Improved survival after variceal hemorrhage over an 11-year period in the Department of Veterans Affairs

Bleeding Complications of Portal Hypertension

In portal hypertension, acute variceal bleed is the cause of 2/3rd of all upper gastrointestinal bleeding episodes. It is a life-threatening emergency in patients with cirrhosis. Nonselective beta-blockers by decreasing the hepatic venous pressure gradient are the mainstay of medical therapy for the prevention of variceal bleeding and rebleeding. Evaluation of the severity of bleed, hemodynamic resuscitation, prophylactic antibiotic, and intravenous splanchnic vasoconstrictors should precede the endoscopy procedure. Endoscopic band ligation is the recommended endotherapy. Rescue transjugular intrahepatic port-systemic shunt (TIPS) is recommended for variceal bleed refractory to endotherapy. In patients with a high risk of failure of combined pharmacologic and endoscopic therapy, pre-emptive TIPS may improve the outcome. For gastric varices, "Sarin classification" is universally applied as it is simple and has therapeutic implication. For IGV1 and GOV2, injection cyanoacrylate glue is considered the endotherapy of choice. Endoscopic ultrasound is a useful modality in the management of gastric varices.

Development and validation of a scoring system for in-hospital mortality following band ligation in esophageal variceal bleeding

OBJECTIVES

We aimed to develop and validate a simple scoring system to predict in-hospital mortality after endoscopic variceal ligation (EVL) for esophageal variceal bleeding.

METHODS

Data from a 13-year study involving 46 Japanese institutions were split into development (initial 7 years) and validation (last 6 years) cohorts. The study subjects were patients hospitalized for esophageal variceal bleeding and treated with EVL. Variable selection was performed using least absolute shrinkage and selection operator regression, targeting in-hospital all-cause mortality as the outcome. We developed the Hospital Outcome Prediction following Endoscopic Variceal Ligation (HOPE-EVL) score from β coefficients of multivariate logistic regression and assessed its discrimination and calibration.

RESULTS

The study included 980 patients: 536 in the development cohort and 444 in the validation cohort. In-hospital mortality was 13.6% and 10.1% for the respective cohorts. The scoring system used five variables: systolic blood pressure (<80 mmHg: 2 points), Glasgow Coma Scale (≤12: 1 point), total bilirubin (≥5 mg/dL: 1 point), creatinine (≥1.5 mg/dL: 1 point), and albumin (<2.8 g/dL: 1 point). The risk groups (low: 0-1, middle: 2-3, high: ≥4) in the validation cohort corresponded to observed and predicted mortality probabilities of 2.0% and 2.5%, 19.0% and 22.9%, and 57.6% and 71.9%, respectively. In this cohort, the HOPE-EVL score demonstrated excellent discrimination ability (area under the curve [AUC] 0.890; 95% confidence interval [CI] 0.850-0.930) compared with the Model for End-stage Liver Disease score (AUC 0.853; 95% CI 0.794-0.912) and the Child-Pugh score (AUC 0.798; 95% CI 0.727-0.869).

CONCLUSIONS

The HOPE-EVL score practically and effectively predicts in-hospital mortality. This score could facilitate the appropriate allocation of resources and effective communication with patients and their families.

Antibiotic Prophylaxis for Upper Gastrointestinal Bleed in Liver Cirrhosis; Less May Be More

INTRODUCTION

Administration of antibiotics in patients with cirrhosis and upper gastrointestinal bleeding has been shown to improve outcomes. Little is known regarding optimum duration of prophylactic antibiotics. Seven days of antibiotics are generally recommended but very few studies have compared antibiotic duration to clinical outcomes in current available scientific literature. The goal of our study was to study the effect of shorter antibiotic duration on patient outcomes.

METHODS

We conducted a retrospective cohort study of patients with cirrhosis presenting with upper GI bleeding at our institute from 2010 to 2018. Patients were divided into three cohorts based on duration of antibiotic administration for prophylaxis: 1-3 days of antibiotics, 4-6 days of antibiotics and 7 days or more of antibiotics. Rates of infection diagnosis within 30 days, rebleeding, and mortality were compared between the three groups with Chi square, Fisher Exact and Kruskall-Wallace tests. Multivariable analysis was conducted to evaluate independent risk factors for infection.

RESULTS

Medical charts of 980 patients with cirrhosis and upper GI bleeding during the study period were reviewed. A total of 303 with upper gastrointestinal bleeding were included in the final sample, of these 243 patients received antibiotics for prophylaxis and were included for analysis. Seventy-seven patients received antibiotic therapy for 3 days or less, 69 patients for 4-6 days, and 97 patients longer than 6 days. The three groups were well matched in demographic and clinical variables. Twenty-seven patients developed infections within 30 days of bleeding. MELD-Na score at presentation and presence of ascites were associated with infection within 30 days. Rates of infection were not statistically different between the three antibiotic groups (p = 0.78). In the thirty days following the GI bleed, pneumonia was the most diagnosed infection (eleven patients) followed by urinary tract infections (eight patients). Four patients developed spontaneous bacterial peritonitis and three were diagnosed with bacteremia. There was no difference in time to infection (Kruskall Wallace test p = 0.75), early re-bleeding (p = 0.81), late re-bleeding (p = 0.37) and in-hospital mortality (p = 0.94) in the three groups. Six patients in the cohort developed C. Difficile infection; no patient in the short antibiotic group developed C. Difficile infection.

CONCLUSION

Short course of antibiotics for prophylaxis (3 days) appears safe and adequate for prophylaxis in patients with cirrhosis with upper gastrointestinal bleeding if there is no active infection.

Update on the management of upper gastrointestinal bleeding

Upper gastrointestinal bleeding is a common emergency presentation requiring prompt resuscitation and management. Peptic ulcers are the most common cause of the condition. Thorough initial management with a structured approach is vital with appropriate intravenous fluid resuscitation and use of a restrictive transfusion threshold of 7-8 g/dL. Pre-endoscopic scoring tools enable identification of patients at high risk and at very low risk who might benefit from specific management. Endoscopy should be carried out within 24 h of presentation for patients admitted to hospital, although optimal timing for patients at a higher risk within this period is less clear. Endoscopic treatment of high risk lesions and use of subsequent high dose proton pump inhibitors is a cornerstone of non-variceal bleeding management. Variceal haemorrhage results in higher mortality than non-variceal haemorrhage and, if suspected, antibiotics and vasopressors should be administered urgently, before endoscopy. Oesophageal variceal bleeding requires endoscopic band ligation, whereas bleeding from gastric varices requires thrombin or tissue glue injection. Recurrent bleeding is managed by repeat endoscopic treatment. If uncontrolled bleeding occurs, interventional radiological embolisation or surgery is required for non-variceal bleeding or transjugular intrahepatic portosystemic shunt placement for variceal bleeding.

Impact of Readmission for Variceal Upper Gastrointestinal Bleeding: A Nationwide Analysis

BACKGROUND

Variceal upper gastrointestinal bleeding (VUGIB) is a common and potentially lethal complication of cirrhosis. Population-based data regarding hospital readmission and other outcomes in VUGIB are limited.

AIM

In a large United States database of patients with VUGIB, we evaluated readmission rates, mortality rates, healthcare resource consumption, and identified predictors of readmission.

METHODS

The 2017 Nationwide Readmission Database using ICD-10 codes was used to identify all adult patients admitted for VUGIB. Primary outcomes were 30- and 90-day readmission rates. Secondary outcomes included mortality, healthcare resource consumption, and predictors of readmission. Multivariate regression analysis was used to adjust for potential confounders.

RESULTS

In 2017, there were 26,498 patients with VUGIB discharged from their index hospitalization, and 24.7% were readmitted (all-cause) within 30-days and 41.5% within 90-days. Recurrent VUGIB accounted for 26.7% and 28.9% of 30- and 90-day readmissions, respectively. Compared to index admissions, 30-day readmissions were associated with higher mortality (4.3% vs. 6.4%, p < 0.01), increased mean hospital length of stay (5.6 days vs. 4.5 days, p < 0.01), and charges ($65,984 vs. $53,784, p < 0.01), with similar findings in 90-day readmissions. Factors associated with 30-day readmission included end-stage renal disease (HR 1.2, p < 0.05), chronic kidney disease (HR 1.31, p < 0.01), and acute kidney injury (HR 1.14, p < 0.05).

CONCLUSION

Based on a nationwide cohort of hospitalized VUGIB patients, 25% were readmitted within 30-days and 42% within 90-days. Readmission was associated with increased mortality and healthcare consumption compared to the index admission. Additionally, acute and chronic renal injury were predictors of patients at high-risk for readmission.

CT-derived quantitative liver volumetric parameters for prediction of severe esophageal varices and the risk of first variceal hemorrhage

PURPOSE

To assess whether CT (computed tomography)-derived quantitative parameters of liver lobe volume can predict severe esophageal varices (EV) and the risk of first varicealhemorrhage (FVH) in patients with liver cirrhosis.

