography, which displays promising results in discerning clinically significant portal hypertension. Novel research into the areas of hepatic stellate cell function and the dynamic components of portal hypertension has revealed promising areas of treatment modalities, targeting intestinal decontamination, angiogenesis, inflammation and oxidative stress. Future studies may reveal if these initiatives lead to developments of new drugs for treatment of portal hypertension.

Role of self-expanding metal stents in the management of variceal haemorrhage: Hype or hope?

Despite the advances of medical, endoscopic and radiological therapy over recent years the mortality rates of acute variceal haemorrhage are still 16%-20% and the medium term outcome has not improved in the last 25 years. Early transjugular intrahepatic portosystemic shunt has proved to be an effective therapy for selected groups of patients with a high risk of re-bleeding and moderate liver disease. However, there is an unmet need for a therapy that can be applied in patients with a high risk of re-bleeding and advanced liver disease either as definitive therapy or as a bridge to permanent therapy. Self-expanding metal stents can be placed without the need for endoscopic or fluoroscopic control and, once in place, will provide effective haemostasis and allow a route for oral fluids and nutrition. They can remain in place whilst liver function recovers and secondary prophylaxis is initiated. We review the results of 6 case series including a total of 83 patients and the first randomised controlled trial of self-expanding metal stents vs balloon tamponade (BT) in the management of refractory variceal haemorrhage. We report that self-expanding metal stents provide effective haemostasis and perform better than BT in refractory bleeding, where they are associated with fewer complications. Whilst the most effective place for self-expanding metal stents in the management algorithm needs to be determined by further randomised controlled trials, currently they provide an effective alternative to BT in selected patients.

Prognosis of acute variceal bleeding: Is being on beta-blockers an aggravating factor? A short-term survival analysis

Nonselective beta-blockers (NSBB) are widely used because they have been proved effective in the prophylaxis of acute variceal bleeding (AVB). However, a significant proportion of patients still experience AVB while on treatment with NSBB, and its impact on prognosis of AVB is unknown. The present study was aimed at assessing the effect of being on prophylactic therapy with NSBB on 5-day failure and 6-week mortality of patients with cirrhosis admitted with AVB. Included were 142 patients: 49 were receiving prophylactic therapy with NSBB (NSBB group) and 93 were not (control group). There were some differences in the baseline characteristics between the groups: higher proportion of alcoholic etiology and active alcoholism (37% versus 10%), higher platelet count, and lower hematocrit at admission in the control group. However, the severity of AVB and initial treatment were similar. Five-day failure occurred in 20% of patients (14% in NSBB versus 24% in controls, P = 0.27). The adjusted odds ratio for 5-day failure under NSBB was 2.46 (95% confidence interval 0.53-11.37, P = 0.25). Nineteen patients (13%) died, and two had liver transplantation within 6 weeks. The probability of survival at 6 weeks was 96% in the NSBB group and 82% in the control group (P = 0.02). After adjusting by propensity score and Model for End-Stage Liver Disease score, the NSBB adjusted odds ratio for 6-week mortality was 0.38 (95% confidence interval 0.05-2.63, P = 0.32). The estimated association between NSBB with both 5-day failure and 6-week mortality was homogenous across all Model for End-Stage Liver Disease spectrums.

CONCLUSION

Prophylactic NSBB treatment is not a negative prognostic indicator for the short-term survival of patients with cirrhosis admitted with AVB.

Acute-on-chronic liver failure

Acute-on-chronic liver failure combines an acute deterioration in liver function in an individual with pre-existing chronic liver disease and hepatic and extrahepatic organ failures, and is associated with substantial short-term mortality. Common precipitants include bacterial and viral infections, alcoholic hepatitis, and surgery, but in more than 40% of patients, no precipitating event is identified. Systemic inflammation and susceptibility to infection are characteristic pathophysiological features. A new diagnostic score, the Chronic Liver Failure Consortium (CLIF-C) organ failure score, has been developed for classification and prognostic assessment of patients with acute-on-chronic liver failure. Disease can be reversed in many patients, and thus clinical management focuses upon the identification and treatment of the precipitant while providing multiorgan-supportive care that addresses the complex pattern of physiological disturbance in critically ill patients with liver disease. Liver transplantation is a highly effective intervention in some specific cases, but recipient identification, organ availability, timing of transplantation, and high resource use are barriers to more widespread application. Recognition of acute-on-chronic liver failure as a clinically and pathophysiologically distinct syndrome with defined diagnostic and prognostic criteria will help to encourage the development of new management pathways and interventions to address the unacceptably high mortality.