METHODS

A total of 217 endoscopically confirmed EV patients were included in this retrospective study and were divided into a low-risk EV group (mild-to-moderate EV, n = 83) and a high-risk EV group (severe EV, n = 134), a FVH group (n = 17) and a non-FVH group (n = 27), patients' clinical findings were recorded. The left, right, caudate lobe, total liver volume and the corresponding functional volume were measured respectively, and the ratio of caudate volume/total volume (CV/TV), caudate functional volume/total functional volume (CFV/TFV) were calculated. Univariate and multivariate logistic analysis were used to determine the independent factors and the receiver operating characteristic (ROC) curves were performed to evaluate the diagnostic performance.

RESULTS

CV, CFV, CV/TV, CFV/TFV were significantly different in the EV severity study and FVH study (p < 0.05). Multivariate analysis indicated that CV/TV and ascites were independent predictive factors for severe EV, a predictive model combing those two factors revealed a satisfactory diagnostic performance (area under the curve (AUC), 0.853, 95 %CI 0.797-0.905). Furthermore, CV/TV and the presence of red color sign under endoscopy were found to be independent predictive factors for FVH, and the former showed a better discriminative performance than the latter (AUC, 0.851 vs 0.779).

CONCLUSIONS

CT-derived quantitative parameters of CV, CFV, CV/TV, CFV/TFV may be used as an alternative to endoscopy in predicting severe varices and the risk of bleeding.

Bedside risk-scoring model for predicting 6-week mortality in cirrhotic patients undergoing endoscopic band ligation for acute variceal bleeding

BACKGROUND AND AIM

Acute variceal bleeding (AVB) is a fatal adverse event of cirrhosis, and endoscopic band ligation (EBL) is the standard treatment for AVB. We developed a novel bedside risk-scoring model to predict the 6-week mortality in cirrhotic patients undergoing EBL for AVB.

METHODS

Cox regression analysis was used to assess the relationship of clinical, biological, and endoscopic variables with the 6-week mortality risk after EBL in a derivation cohort (n = 1373). The primary outcome was the predictive accuracy of the new model for the 6-week mortality in the validation cohort. Moreover, we tested the adequacy of the mortality risk-based stratification and the discriminative performance of our new model in comparison with the Child-Turcotte-Pugh (CTP) and the model for end-stage liver disease scores in the validation cohort (n = 200).

RESULTS

On multivariate Cox regression analysis, five objective variables (use of beta-blockers, hepatocellular carcinoma, CTP class C, hypovolemic shock at initial presentation, and history of hepatic encephalopathy) were scored to generate a 12-point risk-prediction model. The model stratified the 6-week mortality risk in patients as low (3.5%), intermediate (21.1%), and high (53.4%) (P < 0.001). Time-dependent area under the receiver operating characteristic curve for 6-week mortality showed that this model was a better prognostic indicator than the CTP class alone in the derivation (P < 0.001) and validation (P < 0.001) cohorts.

CONCLUSIONS

A simplified scoring model with high potential for generalization refines the prediction of 6-week mortality in high-risk cirrhotic patients, thereby aiding the targeting and individualization of treatment strategies for decreasing the mortality rate.

Secure intravariceal sclerotherapy with red dichromatic imaging decreases the recurrence rate of esophageal varices: A propensity score matching analysis

BACKGROUND

Red dichromatic imaging (RDI) is next-generation image-enhanced endoscopy technique released in July 2020. We previously reported that RDI can predict esophageal varices (EV) depth and decrease their recurrence rate by accurate intravariceal injections during endoscopic injection sclerotherapy (EIS) using unreleased prototype RDI endoscope. In this study, we analyzed whether RDI improves the overall survival (OS) rate and whether it is more accurate independent predictor of EV recurrence than white light imaging (WLI), using propensity score matching.

METHODS

A total of 179 patients were enrolled. Patients were matched for age, platelet count, liver function, EV size, luminal diameter, and EV depth using propensity score matching, and 78 patients (RDI, 39; WLI, 39) were finally matched. Primary endpoints were OS and recurrence rates. Secondary endpoints were success rate of intravariceal injection, operating time, incidence of adverse events (AEs), and predictors associated with OS and recurrence rates.

RESULTS

There was no difference in OS (P = .193), but the cumulative recurrence rate in the RDI group was significantly lower than in the WLI group (P = .002). Success rates of intrainjection, operating time, and incidence of AEs were better in the RDI group (p = 0.035, .026, and .0019, respectively). Independent predictors associated with recurrence rate by Cox proportional regression were RDI function and luminal diameter (P < .001 and .017, respectively).

CONCLUSION

RDI did not improve OS but decreased the recurrence rate. Independent predictors of recurrence rate were RDI and luminal diameter, resulting from secure intravariceal injections in EIS.

High-density lipoprotein cholesterol is a predictor of survival in cirrhotic patients with acute gastrointestinal bleeding: a retrospective study

Background

Lipid profiles are declined in patients with viral liver cirrhosis and correlated with severity of liver disease. Hepatitis B virus (HBV) is the leading cause of liver cirrhosis in China. Our primary aim was to investigate whether serum lipids and lipoproteins associate with survival in patients with HBV-related cirrhosis and acute gastrointestinal bleeding, and develop a 6-week mortality risk score that incorporates it.

Methods

From January 2008 to December 2015, consecutive cirrhotic patients with acute gastrointestinal bleeding admitted to our hospital were evaluated and randomly divided into the derivation (n = 629) and validation (n = 314) cohorts. A logistic regression model was established to confirm the association between lipoprotein cholesterol and mortality. Accuracy to predict mortality were assessed by area under the receiver operating characteristic curves (AUROCs) and compared using the Hanley and McNeil test.

Results

Among study subjects, the 6-week mortality rate was 10.6%. High-density lipoprotein cholesterol (HDL-C) level was found to correlate most strongly with prognostic scores. On ROC analysis, HDL-C showed excellent diagnostic accuracy for 6-week mortality. Logistic regression analysis provided a simple algorithm based on the combined use of 4 variables (total bilirubin (TBIL), HDL-C, International normalized ratio, and hemoglobin), allowing accurate discrimination of 3 distinct prognostic subgroups with 1.7% (low risk), 12.3% (intermediate risk), and 56.9% (high risk) mortality. Its accuracy was significantly better than that of Child–Pugh, model of end-stage liver disease, albumin-bilirubin score, D’Amico model, Augustin model, AIMS65 score and Glasgow-Blatchford score. Baseline HDL-C values ≤ 0.54 mmol/L were associated with markedly lower 6-week survival. Comparable results were found in the validation set.

Conclusion

HDL-C is a potential indicator for the prognosis of patients with cirrhosis and acute gastrointestinal bleeding. The new algorithm based on HDL-C allowed an accurate predictive assessment of 6-week mortality after bleeding attack.

Gender Matters: Characteristics of Hepatocellular Carcinoma in Women From a Large, Multicenter Study in the United States

INTRODUCTION

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related death worldwide, affecting men to women at a ratio of about 4:1. Risk factors, characteristics, and outcomes for HCC in women in the United States remain poorly understood; therefore, we aim to explore gender differences further.

METHODS

Patients diagnosed with HCC between January 2000 and June 2014 at 5 large centers were identified. Clinical information, tumor characteristics, and survival data were extracted manually. The presence of underlying cirrhosis was assessed based on published criteria.

RESULTS

Of 5,327 patients with HCC in our cohort, 1,203 (22.6%) were women. There were important differences in the underlying etiology of liver disease between the 2 genders (P < 0.0001): women had a significantly higher frequency of nonalcoholic fatty liver disease (23% vs 12%) and lower frequency of alcoholic liver disease (5% vs 15%). The proportion of noncirrhotic HCC was significantly higher among women (17% vs 10%, P < 0.0001). Women had less-advanced HCC at presentation by tumor, node, metastasis staging (P < 0.0001) and a higher proportion within Milan criteria (39% vs 35%, P = 0.002). Women had a greater overall survival (2.5 ± 2.9 years vs 2.2 ± 2.7 years, P = 0.0031).

DISCUSSION

The frequency of underlying nonalcoholic fatty liver disease and noncirrhotic HCC were significantly higher in women than men in this large cohort. Women presented with less-advanced HCC and had a greater overall survival. Further investigation is warranted to explore potential mechanisms and implications for these gender differences, especially with noncirrhotic HCC (see Visual Abstract, Supplementary Digital Content 1, http://links.lww.com/AJG/B535).

Risk stratification in acute variceal bleeding: Comparison of the AIMS65 score to established upper gastrointestinal bleeding and liver disease severity risk stratification scoring systems in predicting mortality and rebleeding

BACKGROUND AND AIM

Risk stratification is recommended in all patients with acute variceal bleeding (AVB). It remains unclear whether liver disease severity or upper gastrointestinal bleeding (UGIB) scoring algorithms offer superior predictive ability. We aimed to validate the AIMS65 score as a predictor of mortality in AVB, and to compare AIMS65 with established UGIB and liver disease severity risk stratification scores.

METHODS

International Classification of Diseases, Tenth Revision codes identified patients presenting with AVB to three tertiary centers over a 48-month period. Patients were risk-stratified using AIMS65, Rockall, pre-endoscopy Rockall, Child-Pugh, Model for End-stage Liver Disease (MELD) and United Kingdom MELD (UKELD) scores. Primary outcomes were inpatient and 6-week mortality and inpatient rebleeding.

RESULTS

Two hundred and twenty-three patients were included. Inpatient and 6-week mortality were 13.9% and 15.5% respectively. Prediction of inpatient mortality by AIMS65 (area under the receiver-operating characteristic curve [AUROC: 0.84]) was equivalent to UGIB (Rockall: 0.79, pre-Rockall: 0.78) and liver risk scores (MELD: 0.81, UKELD: 0.79, Child-Pugh: 0.78). AIMS65 score ≥3 best defined high- and low-risk groups for inpatient mortality (mortality 37.7% vs 4.9%). AIMS65 (AUROC: 0.62) was equivalent to UGIB risk scores (pre-Rockall: 0.64, Rockall: 0.70) in predicting inpatient rebleeding and superior to liver risk scores (MELD: 0.56, UKELD: 0.57, Child-Pugh: 0.60).

CONCLUSIONS

AIMS65 is equivalent to established UGIB and liver disease severity risk stratification scores in predicting mortality, and superior to liver scores in predicting rebleeding.

Inpatient burden of esophageal varices in the United States: analysis of trends in demographics, cost of care, and outcomes

Background

Esophageal variceal bleeding remains a common reason for hospitalization in the United States. The main objective of this study was to analyze demographic variations and outcomes in hospitalizations related to esophageal varices (EV) in the US.

Methods

We performed a retrospective observational cohort study using National Inpatient Sample (NIS) database for all hospitalizations with discharge diagnoses of EV, with and without hemorrhage from 2001 to 2011.

Results

In 2001, there were 19,167 hospitalizations with discharge diagnoses of EV with and without bleeding compared to 45,578 in 2011 (P<0.001). There was a 138% increase in the number of total EV hospitalizations, a 221% increase in hospitalizations with EV without hemorrhage, and a 7% increase in hospitalizations for patients with EV and hemorrhage. Age group 50-64 was the most affected, accounting for 31.4% of EV hospitalizations in 2001 and 46.7% of EV hospitalizations in 2011 (P<0.001). The overall in-hospital mortality rate was 3.4% for patients with EV without hemorrhage and 8.7% for patients with EV with hemorrhage (P=0.0003).

Conclusions

The number of hospitalizations for patients with asymptomatic EV increased significantly between 2001 to 2011, with only a small concurrent increase in the number of hospitalizations for patients with esophageal variceal bleeding.

HCC complicated by PVT: Outcome and the role of anticoagulation therapy

BACKGROUND

This retrospective study investigated the clinical impact of PVT on the course of patients with HCC who were and were not treated with anticoagulation (AC).

METHODS

We retrospectively evaluated a cohort of 60 patients diagnosed with HCC and PVT. Nine patients were excluded for lack of follow-up. HCC, PVT diagnosis, and imaging follow-up were performed using contrast-enhanced computed tomography or MRI. Of the 51 patients evaluated, 12 received AC and 39 did not.

RESULTS

Forty-two patients were male; mean age was 60.3 years. Mean survival after HCC diagnosis was 32.9 months; after PVT diagnosis, it was 18.4 months. No symptoms directly related to PVT development were reported. AC therapy was initiated for 12 patients and had to be discontinued for 3 patients because of complications. AC was not associated with a difference in PVT progression (49% in non-AC group vs. 50% in AC group). After adjusting for age, HCC type (single vs. multifocal), and Child-Pugh score, AC was associated with an improved survival after HCC diagnosis (adjusted hazard ratio [HR] = 0.37; 95% confidence interval [CI] 0.14 to 0.99) and after PVT diagnosis (HR = 0.34; 95% CI 0.13 to 0.88).

CONCLUSION

Patients with HCC complicated by PVT in both AC and non-AC groups had a similar rate of progression. Neither group had symptoms attributable to PVT. Possible AC-related complications need to be considered before proceeding with therapy in patients with HCC and PVT. AC may be associated with a survival advantage in patients with HCC and PVT.

A new algorithm for predicting long-term survival in chronic hepatitis B patients with variceal bleeding after endoscopic therapy

BACKGROUND AND AIMS

A predictive algorithm for survival is urgently needed in clinical practice. This study aimed to establish an algorithm to predict long-term survival in chronic hepatitis B (CHB) patients with hepatic cirrhosis and variceal bleeding after endoscopic therapy.

METHODS

This was a retrospective study in which 603 patients who followed-up for three years were randomly assigned into a training cohort and a validation cohort in a 2:1 ratio. A new score model was devised based on the result of Cox regression analysis in the training cohort, and was verified in the validation cohort.

RESULTS

A prediction score model composed of age, neutrophil-lymphocyte ratio, gamma-glutamyl transpeptidase and MELD score was established. The score ranged from 0 to 11. Areas under the ROC curve of the score were 0.821 (p < 0.001, 95% CI: 0.769-0.873) and 0.827 (p < 0.001, 95% CI: 0.753-0.900) in the training cohort and validation cohort, respectively. Scores 0-4 and 5-11 identified patients as low-risk and high-risk categories, respectively. The cumulative 3-year survival rate was significantly higher in the low-risk group than in the high-risk group (p < 0.001).

CONCLUSION

The new score model can be used to predict long-term survival in CHB patients with hepatic cirrhosis and variceal bleeding after endoscopic therapy.

Tranexamic acid for acute gastrointestinal bleeding (the HALT-IT trial): statistical analysis plan for an international, randomised, double-blind, placebo-controlled trial

Background

Acute gastrointestinal (GI) bleeding is an important cause of mortality worldwide. Bleeding can occur from the upper or lower GI tract, with upper GI bleeding accounting for most cases. The main causes include peptic ulcer/erosive mucosal disease, oesophageal varices and malignancy. The case fatality rate is around 10% for upper GI bleeding and 3% for lower GI bleeding. Rebleeding affects 5–40% of patients and is associated with a four-fold increased risk of death. Tranexamic acid (TXA) decreases bleeding and the need for blood transfusion in surgery and reduces death due to bleeding in patients with trauma and postpartum haemorrhage. It reduces bleeding by inhibiting the breakdown of fibrin clots by plasmin. Due to the methodological weaknesses and small size of the existing trials, the effectiveness and safety of TXA in GI bleeding is uncertain. The Haemorrhage ALleviation with Tranexamic acid – Intestinal system (HALT-IT) trial aims to provide reliable evidence about the effects of TXA in acute upper and lower GI bleeding.

Methods

The HALT-IT trial is an international, randomised, double-blind, placebo-controlled trial of tranexamic acid in 12,000 adults (increased from 8000) with acute upper or lower GI bleeding. Eligible patients are randomly allocated to receive TXA (1-g loading dose followed by 3-g maintenance dose over 24 h) or matching placebo. The main analysis will compare those randomised to TXA with those randomised to placebo on an intention-to-treat basis, presenting the results as effect estimates (relative risks) and confidence intervals. The primary outcome is death due to bleeding within 5 days of randomisation and secondary outcomes are: rebleeding; all-cause and cause-specific mortality; thromboembolic events; complications; endoscopic, radiological and surgical interventions; blood transfusion requirements; disability (defined by a measure of patient’s self-care capacity); and number of days spent in intensive care or high-dependency units. Subgroup analyses for the primary outcome will consider time to treatment, location of bleeding, cause of bleed and clinical Rockall score.

Discussion

We present the statistical analysis of the HALT-IT trial. This plan was published before the treatment allocation was unblinded.

Trial registration

Current Controlled Trials, ID: ISRCTN11225767. Registered on 3 July 2012;

Clinicaltrials.gov, ID: NCT01658124. Registered on 26 July 2012.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3561-7) contains supplementary material, which is available to authorized users.

A study on spleen transient elastography in predicting the degree of esophageal varices and bleeding

This study aims to investigate the value and determine the accuracy of spleen stiffness in predicting the degree of esophageal varices and bleeding in patients with liver cirrhosis.The age, gender, liver stiffness, spleen stiffness, and gastroscopy results of 124 inpatients or outpatients with liver cirrhosis and healthy volunteers, who underwent both gastroscopy and FibroScan testing in the fasting state, were retrospectively analyzed. According to the gastroscopy results, the patients and healthy volunteers were divided into six groups: varicose bleeding, severe varices, moderate varices, mild varices, no varices, and healthy control group. Then, the receiver operating characteristic curves were drawn, and the corresponding area under each curve was calculated and evaluated to predict the severity of varices based on the relevance of the area and its parameters.The area under the receiver operating characteristic curve of liver stiffness and spleen stiffness for predicting severe and moderate varices in the bleeding group was 0.955 and 0.989, respectively. The cut-off values were 29.6 kPa and 45.5 kPa, respectively. The area under the receiver operating characteristic curve of liver stiffness for predicting varicose bleeding was 0.860 (95% CI: 0.789-0.931). The liver stiffness cut-off value for predicting varicose bleeding was 33.2 kPa, with a specificity and sensitivity of 66.02% and 95.24%, respectively. The area under the receiver operating characteristic curve of spleen stiffness for predicting varicose bleeding was 0.923 (95% CI: 0.875-0.971). A spleen stiffness cut-off value of 55.2 kPa had a sensitivity and specificity of 90.48% and 86.41%, respectively.Spleen stiffness can predict the degree of esophageal varices and bleeding in liver cirrhosis patients, and has good predictive accuracy.