Addition of Somatostatin After Successful Endoscopic Variceal Ligation Does not Prevent Early Rebleeding in Comparison to Placebo: A Double Blind Randomized Controlled Trial

BACKGROUND

Efficacy of endoscopic sclerotherapy in controlling acute variceal bleeding is significantly improved when vasoactive drug is added. Endoscopic variceal ligation (EVL) is superior to sclerotherapy. Whether efficacy of EVL will also improve with addition of somatostatin is not known. We compared EVL plus somatostatin versus EVL plus placebo in control of acute variceal bleeding.

METHODS

Consecutive cirrhotic patients with acute esophageal variceal bleeding were enrolled. After emergency EVL, patients were randomized to receive either somatostatin (250 mcg/hr) or placebo infusion. Primary endpoint was treatment failure within 5 days. Treatment failure was defined as fresh hematemesis ≥2 h after start of therapy, or a 3 gm drop in Hb, or death.

RESULTS

61 patients were enrolled (EVL plus somatostatin group, n = 31 and EVL plus placebo group, n = 30). The baseline characteristics were similar. Within the initial 5-day period, the frequency of treatment failure was similar in both the groups (EVL plus somatostatin group 8/31 [26%] versus EVL plus placebo group 7/30 [23%]; P = 1.000). The mortality was also similar in the two groups (3/31 [10%] vs. 3/30 [10%]; P = 1.000). Baseline HVPG ≥19 mm Hg and active bleeding at index endoscopy were independent predictors of treatment failure.

CONCLUSIONS

Addition of somatostatin infusion to EVL therapy does not offer any advantage in control of acute variceal bleeding or reducing mortality. The reason for this may be its failure to maintain sustained reduction in portal pressure for five days. Active bleeding at index endoscopy and high baseline HVPG should help choose early alternative treatment options. Trial registered with ClincalTrials.gov vide NCT01267669.

Complications of cirrhosis. A 50 years flashback

In patients with cirrhosis and portal hypertension, it is largely the frequency and severity of complications relating to the diseased liver, degree of portal hypertension and hemodynamic derangement that determine the prognosis. It can be considered as a multiple organ failure that apart from the liver involves the heart, lungs, kidneys, the immune systems and other organ systems. Progressive fibrosis of the liver and subsequent metabolic impairment leads to a systemic and splanchnic arteriolar vasodilatation. With the progression of the disease development of portal hypertension leads to formation of esophageal varices and ascites. The circulation becomes hyperdynamic with cardiac, pulmonary as well as renal consequences for dysfunction and reduced survival. Infections and a changed cardiac function known as cirrhotic cardiomyopathy may be involved in further aggravation of other complications such as renal failure precipitating the hepatorenal syndrome. Patients with end-stage liver disease and related complications as for example the hepatopulmonary syndrome can only radically be treated by liver transplantation.

Effect of recombinant Factor VIIa on outcome of acute variceal bleeding: an individual patient based meta-analysis of two controlled trials

BACKGROUND & AIMS

Two randomized controlled studies have evaluated the effect of recombinant Factor VIIa (rFVIIa) on variceal bleeding in cirrhosis without showing significant benefit. The aim of the present study was to perform a meta-analysis of the two trials on individual patient data with special focus on high risk patients.

METHODS

The primary outcome measure was the effect of rFVIIa on a composite five day endpoint: failure to control bleeding, 5-day rebleeding or death. Analysis was based on intention to treat. High risk was defined as active bleeding on endoscopy while under vasoactive drug infusion and Child-Pugh score >8.

RESULTS

497 patients were eligible for the meta-analysis; 308 (62%) had active variceal bleeding at endoscopy (oozing or spurting) and 283 of these had a Child-Pugh score >8. Analysis on the composite endpoint in all patients with bleeding from oesophageal varices did not show any beneficial treatment effect. However, failure rate for the primary composite end-point was significantly lower in treated patients with active bleeding at endoscopy (17%) compared to placebo (26%, p=0.049). This difference was highly significant in patients with Child-Pugh score >8 and active bleeding at endoscopy (rFVIIa 16%, placebo 27%; p=0.023). No significant treatment effect was found at 42 days. Five thromboembolic events occurred in rFVIIa treated patients compared to none in placebo treated patients.

CONCLUSIONS

The current meta-analysis shows a beneficial effect of rFVIIa on the primary composite endpoint of control of acute bleeding, prevention of rebleeding day 1-5 and 5-day mortality in patients with advanced cirrhosis and active bleeding from oesophageal varices at endoscopy. A major drawback of the treatment is a potential increased risk of arterial thrombo-embolic events. This treatment might be considered in patients with lack of control of bleeding after standard treatment.

Acute variceal haemorrhage in the United Kingdom: patient characteristics, management and outcomes in a nationwide audit

BACKGROUND

Despite advances in treatment, acute variceal haemorrhage remains life-threatening.