Rationale and design of the Hepatocellular carcinoma Early Detection Strategy study: A multi-center longitudinal initiative of the National Cancer Institute's Early Detection Research Network

BACKGROUND

Hepatocellular carcinoma (HCC) is a common malignancy with a steadily rising incidence and associated morbidity and mortality. Cirrhosis of the liver is presently the leading risk factor for developing HCC. Abdominal imaging, with or without alpha-fetoprotein (AFP) testing, every 6 months is the current surveillance strategy for patients at risk. The available biomarkers for detecting this cancer at an early stage have inadequate sensitivity and specificity.

METHODS

The Hepatocellular carcinoma Early Detection Strategy (HEDS) study, a multi-center initiative of the National Cancer Institutes' (NCI) Early Detection Research Network (EDRN), launched an effort to establish what has become the nation's largest comprehensive biorepository and database on patients at high risk of developing HCC. The cohort has been developed in seven clinical centers across the USA. Subjects are enrolled for a five-year period involving data and specimen collection every six months in accordance with standard surveillance for HCC. Extensive clinical data are collected and specimens are stored at a central repository.

RESULTS

The database and biorepository contain longitudinally collected clinical data and serum and plasma samples from 1482 participants with cirrhosis and without evidence of HCC at baseline. Fifty-six percent are male, 85% Caucasian, 30% have a history of chronic HCV and 71% have compensated cirrhosis.

CONCLUSIONS

The HEDS cohort provides opportunities for the continued study of the incidence and course of HCC in a comprehensively followed population of patients at high risk for this malignancy. Further, the EDRN biorepository provides a distinct opportunity for the development of novel biomarkers. Trial registry URL: https://edrn.nci.nih.gov/protocols/316-hepatocellular-carcinoma-early-detection-strategy.

Carcinogenesis on the background of liver fibrosis: Implications for the management of hepatocellular cancer

Hepatocellular carcinoma (HCC) is now the second leading cause of cancer-related deaths globally and many patients have incurable disease. HCC predominantly occurs in the setting of liver cirrhosis and is a paradigm for inflammation-induced cancer. The causes of chronic liver disease promote the development of transformed or premalignant hepatocytes and predisposes to the development of HCC. For HCC to grow and progress it is now clear that it requires an immunosuppressive niche within the fibrogenic microenvironment of cirrhosis. The rationale for targeting this immunosuppression is supported by responses seen in recent trials with checkpoint inhibitors. With the impact of immunotherapy, HCC progression may be delayed and long term durable responses may be seen. This makes the management of the underlying liver cirrhosis in HCC even more crucial as studies demonstrate that measures of liver function are a major prognostic factor in HCC. In this review, we discuss the development of cancer in the setting of liver inflammation and fibrosis, reviewing the microenvironment that leads to this tumourigenic climate and the implications this has for patient management.

Accuracy of liver stiffness, spleen stiffness, and LS-spleen diameter to platelet ratio score in detection of esophageal varices: Systemic review and meta-analysis

BACKGROUND AND AIM

There is increasing evidence of non-invasive measurement using elastography such liver stiffness (LS), spleen stiffness (SS), and LS-spleen diameter to platelet ratio score (LSPS) for detection of esophageal varices (EV); however, data regarding comparison between these three parameters are limited.

METHODS

We performed a systemic review and meta-analysis of studies evaluating performance of LS, SS, and LSPS for detection of EV and high risk/clinically significant EV (HREV). Pooled sensitivity, specificity, log diagnostic odd ratio (LDOR), and area under the receiver operating characteristic curve (AUC) of LS, SS, and LSPS for detection of EV and HREV were analyzed and compared. Publication bias was assessed by Deeks' funnel plot.

RESULTS

SS and LSPS were superior to LS for detection of EV with higher sensitivity (0.90 and 0.91 vs 0.85), specificity (0.73 and 0.76 vs 0.64), LDOR (3.24 and 3.35 vs 2.26), and AUC (0.899 and 0.851 vs 0.817). For HREV, SS had the highest sensitivity (0.87) followed by LS (0.85) and LSPS (0.82); however, SS had the lowest specificity (0.52), LDOR (2.09), and AUC (0.807) whereas LSPS had the highest specificity (0.77), LDOR (2.74), and AUC (0.861).

CONCLUSION

For detection of EV, we prefer using LSPS and SS over LS when available, while LS, SS, and LSPS cannot be recommended for detection of HREV due to their moderate sensitivity and specificity.

Endovascular Treatment for Variceal Hemorrhage: TIPS, BRTO, and Combined Approaches

Variceal hemorrhage is a feared complication of portal hypertension, with high rates of morbidity and mortality. Optimal management requires a thoughtful, multidisciplinary approach. In cases of refractory or recurrent esophageal hemorrhage, endovascular approaches such as transjugular intrahepatic portosystemic shunt (TIPS) have a well-defined role. For hemorrhage related to gastric varices, the optimal treatment remains to be established; however, there is increasing adoption of balloon-occluded retrograde transvenous obliteration (BRTO). This article will review the concept, history, patient selection, basic technique, and outcomes for TIPS, BRTO, and combined TIPS + BRTO procedures for variceal hemorrhage.

Hospital-level balloon tamponade use is associated with increased mortality for all patients presenting with acute variceal haemorrhage

BACKGROUND & AIMS

Balloon tamponade (BT) can bridge patients to salvage therapy for uncontrollable acute variceal haemorrhage (AVH). However, data are limited regarding the reasons for, rate of and outcomes associated with Balloon tamponade use.

METHODS

First, we performed an single-centre cohort study of all patients (N = 139) with oesophageal acute variceal haemorrhage from 01/2009 to 10/2015. Associations between Balloon tamponade use and adherence to four quality metrics (endoscopy within 12 hours, band-ligation, pre-endoscopy antibiotics and octreotide) were evaluated. Second, we analysed the National Inpatient Sample (2005-2011) to determine the association between in-hospital mortality for patients and their hospital's Balloon tamponade-utilization to acute variceal haemorrhage volume ratio.

RESULTS

In the national cohort, 5.5% of 140 521 acute variceal haemorrhage admissions required Balloon tamponade utilization. Adjusting for patient- and hospital-level confounders, the rate of Balloon tamponade use per acute variceal haemorrhage managed at any given hospital was associated with increased mortality for all-comers with acute variceal haemorrhage. Compared to the lowest tertile, acute variceal haemorrhage admissions in the highest Balloon tamponade utilizers were associated with increased mortality of (OR1.17 95%CI (1.01-1.37). In the single-centre cohort, 14 (10.1%) patients required Balloon tamponade. Balloon tamponade utilization was significantly associated with alcohol abuse (50.4% vs 21.4%, P = .04), hepatocellular carcinoma (35.7% vs 8.8%, P = .01), higher median model for end-stage liver disease (MELD) score (26.3vs15.5, P = .002) and active bleeding during endoscopy (64.3% vs 27.5%, P = .01). Failure to provide all quality metrics was associated with a higher model for end-stage liver disease-adjusted risk of Balloon tamponade use: OR 16.7 95% CI(4.17-100.0, P < .0001).

CONCLUSION

Balloon tamponade use is associated with severity of bleeding but may also implicate deficits in processes of care. Even for patients who did not need Balloon tamponade, presentation to hospitals with high Balloon tamponade utilization increases their odds of dying from acute variceal haemorrhage.

Multicenter External Validation of Risk Stratification Criteria for Patients With Variceal Bleeding

BACKGROUND & AIMS

Early placement of a transjugular intrahepatic portosystemic shunts (TIPS) is considered the treatment of choice for patients with acute variceal bleeding (AVB) and cirrhosis who have a high risk of death (Child-Pugh class B with active bleeding at endoscopy or Child-Pugh class C). It has been proposed that patients of Child-Pugh class B, even with active bleeding, should not be considered high risk. Alternative criteria have been proposed for identification of high-risk patients, such as Child-Pugh class C with plasma level of creatinine of 1 mg/dL or more (ChildC-C1) and a model for end-stage liver disease (MELD) score of 19 or more. We analyzed outcomes of a large cohort of patients with AVB who received the standard of care at different centers to validate these systems of risk stratification.

METHODS

We performed an observational study of 915 patients with liver cirrhosis and AVB who received standard treatment (drugs, antibiotics, and endoscopic ligation, with TIPS as the rescue treatment), over different time periods between 2006 and 2014 in Canada and Europe. All patients were followed until day 42 (week 6) after index AVB or death. Child-Pugh and MELD scores were calculated at time of hospital admission. The primary outcome was mortality 6 weeks after index AVB among patients who met the early TIPS criteria (Child-Pugh class B with active bleeding at endoscopy or Child-Pugh class C), MELD19 criteria (patients with MELD scores of 19 or more), and ChildC-C1 criteria.

RESULTS

Among 915 patients with AVB, 18% died within 6 weeks. Among the 523 patients who met the early TIPS criteria, 17% died within 6 weeks. All 3 rules discriminated patients at high risk of death from those with low risk: 28.3% of the patients classified as high risk by the early TIPS criteria died whereas only 7.0% of patients classified as low risk died; 46.0% of patients classified as high risk by the MELD19 criteria died vs 8.1% of patients classified as low risk; 51.9% of patients classified as high risk by the ChildC-C1 criteria died compared with 10.9% of patients classified as low risk. Mortality was significantly lower among patients with Child-Pugh class B (11.7%) than with Child-Pugh class C (35.6%) (P ≤ .001). Mortality was similar between patients with Child-Pugh class B cirrhosis with or without active bleeding (11.7%). Patients with Child-Pugh class A cirrhosis or MELD scores of 11 or less had low mortality (2%-4%), patients with Child-Pugh class B cirrhosis or MELD scores of 12 to 18 had intermediate mortality (10%-12%), and patients with Child-Pugh class C cirrhosis or MELD scores of 19 or more had high mortality (22%-46%).

CONCLUSIONS

Patients with Child-Pugh class B cirrhosis and AVB who receive standard therapy, regardless of the presence of active bleeding, have 3-fold lower mortality than patients with Child-Pugh C cirrhosis and might not need TIPS. Patients with Child-Pugh class C and/or MELD scores of 19 or more should be considered at high risk of death. These findings might help refine criteria for early TIPS.

African-Americans with Cirrhosis Are Less Likely to Receive Endoscopic Variceal Screening Within One Year of Cirrhosis Diagnosis

BACKGROUND

Esophageal variceal hemorrhage is a complication of cirrhosis that carries high mortality, and can be reduced with timely endoscopic variceal screening and treatment.

AIM

We aim to evaluate overall rates of and disparities in receipt of endoscopic variceal screening among an ethnically diverse urban safety-net hospital.

METHODS

All consecutive adults with cirrhosis (7/1/2014 to 12/31/2015) were retrospectively evaluated to determine the rates of receiving esophageal variceal screening within 6 months and within 1 year after cirrhosis diagnosis. Race-/ethnicity-specific differences in rates of variceal screening were compared using chi-square testing and multivariate regression methods.

RESULTS

Among 157 patients (65% male, 33.8% Hispanic, 22.3% African-American, 44.6% alcoholic liver disease, 29.9% chronic HCV), 56.8% received variceal screening within 6 months and 65.8% received screening within 1 year. Compared to non-Hispanic whites with cirrhosis, African-Americans (52.2 vs. 76.2%, p < 0.05), Asians (57.1 vs. 76.2%, p < 0.05), and Hispanics (43.9 vs. 76.2%, p < 0.05) were all significantly less likely to receive endoscopic variceal screening within 6 months after cirrhosis diagnosis. On multivariate analysis, African-Americans with cirrhosis were 66% less likely to receive variceal screening compared to non-Hispanic whites (HR 0.34, 95% CI 0.15-0.77, p < 0.01).

CONCLUSION

Among adults with cirrhosis at a community-based safety-net hospital system, overall first-time variceal screening remains suboptimal. African-Americans were the least likely to receive timely variceal screening. These findings are particularly concerning given the significant barriers that ethnic minorities and safety-net populations already face in timely access to medical care.

Suboptimal Implementation of Evidence-based Therapy for Acute Variceal Hemorrhage: A Systematic Review of Observational Studies

BACKGROUND & AIMS

Gastroenterologists should strive to improve the outcomes associated with acute variceal hemorrhage (AVH) by optimizing care delivery and clinician preparedness through training. Unfortunately, data regarding contemporary outcomes and management of AVH are limited.

METHODS

We performed a systematic review of cohort studies examining outcomes and management of AVH from January 1990 to September 2016. We pooled data on mortality and utilization of medical therapy, endoscopic interventions, balloon tamponade (BT), and salvage procedures (portal decompressive surgery or transjugular portosystemic shunt).

RESULTS

The pooled 6-week mortality rate after AVH was 17.7% (95% confidence interval [CI], 14.4%-21.7%). Sclerotherapy was used in 18.7% of cases (95% CI, 9.2%-34.3%), and no endoscopic intervention was provided in 14.3% of patients (95% CI, 9.7%-20.6%). The overall rate of BT use was 10.8% (95% CI, 8.2%-14.1%). Salvage procedures were used in 5.7% (95% CI, 3.7%-8.6%), falling to 1.7% (95% CI, 0.7%-3.8%) among patients treated after 2000. Although pooled rates of timely endoscopy and vasoactive medication use were high (85.8% and 83.0%, respectively), only half of patients received prophylactic antibiotics (52.8%; 95% CI, 40.0%-66.2%). In studies that enrolled patients exclusively after 2000, 13.8% of patients (95% CI, 7.0%-25.4%) received sclerotherapy, salvage transjugular portosystemic shunt fell to 1.7% (95% CI, 0.7%-3.8%), BT use fell slightly to 8.7% (95% CI, 6.4%-11.6%), and vasoactive medication and prophylactic antibiotic use rose to 91.4% (95% CI, 86.0%-94.9%) and 62.7% (95% CI, 48.9%-74.9%), respectively.

CONCLUSIONS

AVH is associated with high mortality rates and suboptimal implementation of evidence-based therapies including prophylactic antibiotics and endoscopic interventions, suggesting a need for quality improvement. In addition, the frequent need for BT and sclerotherapy suggests that specific attention to these procedures in gastroenterology training curricula may be warranted.

Application of chronic liver failure-sequential organ failure assessment score for the predication of mortality after esophageal variceal hemorrhage post endoscopic ligation

Background

Esophageal variceal hemorrhage (EVH) is one of the high mortality complications in cirrhotic patients. Endoscopic variceal ligation (EVL) is currently the standard therapy for EVH. However, some patients have expired during hospitalization or survived shortly after management.

Aim

To evaluate hospital and 6-week mortality by receiver operating characteristic (ROC) curve of chronic liver failure-sequential organ failure assessment (CLIF-SOFA) score compared to a model for end-stage liver disease (MELD) score and Child–Turcotte–Pugh (CTP) class.

Methods

We retrospectively collected 714 cirrhotic patients with EVH post EVL between July 2010 and June 2016 at Taitung MacKay Memorial Hospital, Taiwan. CLIF-SOFA score, MELD score, and CTP class were calculated for all patients admitted.

Results

Among the 714 patients, the overall hospital and 6-week mortality rates were 6.9% (49/715) and 13.1% (94/715) respectively. For predicting hospital death, area under receiver operating characteristic curve (AUROC) values of CLIF-SOFA score, MELD score, and CTP class were 0.964, 0.876, and 0.846. For predicting 6-week death, AUROC values of CLIF-SOFA score, MELD score, and CTP class were 0.943, 0.817, and 0.834. CLIF-SOFA score had higher AUROC value with statistical significance under pairwise comparison than did MELD score and CTP class in prediction of not only hospital but also 6-week mortality. The history of hepatocellular carcinoma was the risk factor for 6-week mortality. For patients with hepatocellular carcinoma the cut-point of CLIF-SOFA score was 5.5 for 6-week mortality and 6.5 for hospital mortality on admission. For patients without hepatocellular carcinoma, the cut-point of CLIF-SOFA score was 6.5 for both 6-week and hospital mortality.

Conclusion

CLIF-SOFA score predicted post-EVL prognosis well. For patients without hepatocellular carcinoma, CLIF-SOFA score ≥6 suggests higher 6-week mortality and CLIF-SOFA score ≥7 suggests higher hospital mortality. For patients with hepatocellular carcinoma, CLIF-SOFA score ≥7 suggests higher 6-week and hospital mortality.

Recent advances in the management of variceal bleeding

Acute haemorrhage from ruptured gastroesophageal varices is perhaps the most serious consequence of uncontrolled portal hypertension in cirrhotic patients. It represents a medical emergency and is associated with a high morbidity and mortality. In those who survive the initial bleeding event, the risks of further bleeding and other decompensated events remain high. The past 30 years have seen a slow evolution of management strategies that have greatly improved the chances of surviving a variceal haemorrhage. Liver cirrhosis is a multi-staged pathological process and we are moving away from a one-size-fits-all therapeutic approach. Instead there is an increasing recognition that a more nuanced approach will yield optimal survival for patients. This approach seeks to risk stratify patients according to their disease stage. The exact type and timing of treatment offered can then be varied to suit individual patients. At the same time, the toolbox of available therapy is expanding and there is a continual stream of emerging evidence to support the use of endoscopic and pharmacological therapies. In this review, we present a summary of the treatment options for a variety of different clinical scenarios and for when there is failure to control bleeding. We have conducted a detailed literature review and presented up-to-date evidence from either primary randomized-controlled trials or meta-analyses that support current treatment algorithms.

Use of Wireless Capsule Endoscopy for the Diagnosis and Grading of Esophageal Varices in Patients With Portal Hypertension: A Systematic Review and Meta-Analysis

INTRODUCTION

Esophageal variceal bleeding is a severe complication of portal hypertension with significant morbidity and mortality. Although traditional screening and grading of esophageal varices has been performed by endogastroduodenoscopy (EGD), wireless video capsule endoscopy provides a minimally invasive alternative that may improve screening and surveillance compliance.