AIM

To describe contemporary characteristics, management and outcomes of patients with cirrhosis and acute variceal haemorrhage and risk factors for rebleeding and mortality.

METHODS

Multi-centre clinical audit conducted in 212 UK hospitals.

RESULTS

In 526 cases of acute variceal haemorrhage, 66% underwent endoscopy within 24h with 64% (n=339) receiving endoscopic therapy. Prior to endoscopy, 57% (n=299) received proton pump inhibitors, 44% (n=232) vasopressors and 27% (n=144) antibiotics. 73% (n=386) received red cell transfusion, 35% (n=184) fresh frozen plasma and 14% (n=76) platelets, with widely varying transfusion thresholds. 26% (n=135) experienced further bleeding and 15% (n=80) died by day 30. The Model for End Stage Liver Disease score was the best predictor of mortality (area under the receiver operating curve=0.74, P<0.001). Neither the clinical nor full Rockall scores were useful predictors of outcome. Coagulopathy was strongly associated with rebleeding (odds ratio 2.23, 95% CI 1.22-4.07, P=0.01, up to day 30) and mortality (odds ratio 3.06, 95% CI 1.29-7.26, P=0.01).

CONCLUSIONS

Although mortality has improved following acute variceal haemorrhage, rebleeding rates remain appreciably high. There are notable deficiencies in the use of vasopressors and endoscopic therapy. More work is needed to understand the optimum transfusion strategies. Better risk stratification tools are required to identify patients needing more intensive support.

Gastric varices: is there a role for endoscopic cyanoacrylates, or are we entering the BRTO era?

Bleeding from portal hypertension-related gastric varices arising in the cardiofundal region of the stomach presents a challenge due to the unique underlying vascular anatomy which is sometimes underappreciated in endoscopic classification schemes. They often have dominant tributaries from the splenic vein or splenic hilum and terminate in the left renal vein (spontaneous splenorenal or gastrorenal shunts). This may limit the applicability of a transjugular intrahepatic portosystemic shunt (TIPS), because of the shunt's distance from the hilum of the liver. Endoscopically, the presence of a large systemic outflow track also may influence the performance of different cyanoacrylates. However, this anatomy allows an alternative approach, balloon-occluded retrograde transvenous obliteration (BRTO), which accesses the varix via the outflow pathway. Definitive comparisons between TIPS, endoscopic cyanoacrylate, and BRTO will be challenging because the incidence of this type of varix is insufficient for large trials. Here, I provide a perspective based on existing literature, 15 years of experience with various cyanoacrylates, and 4 years of experience with BRTO.

Indications for portal pressure measurement in chronic liver disease

Portal hypertension leads to development of serious complications such as esophageal varices, ascites, renal and cardiovascular dysfunction. The importance of the degree of portal hypertension has been substantiated within recent years. Measurement of the portal pressure is simple and safe and the hepatic venous pressure gradient (HVPG) independently predicts survival and development of complications such as ascites, HCC and bleeding from esophageal varices. Moreover, measurements of HVPG can be used to guide pharmacotherapy for primary and secondary prophylaxis for variceal bleeding. Assessment of HVPG should therefore be considered as a part of the general characterization of patients with portal hypertension in departments assessing and treating this condition.

Meta-analysis: banding ligation and medical interventions for the prevention of rebleeding from oesophageal varices

BACKGROUND

In patients with oesophageal varices, the combination of endoscopic variceal ligation (EVL) and medical therapy is recommended as standard of care for prevention of rebleeding. The results of previous meta-analyses on this topic are equivocal.

AIM

To assess the effects of EVL plus medical therapy vs. monotherapy (EVL or medical therapy alone) for secondary prevention in oesophageal varices.

METHODS

Electronic and manual searches were combined. The primary outcome measures were overall rebleeding (variceal and nonvariceal) and mortality. Random-effects meta-analyses were performed with subgroup, sensitivity, regression and sequential analyses to identify sources of intertrial heterogeneity and the robustness of the results.

RESULTS

Nine randomised trials were included. In total, 442 patients were randomised to combination therapy and 513 to monotherapy. Combination therapy reduced rebleeding (RR = 0.68; 95% CI = 0.54-0.85; number needed to treat eight patients). The result was confirmed in sequential and regression analyses, but not when limiting the analysis to trials with adequate selection bias control. No effect on overall mortality was identified (RR = 0.89; 95% CI = 0.65-1.21). Combination therapy reduced bleeding-related mortality (RR = 0.52; 95% CI 0.27-0.99; number needed to treat 33 patients) and the risk of rebleeding from oesophageal varices. Combination therapy increased the risk of serious adverse events in fixed, but not in random-effects meta-analyses.