AIM OF THE STUDY

The aim of the study was to perform a systematic review and structured meta-analysis of all eligible studies to evaluate the efficacy of wireless capsule endoscopy for screening and diagnosis of esophageal varices among patients with portal hypertension.

METHODS

Searches of PubMed, EMBASE, Web of Science, and the Cochrane Library databases were performed through December 2015. Bivariate and hierarchical models were used to compute the pooled sensitivity and specificity, and to plot the summary receiver operating characteristics curve with summary point and corresponding 95% confidence region. Bias of included studies was assessed using the quality assessment of diagnostic accuracy studies-2.

RESULTS

Seventeen studies from 2005 to 2015 were included in this meta-analysis (n=1328). The diagnostic accuracy of wireless capsule endoscopy in the diagnosis of esophageal varices was 90% [95% confidence interval (CI), 0.88-0.93]. The diagnostic pooled sensitivity and specificity were 83% (95% CI, 0.76-0.89) and 85% (95% CI, 0.75-0.91), respectively. The diagnostic accuracy of wireless capsule endoscopy for the grading of medium to large varices was 92% (95% CI, 0.90-0.94). The pooled sensitivity and specificity were 72% (95% CI, 0.54-0.85) and 91% (95% CI, 0.86-0.94), respectively, for the grading of medium to large varices. The use of capsule demonstrated only mild adverse events. A sensitivity analysis limited to only high quality studies revealed similar results.

DISCUSSION

Wireless esophageal capsule endoscopy is well tolerated and safe in patients with liver cirrhosis and suspicion of portal hypertension. The sensitivity of capsule endoscopy is not currently sufficient to replace EGD as a first exploration in these patients, but given its high accuracy, it may have a role in cases of refusal or contraindication to EGD.

Recurrence and prognosis of patients emergently hospitalized for acute esophageal variceal bleeding: A long-term cohort study

AIM

To elucidate the rates of recurrence and mortality in acute esophageal variceal bleeding and the associated risk factors.

METHODS

A cohort of 174 patients emergently hospitalized for esophageal variceal bleeding was analyzed. All patients underwent endoscopic variceal ligation within 3 h of arrival. Comorbidities, vital signs, drug use, laboratory data, etiology, endoscopic findings, transfusion requirement, and follow-up endoscopy were assessed. Cox's proportional hazards model was used to estimate hazard ratios (HR).

RESULTS

Rebleeding was identified in 49 patients with a mean follow-up of 18 months. The cumulative rebleeding rate at 1 month, 1 year, and 5 years was 10.2%, 30.0%, and 51.0%, respectively. In multivariate analysis, independent risk factors for rebleeding were child-Pugh class C (HR 1.94; P = 0.027), alcoholic liver cirrhosis (HR 2.32; P = 0.01), and no follow-up endoscopy (HR 13.3; P < 0.001). During the overall mean follow-up of 22 months, 69 patients died (17 due to bleeding), and the cumulative mortality rate at 1 month, 1 year, and 5 years was 12.2%, 26.6%, and 63.0%, respectively. In multivariate analysis, independent risk factors for mortality were child-Pugh class C (HR 2.91; P < 0.001), coexistence of hepatocellular carcinoma (HR 1.92; P = 0.013), and no follow-up endoscopy (HR 23.6; P < 0.001).

CONCLUSION

This study revealed more than 50% cumulative rebleeding and mortality in the 5-year period after endoscopic variceal ligation for esophageal variceal bleeding in an emergency setting. Child-Pugh C, alcoholic liver cirrhosis, and no follow-up endoscopy increased the risk of rebleeding; Child-Pugh C, coexistence of hepatocellular carcinoma, and no follow-up endoscopy increased the risk of mortality.

Early TIPS versus endoscopic therapy for secondary prophylaxis after management of acute esophageal variceal bleeding in cirrhotic patients: a meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

American College of Gastroenterology and American Association for the Study of Liver Disease guidelines recommend endoscopic and pharmacologic treatment for esophageal variceal bleed. Transjugular intrahepatic portosystemic shunt (TIPS) placement is reserved for cases of therapeutic failure. Several studies have suggested improved prevention of rebleeding and improved survival without excess hepatic encephalopathy in patients who receive TIPS within the first 5 days after bleeding (early TIPS). In this meta-analysis, we evaluated the safety and efficacy of early TIPS versus endoscopic therapy for secondary prophylaxis after acute esophageal variceal bleeding in cirrhotic patients.

METHODS

Pubmed, Medline, Embase, ClinicalTrials.gov, and ISI Web of Science were searched for randomized controlled trials that compared early TIPS to endoscopic therapy. The primary outcome was mortality at 1 year; secondary outcomes were rebleeding and hepatic encephalopathy at 1 year.

RESULTS

Nine randomized controlled trials involving 608 cirrhotic patients were identified. Early TIPS was associated with a significant risk reduction in 1-year mortality (RR, 0.68; 95% CI, 0.49-0.96; P = 0.03) and 1-year incidence of variceal rebleeding (RR, 0.28; 95% CI, 0.20-0.40; P < 0.001) without significant heterogeneity among studies (I(2)  = 30% and 47%, respectively). No significant difference in the incidence of hepatic encephalopathy at 1 year was observed (RR, 1.36; 95% CI, 0.72-2.56; P = 0.34); however, there was significant heterogeneity among studies (I(2)  = 68%).

CONCLUSION

TIPS placed within 5 days after a major esophageal variceal hemorrhage is superior to endoscopic treatment in reducing subsequent bleeding. Early TIPS placement is also associated with superior 1-year survival without significantly increasing the incidence of hepatic encephalopathy.

The Beneficial Effect of Beta-Blockers in Patients With Cirrhosis, Portal Hypertension and Ascites

BACKGROUND

Patients with cirrhosis and portal hypertensive complications have reduced survival. As such, it has been suggested that nonselective beta-blocker therapy in patients with advanced ascites is harmful. The aim of this study was, therefore, to determine the risk of mortality in patients with cirrhosis and ascites taking nonselective beta-blocker therapy for the prevention of variceal hemorrhage.

MATERIALS AND METHODS

This study was a retrospective analysis of 2,419 patients with cirrhosis and portal hypertension admitted to Parkland Memorial Hospital (a university-affiliated county teaching hospital) from 2003-2010. Patients were subdivided into those with varices only, ascites only and those with both varices and ascites. The primary outcome measure for this study was all-cause in-hospital mortality.

RESULTS

Overall, 68 of 1,039 (6.5%) patients taking beta-blockers died during their hospitalization, while 223 of 1,380 (16.2%) patients not taking beta-blockers died (P < 0.001). Beta-blocker use was also assessed in specific cohorts; mortality was 21.1% in patients with severe ascites with varices who were not taking beta-blockers compared with 8.9% in patients who were taking beta-blockers (P = 0.05). Overall, fewer patients taking beta-blockers died compared with those not taking beta-blockers in patients with varices only (6.4% versus 12.1%) and those with ascites with or without varices (6.6% versus 18.1%) (P < 0.001).

CONCLUSIONS

Mortality was lower in patients with cirrhosis and portal hypertension taking nonselective beta-blockers than in those not taking beta-blockers. The use of nonselective beta-blockers provided a significant survival benefit in patients with all grades of ascites, including those with severe ascites.

Gastric varices: Classification, endoscopic and ultrasonographic management

Gastric varices (GV) are responsible for 10-30% of all variceal hemorrhage. However, they tend to bleed more severely with higher mortality. Around 35-90% rebleed after spontaneous hemostasis. Approximately 50% of patients with cirrhosis of liver harbor gastroesophageal varices. In this review, new treatment modalities in the form of endoscopic treatment options and interventional radiological procedures have been discussed besides discussion on classification and pathophysiology of GV.

Regression of esophageal varices during entecavir treatment in patients with hepatitis-B-virus-related liver cirrhosis

Recent studies suggest that liver cirrhosis is reversible after administering oral nucleos(t)ide analogue therapy to patients with hepatitis B virus (HBV) infection. However, few studies have addressed whether esophageal varices can regress after such therapy. We report a case of complete regression of esophageal varices during entecavir therapy in patients with HBV-related liver cirrhosis, suggesting that complications of liver cirrhosis such as esophageal varices can regress after the long-term suppression of HBV replication.

Facility- and Patient-Level Factors Associated with Esophageal Variceal Screening in the USA

BACKGROUND AND AIM

The American Association for the Study of Liver Disease (AASLD) recommends screening for esophageal varices (EV) by esophagoduodenoscopy (EGD) in patients with cirrhosis to guide decisions regarding primary prophylaxis for EV hemorrhage. We aimed to identify patient and facility factors associated with EV screening in veterans with hepatitis C (HCV)-associated cirrhosis.

METHODS

This was a population-based cohort study. Veterans with HCV and newly diagnosed cirrhosis between 1/1/2004 and 12/31/2005 and followed until 12/31/2011 were included. The primary outcome was receipt of EGD within 1 year of cirrhosis diagnosis. Patient- and facility-level factors associated with EV screening were determined.

RESULTS

A total of 4230 patients with HCV cirrhosis were identified. During median follow-up of 6.1 years (IQR: 4.0-8.0), 21.5 % developed a decompensating event, and 38.3 % died. Fifty-four percent received an EGD, and 33.8 % had an EGD within guidelines. Median time from cirrhosis diagnosis to EGD was 72 days (IQR: 12-176). Factors independently associated with receipt of EV screening were a decompensation event (OR 1.16, CI 1.01-1.32) and gastroenterology/hepatology clinic access (OR 2.1, CI 1.73-2.46), whereas cardiovascular (OR 0.81, CI 0.69-0.95), mental health (OR 0.79, CI 0.68-0.91), and respiratory (OR 0.85, CI 0.72-0.99) comorbidities were associated with reduced likelihood of EV screening.

CONCLUSION

EV screening per AASLD guidelines occurs in only one-third of patients. This missed opportunity was strongly associated with access to gastroenterology/hepatology specialty care. Additionally, providers may be relying on clinical cues (i.e., decompensation) to prompt referral for endoscopy suggesting education to improve compliance with guidelines is needed.

Pharmacological Treatment in Upper Gastrointestinal Bleeding

Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency. Bleeding peptic ulcers account for the majority of causes in patients presenting with AUGIB, whereas variceal bleeding in cirrhotic patients represents a more severe form of bleeding. Endoscopic therapy is the mainstay of treatment in patients with active bleeding, as it achieves hemostasis and improves patient outcomes. Pharmacotherapy is an important adjunct to endoscopic hemostasis. In the management of patients with bleeding peptic ulcers, acid suppression after endoscopic hemostasis reduces rates of further bleeding and interventions. In patients with stable hemodynamics awaiting endoscopy, acid suppression starts ulcer healing and downstages stigmata of bleeding, thereby reducing the need for endoscopic therapy. In managing patients with variceal bleeding, early administration of vasoactive drugs lowers splanchnic blood flow, promotes hemostasis, and makes subsequent endoscopic treatment easier. The use of vasoactive agents and antibiotics have both been shown to reduce mortality. In this review article, strategies of acid suppression therapy for peptic ulcer bleeds, vasoactive agents, and antibiotics for variceal bleeding, together with recent evidence on the use of tranexamic acid in gastrointestinal bleeding, are discussed.

Predictors of In-Hospital Mortality in patients with hepatocellular carcinoma and Acute Variceal bleeding

Introduction

Detection of hepatocellular carcinoma (HCC) in cirrhotic patients remains a serious, unsolved problem, and the risk factors for acute variceal bleeding (AVB) in HCC patients remain unclear. This study aimed to determine the in-hospital mortality (IHM) and factors influencing the clinical outcomes of AVB in patients with liver cirrhosis and HCC.

Methods

This was a retrospective, non-randomized, clinical study that was conducted in 2014. The study was conducted on 70 patients with liver cirrhosis and HCC presenting by acute upper gastrointestinal bleeding (AUGIH). All patients were examined endoscopically within 24 hours from presentation and bleeding varices accounted for AUGIH. Full medical history, clinical examination, and laboratory and radiologic data were collected from admission charts, and hospital medical records were statistically analyzed with SSPS version 22.

Results

Thirty-two patients (45.7%) survived and 38 died (54.3%). Survivors are more likely to be Child-Pugh class A or B, and the non-survivors were class C. The Model for End-Stage Liver Disease (MELD) was highly predictive of IHM at an optimized cut-off value of ≥ 12.9. Higher esophageal varices grades and presence of active bleeding on index endoscopy were significant (p < 0.01) in the non-survivors compared to survivors. Complications of liver cirrhosis and associated major comorbidity were significantly higher (p < 0.01) in the non-survivors than the survivors. Univariate logistic regression analysis identified higher Grade Esophageal Varices and number of transfused packed red blood cells units as two independent predictors of IHM.

Conclusions

IHM was particularly high (54.3%) among HCC patients with AVB who had MELD score > 12.9, higher grade Esophageal Varices, active bleeding on index endoscopy, more increased needs for blood transfusion, longer hospital stay, decompensated liver disease with major comorbidity.

Risk of Bacterial Infection in Patients With Cirrhosis and Acute Variceal Hemorrhage, Based on Child-Pugh Class, and Effects of Antibiotics

BACKGROUND & AIMS

Antibiotics frequently are overused and are associated with serious adverse events in patients with cirrhosis. However, these drugs are recommended for all patients presenting with acute variceal hemorrhage (AVH). We investigated whether patients should be stratified for antibiotic prophylaxis based on Child-Pugh scores, to estimate risks of bacterial infection, rebleeding, and mortality, and whether antibiotics have equal effects on patients of all Child-Pugh classes. We performed a sensitivity analysis using model for end-stage liver disease (MELD) scores.

METHODS

In a retrospective study, we analyzed data from 381 adult patients with cirrhosis and AVH (70% men; mean age, 56 y), admitted from 2000 through 2009 to 2 tertiary care hospitals in Edmonton, Alberta, Canada. We excluded patients with bacterial infection on the day of AVH. The association between antibiotic prophylaxis and outcomes was adjusted by liver disease severity and by a propensity score.

RESULTS

The patients included in the study had mean MELD scores of 16, and 54% received antibiotic prophylaxis. Overall, antibiotic therapy was associated with lower risks of infection (adjusted odds ratio, 0.37; 95% confidence interval, 0.91-0.74) and mortality (adjusted odds ratio, 0.63; 95% confidence interval, 0.31-1.29). Among patients categorized as Child-Pugh class A given antibiotics, only 2% developed infections and the mortality rate was 0.4%. Among patients categorized as Child-Pugh class B given antibiotics, 6% developed infections, compared with 14% of patients who did not receive antibiotics; antibiotics did not affect mortality. Administration of antibiotics to patients categorized as Child-Pugh class C reduced infections and mortality by approximately 50%, compared with patients who did not receive antibiotics. MELD scores were not as useful as Child-Pugh class in identifying patients at risk for infection.

CONCLUSIONS

Based on a retrospective analysis of patients with cirrhosis and AVH, those categorized as Child-Pugh class A had lower rates of bacterial infection and lower mortality rates in the absence of antibiotic prophylaxis than patients categorized as classes B or C. The recommendation for routine antibiotic prophylaxis for this subgroup requires further evaluation.

Variceal hemorrhage: Analysis of 9987 cases from a Japanese nationwide database

AIM

Gastroesophageal variceal hemorrhage is an important complication of cirrhosis. We investigated the in-hospital mortality and its risk factors after variceal hemorrhage in a large sample population, using a nationwide Japanese database.

METHODS

Data on the patients with variceal hemorrhage were collected for a total of 39 months from a nationwide administrative database covering approximately 1000 hospitals in Japan. The risk factors for fatal outcome after variceal hemorrhage were analyzed with receiver-operator curves (ROC) and univariate and multivariate logistic regression. Comorbidities were assessed with the Charlson Comorbidity Index.

RESULTS

We identified 9987 patients with variceal hemorrhage from a total of 20.3 million inpatients in the database. The median age was 63 years and 68.8% were male. The overall in-hospital mortality was 16.8% (1676 cases). In univariate analysis, Child-Pugh class was the strongest predictor; the area under the ROC of Child-Pugh score for predicting in-hospital mortality was 0.802. In multivariate analysis, increased in-hospital mortality was significantly associated with male sex (vs female: odds ratio [OR] = 1.19, P = 0.01), older age, Child-Pugh class B or C (B vs A: OR = 2.80, P < 0.001; C vs A: OR = 20.1, P < 0.001) and higher Charlson Comorbidity Index (≥6 vs ≤5; OR = 1.29, P < 0.001).

CONCLUSION

In spite of recent advances in the treatment of variceal hemorrhage, the in-hospital mortality remained as high as 16%. Poor liver function was the most important predictor, suggesting that liver failure after variceal hemorrhage might have been the cause of death.

Improved survival of cirrhotic patients with variceal bleeding over the decade 2000-2010

BACKGROUND AND OBJECTIVE

Advances in the management of variceal bleeding (VB) have been highlighted recently. We aimed at assessing whether changing the management of VB has improved the outcome (mortality and rebleeding rates).

METHODS

The files of two cohorts (n=57, 2000-2001 and n=64, 2008-2009) of patients referred to our university center were reviewed after a cross-searching using two coding systems. Data were recorded during the six months after VB.

RESULTS

As compared to 2000-2001, more use of general anesthesia (25.4% vs. 11.1%; P=0.049), band ligations (96.1% vs. 71.4%; P=0.001), octreotide (95.3% vs. 80.7%; P=0.012) and antibiotic prophylaxis (93.8% vs. 82.5%; P=0.09) were performed in 2008-2009, whereas the number of red-cell units transfused during the hospital stay (4.3 ± 3.2 vs. 7.1 ± 5.7; P=0.005) decreased. Surprisingly, more than 60% of patients reached the emergency department from home without medical assistance in both periods. In 2008-2009, patients had more comorbidities and no patients underwent early-TIPS but the 6-week mortality rate (24.6% vs.10.9%; P=0.048) was lower. The 6-week mortality was associated with high MELD score (HR=1.13; 95%CI: 1.08-1.18) and hypovolemic shock (HR=5.36; 95%CI: 1.96-14.67) at admission. In multivariate analysis adjusted on MELD and comorbidities, the 2008-2009 period (HR: 0.42; 95%CI: 0.20-0.87; P=0.02) was associated with a lower 6-month mortality rate.