CONCLUSIONS

The combination of endoscopic variceal ligation and medical therapy reduce the risk of rebleeding, but not overall mortality. Additional research is needed to determine why reduced rebleeding rates do not lead to reduced mortality.

Carvedilol or propranolol in portal hypertension? A randomized comparison

OBJECTIVES

Carvedilol is a non-selective β-blocker with intrinsic anti-α(1)-adrenergic activity, potentially more effective than propranolol in reducing hepatic venous pressure gradient (HVPG). We compared the long-term effect of carvedilol and propranolol on HVPG and assessed whether the acute response to oral propranolol predicted the long-term HVPG response on either drug.

MATERIAL AND METHODS

HVPG was measured in 38 patients with cirrhosis and HVPG ≥ 12 mm Hg at baseline and then again 90 min after an oral dose of 80 mg propranolol. Patients were double-blinded randomized to either carvedilol (21 patients) or propranolol (17 patients) and after 90 days of treatment HVPG measurements were repeated.

RESULTS

HVPG decreased by 19.3 ± 16.1% (p < 0.01) and by 12.5 ± 16.7% (p < 0.01) in the carvedilol and propranolol groups, respectively, with no significant difference between treatment regimens (p = 0.21). Although insignificant, an acute decrease in HVPG of ≥12% was the best cut-off value to predict long-term HVPG response to propranolol when using ROC curve analysis.

CONCLUSIONS

This randomized study showed that carvedilol is at least as effective as propranolol on HVPG after long-term administration. Furthermore, a predictive value of an acute propranolol test on HVPG could not be confirmed.

Development of quality measures for monitoring and improving care in gastroenterology

Over the past decade, most quality assurance (QA) efforts in gastroenterology have been aimed at endoscopy. Endoscopic quality improvement was the rational area to begin QA work in gastroenterology due to the relatively acute nature of complications and the high volume of procedures performed. While endoscopy is currently the focus of most quality assurance (QA) measures in gastroenterology, more recent efforts have begun to address clinical gastroenterology practices both in the outpatient and inpatient settings. Clinical outpatient and inpatient gastroenterology is laden with areas where standardization could benefit patient care. While data and experience in clinical gastroenterology QA is relatively limited, it is clear that inconsistent use of guidelines and practice variations in gastroenterology can lead to lower quality care. In this review, we review a variety of areas in clinical gastroenterology where existing guidelines and published data suggest both the need and practicality of active QA measures.

Portal hypertension: diagnosis and management with particular reference to variceal hemorrhage

Portal hypertension is a cause a major luminal gut hemorrhage, most often from esophageal varices. Identification of those with varices, and administration of therapies to reduce the likelihood of initial bleeding improve patient outcomes. Beta blocker therapy or variceal band ligation are most often used in this context. Management of acute variceal hemorrhage (including routine use of antibiotics) is followed by initiating strategies to reduce the frequency of recurrent bleeding. Mortality from portal hypertensive bleeding has been diminished by use of these interventions.

Adherence to guidelines in bleeding oesophageal varices and effects on outcome: comparison between a specialized unit and a community hospital

OBJECTIVES

Randomized controlled trials have shown beneficial effects of vasoactive drugs, endoscopic treatment and prophylactic antibiotics on the outcome of bleeding oesophageal varices (BOV). However, translating guidelines based on randomized controlled trials into clinical practice is difficult. Our aims were to compare adherence to evidence-based guidelines in BOV between a specialized unit and a community hospital, and to investigate whether differences in adherence affected the outcome.

METHODS

Two cohorts hospitalized during 2000-2007 with a first episode of BOV were retrospectively enrolled, one in a community hospital comprising 66 patients and one in a specialized unit comprising 111 patients. Data on treatment, rebleeding and mortality were collected from medical records according to the Baveno III/IV Criteria.

RESULTS

Treatments in the specialized unit versus the community hospital were: vasoactive drugs 79 vs. 66% (P = 0.06), prophylactic antibiotics 55 vs. 27% (P < 0.01), endoscopic treatment 86 vs. 74% (P= 0.04) and Sengstaken-Blakemore tube was used in 5 vs. 21% (P < 0.01). Secondary prophylaxis with pharmacological, endoscopic or transjugular intrahepatic portosystemic shunt therapy was initiated in 91 vs. 74% (P < 0.01) (specialized vs. community). Six-week mortality was 17 vs. 24% (P = 0.25) with 5-day mortality of 6 vs. 3% (P = 0.34) and mortality day 6-42, 12 vs. 22% (P = 0.07) (specialized vs. community). Failure to control bleeding and failure to prevent rebleeding were not statistically different.

CONCLUSION

Our study shows that patients with BOV are more likely to receive therapy according to guidelines when hospitalized in a specialized unit compared with a community hospital. This however did not affect mortality.