CONCLUSIONS

Although cirrhotic patients with VB had more comorbidities in 2008-2009 and received no early-TIPS, their prognosis has improved during this last decade concomitantly to a more intensive care and a lower transfusion strategy.

The international normalized ratio does not reflect bleeding risk in esophageal variceal hemorrhage

BACKGROUND/AIMS

The international normalized ratio (INR) has not been validated as a predictor of bleeding risk in cirrhotics. The aim of this study was to determine whether elevation in the INR correlated with risk of esophageal variceal hemorrhage and whether correction of the INR prior to endoscopic therapy affects failure to control bleeding.

PATIENTS AND METHODS

Patient records were retrospectively reviewed from January 1, 2000 to December 31, 2010. Cases were cirrhotics admitted to the hospital due to bleeding esophageal varices. Controls were cirrhotics with a history of non-bleeding esophageal varices admitted with ascites or encephalopathy. All variceal bleeders were treated with octreotide, antibiotics, and band ligation. Failure to control bleeding was defined according to the Baveno V criteria.

RESULTS

We analyzed 74 cases and 74 controls. The mean INR at presentation was lower in those with bleeding varices compared to non-bleeders (1.61 vs 1.74, P = 0.03). Those with bleeding varices had higher serum sodium (136.1 vs 133.8, P = 0.02), lower hemoglobin (9.59 vs 11.0, P < 0.001), and lower total bilirubin (2.47 vs 5.50, P < 0.001). Multivariable logistic regression showed total bilirubin to inversely correlate with bleeding (OR = 0.74). Bleeders received a mean of 1.14 units of fresh frozen plasma (FFP) prior to endoscopy (range 0-11 units). Of the 14 patients (20%) with failure to control bleeding, median INR (1.8 vs 1.5, P = 0.02) and median units of FFP transfused (2 vs 0, P = 0.01) were higher than those with hemostasis after the initial endoscopy.

CONCLUSIONS

The INR reflects liver dysfunction, not bleeding risk. Correction of INR with FFP has little effect on hemostasis.

Endoscopic treatment of gastric varices

Gastric varices (GV) are present in one in 5 patients with portal hypertension and variceal bleeding. GV bleeds tend to be more severe with higher mortality. High index of suspicion, early detection and proper locational diagnosis are important. An algorithmic approach to the management of GV bleeding prevents rebleeds and improves survival. Vasoactive drugs should be started with in 30 minutes (door to needle time) and early endotherapy be done. Cyanoacrylate injection in experienced hands achieves hemostasis in >90% patients. A repeat session is sometimes needed for complete obturation of GV. Transjugular intrahepatic portosystemic shunt and balloon retrograde transvenous obliteration are effective rescue options. Secondary prophylaxis of GV bleeding is done with beta-blocker and endotherapy.

A risk scoring system to predict in-hospital mortality in patients with cirrhosis presenting with upper gastrointestinal bleeding

GOALS

We aimed to develop a simple and practical risk scoring system to predict in-hospital mortality in cirrhotics presenting with upper gastrointestinal (GI) bleeding.

STUDY

Extensive clinical data were captured in patients with documented cirrhosis who underwent endoscopic evaluation for upper GI bleeding between January 1, 2003 and June 30, 2011 at Parkland Memorial Hospital. Predictors of mortality were identified by multivariate regression analysis.

RESULTS

A total of 884 patients with cirrhosis admitted for upper GI bleeding were identified; 809 patients survived and 75 died (8.4%). The etiology of bleeding was similar in both groups, with bleeding attributed to esophageal varices in 59% of survivors and 60% of non-survivors (ulcer disease and other etiologies of bleeding accounted for the other causes of bleeding). Mortality was 8.6% and 8.3% in patients with variceal bleeding and nonvariceal bleeding, respectively. While survivors and those who died were similarly matched with regard to gender, age, ethnicity and etiology of cirrhosis, patients who died had lower systolic blood pressures, higher pulse rates and lower mean arterial pressures at admission than patients who survived. Non-survivors were more likely to be Childs C (61% vs. 19%, P<0.001). Multivariate regression analysis identified the following 4 predictors of in-hospital mortality: use of vasoactive pressors, number of packed red blood cells transfused, model for end-stage liver disease (MELD) score, and serum albumin. A receiver operating characteristic curve including these 4 variables yielded an area under the receiver operating characteristic (AUROC) curve of 0.94 (95% confidence interval, 0.91-0.98). Classification and Regression Tree analysis yielded similar results, identifying vasoactive pressors and then MELD>21 as the most important decision nodes for predicting death. By comparison, using the Rockall scoring system in the same patients, the AUROC curve was 0.70 (95% confidence interval, 0.64-0.76 and the comparison of the University of Texas Southwestern model to the Rockall model revealed P<0.0001). A validation set comprised of 150 unique admissions between July 1, 2011 and July 31, 2012, had an AUROC of 0.92, and the outcomes of 97% of the subjects in this set were accurately predicted by the risk score model.

CONCLUSIONS

Use of vasoactive agents, packed red blood cell transfusion, albumin, and MELD score were highly predictive of in-hospital mortality in cirrhotics presenting with upper GI bleeding. These variables were used to formulate a clinical risk scoring system for in-hospital mortality, which is available at: http://medweb.musc.edu/LogisticModelPredictor.

Comparison of scoring systems and outcome of patients admitted to a liver intensive care unit of a tertiary referral centre with severe variceal bleeding

BACKGROUND

Acute variceal haemorrhage (AVH) is associated with significant mortality.

AIMS

To determine outcome and factors associated with hospital mortality (HM) in patients with AVH admitted to intensive care unit (ICU) and to compare outcomes of patients requiring transfer to a tertiary ICU (transfer group, TG) to a local in-patient group (LG).

METHODS

A retrospective study of all adult patients (N = 177) admitted to ICU with AVH from 2000-2008 was performed.

RESULTS

Median age was 48 years (16-80). Male represented 58%. Median MELD score was 16 (6-39), SOFA score was 8 (6-11). HM was higher in patients who had severe liver disease or critical illness measured by MELD, SOFA, APACHE II scores and number of failed organs (NFO), P < 0.05. Patients with day-1 lactate ≥ 2 mmol/L had increased HM (P < 0.001). MELD score performed as well as APACHE II, SOFA and NFO (P < 0.001) in predicting HM (AUROC = 0.84, 0.81, 0.79 and 0.82, respectively P > 0.05 for pair wise comparisons). Re-bleeding was associated with increased HM (56.9% vs. 31.6%, P = 0.002). The TG (n = 124) had less severe liver disease and critical illness and consequently had lower HM than local patients (32% vs. 57%, P = 0.002). TG patients with ≥2 endoscopies prior to transfer had increased 6-week mortality (P = 0.03). Time from bleeding to transfer ≥3 days was associated with re-bleeding (OR = 2.290, P = 0.043).

CONCLUSIONS

MELD score was comparable to ICU prognostic models in predicting mortality. Blood lactate was also predictive of hospital mortality. Delays in referrals and repeated endoscopy were associated with increased re-bleeding and mortality in this group.

Laparoscope-assisted Hassab's operation for esophagogastric varices after living donor liver transplantation: a case report

This is the first successful report of a laparoscope-assisted Hassab's operation for esophagogastric varices after living donor liver transplantation (LDLT). A 35-year-old man underwent LDLT using a right lobe graft as an aid for primary sclerosing cholangitis (PSC) in 2005. Follow-up endoscopic and computed tomography (CT) examinations showed esophagogastric varices with splenomegaly in 2009 that increased (esophageal varices [EV]: locus superior [Ls], moderator enlarged, beady varices [F2], medium in number and intermediate between localized and circumferential red color signs [RC2]; gastric varices [GV]: extension from the cardiac orifice to the fornix [Lg-cf], moderator enlarged, beady varices [F2], absent red color signs [RC0]). A portal venous flow to the esophagogastric varices through a large left gastric vein was also confirmed. Preoperative Child-Pugh was grade B and score was 9. Because these esophagogastric varices had a high risk of variceal bleeding, we proceeded with a laparoscope-assisted Hassab's operation. Operative time was 464 minutes. Blood loss was 1660 mL. A graft liver biopsy was also performed and recurrence of PSC was confirmed histologically. It was suggested that portal hypertension and esophagogastric varices were caused by recurrence of PSC. Postoperative complications were massive ascites and enteritis. Both of them were treated successfully. This patient was discharged on postoperative day 43. Follow-up endoscopic study showed improvement in the esophagogastric varices (esophageal varices [EV]: locus superior [Ls], no varicose appearance [F0], absent red color signs [RC0], gastric varices [GV]: adjacent to the cardiac orifice [Lg-c], no varicose appearance [F0], absent red color signs [RC0]) at 6 months after the operation. We also confirmed the improvement of esophagogastric varices by serial examinations of CT.